PRACTICE RESOURCES > Regulation/AUA Positions, Letters, and Talking Points > AUA Comments to CMS Regarding ASC List

AUA Comments to CMS Regarding ASC List

May 27, 2003

Thomas A. Scully
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-1885-FC
P.O. Box 8013
Baltimore, MD 21244-8013

Re: CMS-1885-FC—Medicare Program; Update of Ambulatory Surgical Center List of Covered Procedures Effective July 1, 2003; Final Rule

Dear Mr. Scully:

On behalf of the American Urological Association's (AUA) 10,000 U.S. members, I am pleased to submit comments on the Ambulatory Surgical Center (ASC) final rule. As you know, for procedures that can be performed safely in an ASC, this site of service represents an opportunity for cost savings in the Medicare program, safety and convenience for patients and convenience for physicians. Therefore, it would be sensible for CMS to add any procedure to its ASC list that meets the criteria for addition. Unfortunately, adding a procedure to the list does not assure that it will be performed in an ASC, especially if the payment rate is inadequate or if there are unanswered questions about how to bill for items used in the procedure (e.g. prosthetic devices, synthetic implant materials, expensive laser fibers) that fall outside the scope of what is included in the ASC Facility payment.

According to the March 28 final rule, about 56 urological procedures are slated to be added to the ASC list as of July 1. While we agree that these procedures can be safely performed in an ASC and welcome their addition to the list, we are concerned that certain intricacies of Medicare's ASC payment system will actually prevent some of these procedures from being performed in an ASC even though they are on the list. In this case, physicians certainly have the choice of doing any of these procedures in the more expensive hospital setting, or in the office in some cases. However, urologists would like to be able to offer these procedures to their patients in an ASC, especially if they are on the list.

We offer some suggestions below that would increase the likelihood of certain urological procedures being performed in an ASC, which would help to realize the full potential of the benefits of having an ASC payment system in the first place. Our suggestions are divided into two groups-one group that deals with ASC payment rates and the cost of performing procedures, and one group that deals with additions and deletions to the list.

I. Payment groups and high cost supplies

There are some codes that will be added to the list as of July 1, 2003 that are in payment groups that are too low to allow an ASC to recoup its costs for performing them. Urologists want to be able to give their Medicare patients the choice of having these procedures done in the ASC setting, but the suggested payments are inadequate and will not really result in any changes in where these procedures are performed. By paying them appropriately in the ASC setting, the Medicare program could save money on procedures that are done in an ASC instead of a hospital setting.

Based on this, we recommend that the following codes be moved to payment group nine:

Table I. CPT® codes that should be moved to payment group nine

CPT® Code


Current Pmt. Group


Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included)

4 - $630


Insertion of tandem cuff (dual cuff)

2 - $446


Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff

1 - $333


Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff

1 - $333


Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session

1 - $333


Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff

1 - $333


Insertion of penile prosthesis; non-inflatable (semi-rigid)

3 - $510


Insertion of penile prosthesis; inflatable (self-contained)

3 - $510


Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir

3 - $510


Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis

3 - $510


Repair of component(s) of a multi-component, inflatable penile prosthesis

3 - $510


Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session

3 - $510


Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis

3 - $510


Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session

3 - $510

Moving these codes to payment group nine would bring the payment closer to the actual costs of performing the procedures, and would save money by shifting these from the more resource-intensive hospital setting to the ASC setting. This would also benefit Medicare beneficiaries because they would be paying lower copayments and would be offered the more convenient ASC setting.

There are also many procedures that are being added to the list that require the use of high-cost supplies or prosthetics. For example, the cost of a penile prosthesis or a urinary sphincter ranges from $4,500 to $5,000. Based on our understanding of the ASC payment system, these items are separately reimbursable items as long as the ASC is also approved as a supplier of prosthetic implants. However, there are no specific HCPCS codes for these items, which means the ASC would have to bill using HCPCS code L8699, Prosthetic implant, not otherwise specified. Because this code is paid based on carrier discretion, it seems that the decisions of reasonable and necessary will vary from carrier to carrier.

We would like clarification on whether there is a way that CMS can institute a more uniform payment method for these items based on section 35-24 of CMS's Coverage Issues Manual, Diagnosis and Treatment of Impotence. Because these codes will be added to the ASC list for the first time as of July 1, we are concerned that ASCs will not understand how to bill for these items or that they will purchase the items and then lose money on them if certain carriers decide not to reimburse for them. We would like to do everything possible to educate our members who want to perform these procedures in an ASC on the proper and most efficient way to bill for these procedures.

II. List additions and deletions

However, as CMS noted in its 1998 proposed rule, numeric site-of-service thresholds should not be the principal determinant for adding procedures to and deleting procedures from the ASC coverage list. It is important that physicians-in concert with their patients-determine the appropriate site to perform a procedure based on clinical indications. Currently, physicians can perform TUMT in an ASC and the ASC can still recoup its costs for this expensive procedure because the in-office physician fee schedule payment substantially exceeds the highest ASC payment category.

Because Medicare payment policy reimburses physicians the in-office payment rate for procedures done in an ASC that aren't on the list, many physicians have negotiated payment contracts with ASCs to have the option of doing TUMT in an ASC. Because of this, we are concerned that current Medicare payment policies would actually take away a physician's option to perform TUMT in an ASC if it is added to the list. This would mean that patients who could not receive TUMT in the office due to clinical concerns would probably have the procedure done in the hospital outpatient setting, which adds to Medicare's costs. Given the current cost of the TUMT supplies and equipment, ASCs can not recoup their costs of providing this service for $1,339. For these reasons, we urge CMS not to add this code to the ASC list at this time.

Thank you for considering our comments. If you have any questions or need additional information, please contact Robin Hudson, Manager of Regulatory Affairs, at 410-689-3762 or


Martin I. Resnick, MD
American Urological Association

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