Medicare Adds 4 Key Ortho Interventions to ASC Covered List

The Centers for Medicare & Medicaid Services (CMS) will now pay for total shoulder arthroplasty, total ankle replacement, hip tendon incision and meniscal knee replacement in both the ambulatory surgery center (ASC) and inpatient settings.

In its 2024 final payment rule for ambulatory surgery centers and hospital outpatient departments (HOPD), CMS added 37 new procedures to its covered procedures list.

These included 26 dental codes and 11 surgical codes. Two codes were added to allow Medicare reimbursement for total shoulder replacement. Codes were also added to allow Medicare reimbursement for total ankle replacement. Additional surgical codes pertained to hip tendon incision and meniscal knee replacement.

Prior to the final payment rule being issued, the Ambulatory Surgery Center Association (ASCA) advocated for the addition of total shoulder arthroplasty to the ASC payable list. Advocacy included a virtual meeting in October 2023 between ASCA representatives and Doug Jacobs, M.D., chief transformation officer of the Center for Medicare at CMS. During the meeting, questions were raised as to why total shoulder arthroplasty was not on the list while total knee arthroplasty and total hip arthroplasty were on the list.

In an ASCA press release, ASCA Chief Executive Officer Bill Prentice expressed gratitude, stating, “We thank CMS for heeding our request to move additional surgical procedures—including total shoulder arthroplasty—onto the ASC payable list.”

Prentice continued, “Doing so benefits both Medicare beneficiaries, who now have a lower-cost choice for the care they need, and the Medicare program itself, which will save millions of dollars as volume moves to the high-quality surgery center site of service.”

CMS also updated Outpatient Prospective Payment System payment rates for certain hospitals and ASCs by 3.1%. According to a CMS fact sheet, “This update is based on the projected hospital market basket percentage increase of 3.3%, reduced by a 0.2 percentage point for the productivity adjustment.”