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News -> April, 2005 News
Michael Setzen MD, FACS
Chair, Patient Advocacy Committee
There has been a flurry of activity pertaining to CMS's opinion on Image Guidance Surgery (IGS) in an Ambulatory Surgical Center (ASC). On November 26th, CMS published in the Federal Register the 2005 proposed rule of covered procedures in an ASC. Currently +61795 is excluded from the list of covered procedures to be done in an ASC facility.
A delegation of otolaryngologists from the American Rhinologic Society and AAO-HNS met with CMS on November 10th, 2004 in Baltimore, Maryland. Representatives included Michael Setzen, MD; Michael Sillers, MD; Martin Citardi, MD; Charles Koopman, MD; Beth Roberts, attorney for the ARS; and Linda Taliaferro, Director of Regulatory and Socioeconomic Affairs, AAO-HNS. We presented the case for IGS in an ACS facility.
Initially, CMS was confused as to how and why we as Ear, Nose and Throat surgeons should and can use this sophisticated neurosurgical technology in an ASC setting. CMS, under the leadership of Dr. Ken Simon, allowed us to give a full and comprehensive presentation elucidating why we should be allowed to use IGS in an ASC setting. We let it be known that this kind of surgery is better suited in an ambulatory setting and it would be more costly if this were done as an inpatient in a hospital.
We showed how we use "brain technology in sinus surgery to stay out of the brain and eye." We also explained that most nasal and sinus surgeries, in particular Functional Endoscopic Sinus Surgery (FESS), are being performed on an ambulatory basis both in an ASC and an ambulatory facility attached to a hospital.
CMS, not recognizing the need for use IGS in an ASC, will not reimburse for the technical component (facility fee) of +61795 when done in an ASC. They will continue to pay for the physician's component under the Medicare Part B Physician Fee Schedule. We explained why denial of payment of the technical component could prevent both access to care and access to sophisticated and important technology for the Medicare sinus patient. We also expressed the concern that CMS's denial could have a domino effect and that all third party payers and private insures may do likewise. CMS will reimburse for +61795 when performed in an inpatient or outpatient hospital setting.
FESS CPT codes are approved in an ASC setting and as +61795 is an add on code it should also be an approved ASC procedure.
CMS specifically asked if more than 50 % of endoscopic sinus surgeries are performed using IGS. Our response was no and fortunately so. If IGS were being used more than 50% of the time, then it could become part of the standard of care and part of the overall fee which would then affect both the physician and technical components of reimbursement.
It is therefore important to take heed of what CMS is asking. We should only use IGS in appropriate situations according to the Academy guidelines. The AAO-HNS guidelines include revision FESS; diffuse nasal polyposis; sphenoid, frontal and posterior ethmoid disease; bizarre anatomy, congenital, acquired or traumatic; and any neoplastic case, benign or malignant. If abuse of IGS takes place, we will all suffer and reimbursement will be denied.
We now have 60 days to respond to the proposed rule and we will do so on behalf of the ARS and the AAO-HNS. We will ask that +61795 be an approved procedure in an ASC setting as well as an inpatient or outpatient facility. Furthermore, the 2005 ASC covered services proposed rule has four other codes - 31233, 31235, 31237 and 31238 - that are deleted from the ACS list as well. We may consider requesting that these codes not be deleted from the ASC Procedure List for 2005.
It must be noted that we are not doing this on behalf of Image Guidance Companies or ASC's but rather in the interest of patient safety. CMS and the AMA prefer to hear from physicians rather than from industry representatives who may have an inherent bias. IGS is state of the art but not the standard of care. This will be discussed in an upcoming Nose News article.
In summary, we differ in opinion with CMS and have clarified this and in so doing, we hope to have IGS approved on the ASC list of procedures for 2005. High on the agenda of the ARS is seeking appropriate care for the rhinologic patient and with this in mind, +61795 belongs on the ASC list since many nasal and sinus surgeries, in particular FESS, are being done in an ASC. In so doing, patients seeking ASC treatment will be better served.
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