CMS Publishes New Payment Rates for Urological Services Performed in Outpatient Hospital Departments and Ambulatory Surgical Centers for 2018

By Policy and Advocacy Brief posted 11-03-2017 10:58


On November 1, 2017, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period, which includes updates for 2018 payment rates, quality provisions, and other policy changes. CMS adopted a number of policies recommended by the AUA that will support urologic services in CY 2018. 

Brachytherapy Insertion Procedures

CMS finalized the proposal to delete composite APC 8001 (LDR Prostate Brachytherapy

Composite) and assign HCPCS code 55875 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy) to status indicator J1 (Hospital Part B services paid through a comprehensive APC) payable under APC 5375. This means that payment for low-dose prostate brachytherapy will increase from the current rate of $3500.25 to $3705.77 for CY 2018.

Complexity Adjustment for Blue Light Cystoscopy Procedures  

As proposed, CMS created a new HCPCS code (C9738 Adjunctive blue light cystoscopy with fluorescent imaging agent (List separately in addition to code for primary procedure)) to describe blue light cystoscopy (Cysview® (hexaminolevulinate HCI) to allow for a complexity payment adjustment. When Cysview is reported in combination with HCPCS codes 52204, 52214 and 52224, these services will result in a payment reassignment from proposed APC 5373 with a payment rate of $1695.57 to APC 5374 at $2696.58 for CY 2018.

Transurethral Waterjet Ablation of the Prostate

Next year, CMS will reassign payment for transuretheral waterjet ablation of the prostate, referred to as aquablation, from APC 5374 to higher paying APC 5375 with status indicator J1.  Aquablation, a new and novel device for treatment of benign prostatic hyperplasia (BPH), was changed recently from status indicator E1 (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type)) to status indicator J1 and assigned to APC 5374 with a current national rate of $2542.56.  In 2018, the payment rate will increase to $3705.77. However, CMS declined to allow transurethral water vapor thermal therapy for treatment of BPH, referred to as the Rezūm system, to be reported with HCPCS code 53852. Instead, outpatient hospitals using Rezūm for BPH must report HCPCS code C9748 effective January 1, 2018. This procedure will be assigned to APC 5373.

Changes to Inpatient Only List

CMS has confirmed that CPT code 55866 (Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed) will be removed from the Inpatient Only List for CY 2018; however, CMS has decided that this procedure cannot be appropriately and safely performed in an ambulatory surgical center.

ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures Measure

CMS will submit the ASC-18: Hospital Visits after Urology Ambulatory Surgical Center Procedures measure for review and endorsement by the National Quality Forum to begin tracking unplanned hospital visits following urology procedures to be added to the Ambulatory Surgical Center Quality Reporting (ASCQR) Program for CY 2022 payment determinations.

The final rule will publish in the November 13, 2017, Federal Register and can be downloaded here.  The AUA will continue to analyze the final rule and prepare written comments.