2021 Final Medicare Payment Rule Released


December 2, 2020

The Centers for Medicare & Medicaid Services (CMS) released the 2021 final payment rule for ASCs and hospital outpatient departments (HOPD) today. Of note, CMS is adding 267 codes to the ASC Covered Procedures List (ASC-CPL), including total hip arthroplasty (THA). CMS also continued to align the ASC update factor with that used to update HOPD payments, using the hospital market basket to update ASC payments for calendar year (CY) 2021 through CY 2023 as the agency continues to assess this policy’s impact on volume migration.

"CMS should be commended for recognizing that ASCs are increasingly able to safely provide a greater range of services as medical practice evolves," said Bill Prentice, ASCA chief executive officer. "While we wish CMS had addressed our concerns about budget policies that negatively impact ASC payments, we sincerely appreciate the policies relating to allowable procedures that rely on the critical role of physicians and their clinical judgment in making site-of-service determinations."

Download the final rule PDF.

Some other initial observations about the 1,312-page rule follow. ASCA will be providing additional analysis soon, including a rate calculator that allows users to determine what ASCs will be paid locally beginning January 1, 2021.

2.4% Average Rate Update

ASCs will see, on average across all covered procedures, an effective update of 2.4 percent. Please note that this is an average, and that updates may vary significantly by code and specialty.

The information below provides a comparison between the 2021 ASC and HOPD reimbursement updates:

ASC HOPD
Inflation update factor 2.4% 2.4%
Productivity reduction mandated by the ACA 0.0 percentage points 0.0 percentage points
Effective update 2.4% 2.4%
Conversion factor $48.952 $82.797

Hundreds of Codes Added to ASC Covered Procedures List

CMS finalized the addition of 267 codes to the ASC Covered Procedures List (ASC-CPL) for 2021. These additions include the following eleven codes that were added after reviewing the current exclusion criteria:

  • 0266T (Implt/rpl crtd sns dev total)
  • 0268T (Implt/rpl crtd sns dev gen)
  • 0404T (Trnscrv uterin fibroid abltj)
  • 21365 (Opn tx complx malar fx)
  • 27130 (Total hip arthroplasty)
  • 27412 (Autochondrocyte implant knee)
  • 57282 (Colpopexy extraperitoneal)
  • 57283 (Colpopexy intraperitoneal)
  • 57425 (Laparoscopy surg colpopexy)
  • C9764 (Revasc intravasc lithotripsy)
  • C9766 (Revasc intra lithotrip-ather)

CMS also finalized its proposal to revise the ASC-CPL criteria under 42 CFR 416.166, retaining the general standard criteria and eliminating five of the general exclusion criteria. Using these revised criteria, CMS is adding an additional 256 codes to the ASC-CPL that are not currently on the CY 2020 inpatient-only (IPO) list.

Elimination of the Inpatient-Only List by 2024

CMS is finalizing its proposal to transition codes off the IPO list, indicating in the final rule that the list will be eliminated by 2024. CMS is starting with approximately 300 services for removal from the IPO list in 2021, primarily musculoskeletal services.

No Changes to the ASC Quality Reporting Program Measure Set

CMS is not removing any existing measures or adopting any new measures for the CY 2023 payment determinations. As a reminder, data submission was voluntary for web-based measures for the CY 2019 reporting period that affects the CY 2021 payment determinations. Therefore, 100 percent of ASCs will receive the full ASCQR payment update for CY 2021.

ASCA will continue to analyze the rule in detail and will soon provide more information to help ASC operators understand the impact of the final rule on their centers.