Image by Roy Harryman from PixabayMore cardiovascular (CV) procedures are coming to ambulatory surgery centers (ASCs), but the barrier to entry remains high.
Varied state regulations, high capital costs and tight staffing are likely to limit the pace of outpatient migration for these CV procedures, industry insiders told ASC News.
“I don’t think we’re going to see a huge shift in volume in the first couple of years,” Kara Newbury, chief advocacy officer at the Ambulatory Surgery Center Association (ASCA), told ASC News.
Even so, the regulatory shift that led to the opening of these codes was an advocacy win for ASCA and the industry, Newbury said. For instance, cardiac ablations are performed primarily on older patients, so Medicare coverage is critical to developing the market. With the addition of multiple cardiac ablation codes to the ASC Covered Procedure List (CPL) for 2026, the U.S. Centers for Medicare & Medicaid Services (CMS) removed a key barrier for existing specialists and new entrants alike.
However, beyond the need for CMS certification and other safety and regulatory prerequisites, building a CV-focused facility or converting an office-based lab “costs a lot of money,” Newbury explained.
“Those facilities were not going to be built until there was assurance that these procedures were going to be reimbursed by Medicare,” she said.
Specifically, 86 new cardiovascular codes were added for 2026. ASCA advocated directly for more than a dozen of those codes, according to background provided by Newbury.
What’s more, during the period CMS released its proposed payment rule for 2026 and when it finalized the rule, the agency added at least 21 that were not in CMS’ original proposed rule, reflecting a growing acceptance and appreciation for what types of procedures ASCs can safely perform.
But capital availability and steep investments aren’t the only hurdles holding back new CV-focused ASCs or programs. State policy can also raise barriers to ASCs.
“There’s still a lot of variation in the way different states approach this,” Stephen Abresch, director of government affairs at ASCA, told ASC News. “When we get asked, ‘Can I do ablation in an ASC in this state?’ the answer usually involves a lot more gray area than people would like.”
ASCs have seen this movie before, Abresch said. Years after the addition of PCI codes to the CPL, only “a handful” of states, such as Mississippi, Michigan and Pennsylvania, have “actually made the changes they’ve needed to allow ASCs to perform these procedures,” Abresch said.
States might also move selectively, allowing only certain cardiac procedures and in some cases explicitly barring others.
For example, Washington has introduced legislation allowing PCIs in ASCs, but nothing related to ablation. Ohio is also opening up these procedures. Yet in that case, the language in the proposed rules “explicitly states you can’t perform some ablation procedures in an ASC,” Abresch said.
And when states do allow cardiac procedures in ASCs, approval is rarely a simple greenlight.
“If you’re in a state that currently has explicit language saying this kind of procedure can only be performed on a hospital campus, and they’re working to move to opening it up for ASCs, you’re probably going to have some new requirements that you’ll have to meet if you want to provide those services,” Abresch said.
Among the most permissive states, he cited Florida, Texas and Arizona.
And yet even in Florida, CV-focused ASCs face a long checklist of physical facility requirements, inspections and local rules. Just ask Dr. David Kenigsberg, co-founder of Fort Lauderdale Heart and Rhythm Surgical Center and president of the Florida Chapter of the American College of Cardiology, who performed his first ASC ablations earlier this year.
“We had to buy another building to meet code,” he told ASC News, referring to a costly lesson from early in the development process.
Based on his experience, operators and physicians hoping to capitalize on new CV opportunities should seek experienced ASC developers as partners, especially if they have worked in the same state, Kenigsberg said.
Dr. Kenigsberg also emphasized the importance of being realistic about readiness.
“Be honest with what your skill set is — don’t overstate in your own mind what you can do,” he said.
And, again, there’s the investment cost.
“The catheters themselves could cost $10,000 to $15,000 per case, and the capital equipment, when you include everything that we may need could be in excess of $1 million or $1.5 million,” Dr. Kenigsberg said.
Capital demands are one of the chief factors limiting participation to a narrow group of operators, many of which are purpose-built cardiovascular ASCs and office-based labs converting into surgery centers, Newbury said.
Even so, both she and Dr. Kenigsberg view the opening of these procedures for ASCs as part of a gradual and positive shift driven by continued advocacy on the part of ASCs.
“We were fortunate this go around to have a lot of support from the cardiovascular community in terms of national specialty organizations,” Newbury said.
Dr. Kenigsberg said he and colleagues spent years pressing national societies to advocate directly to CMS. He pointed to left atrial appendage occlusion devices as a next target for advocacy efforts.
ASCA, meanwhile, is actively gathering member input on what to pursue next, Newbury said. The group also is focusing on broader issues, such as potential reimbursement impacts tied to Medicare’s prospective payment system.
“If they assign any volume to those newly added codes, even if there isn’t going to be volume, that could potentially negatively impact us on the codes that we are already performing,” she said.
Overall, Dr. Kenigsberg described the clinical argument as aligned with what ASCs have already done in other specialties.
“Just like in orthopedics or in GI there are patients that are relatively healthy that can come into an ASC, get a procedure done and be discharged within a few hours,” he said. “Good doctors are going to do good things regardless of where they work.”
