AMERICAN SOCIETY OF INTERVENTIONAL PAIN PHYSICIANS
AND SOCIETY FOR INTERVENTIONAL PAIN MANAGEMENT
SURGERY CENTERS
81 Lakeview Drive • Paducah, Kentucky 42001 • Phone: 270-554-9412 • Fax: 270-554-5394 • http://www.asipp.org
OUTPATIENT INTERVENTIONAL PROCEDURES IN
AMBULATORY SURGERY CENTERS FACT SHEET
Interventional pain management is defined as the discipline of medicine devoted to the diagnosis
and treatment of pain related disorders principally with the application of interventional
techniques in managing sub acute, chronic, persistent, and intractable pain, independently or in
conjunction with other modalities of treatment.
Interventional pain management techniques are defined as minimally invasive procedures
including, percutaneous precision needle placement, with placement of drugs in targeted areas or
ablation of targeted nerves; and some surgical techniques such as laser or endoscopic
diskectomy, intrathecal infusion pumps and spinal cord stimulators, for the diagnosis and
management of chronic, persistent or intractable pain.
Background
In June 1998, the Centers for Medicare and Medicaid Services (CMS) proposed an Ambulatory
Surgery Center (ASC) rule in which at least 60% of the interventional procedures were
eliminated from the ASCs and the remaining 40% faced substantial cuts. The cuts were so
substantial, it would have been impossible for independent interventional pain management
centers to survive and multispecialty centers would have stopped interventional techniques from
being performed.
Since 1998, many interventions were made by Congress, eventually reversing this proposal and
the final proposal.
The Present Landscape
The Medicare Prescription Drug Improvement and Modernization Act of 2003 directed CMS to
implement a new Ambulatory Surgery Center (ASC) payment system to take effect no later than
January 2008. It also directed the Government Accountability Office (GAO) to compare ASC
and Hospital Outpatient Department (HOPD) payments.
On August 8, 2006, CMS issued the Outpatient Prospective Payment System (OPPS) and
Ambulatory Surgery Center proposed rule. CMS proposed a more significant expansion of the
approved list of procedures that can be safely performed in an ASC setting. Since the proposed
rule must be budget neutral, certain procedures will see an increase, while others will be
decreased.
The Findings of GAO on ASC procedural costs
The report to Congressional Committees from United States Government Accountability Office
(GAO) released in November 2006 entitled Payment for Ambulatory Surgical Centers should be
based on the hospital outpatient system estimated. The differences in the cost of procedures in
hospital outpatient setting versus ambulatory surgery center settings. Cost ratio of ASC
procedures when weighted by Medicaid claims value was 0.84. Thus, cost of the procedures in
ASCs is 26% lower than the corresponding cost in hospital outpatient department. However, this
evaluation takes into consideration all types of procedures. Interventional procedures are low
paid and high volume as shown by 15% of the procedures constituting only 7% of the payments.
It is estimated that cost of care is higher than 84% of HOPD for these procedures.
The Problem with HOPD Payment System
HOPD payment systems have historically disadvantaged interventional pain management.
Under the HOPD system, low payments to hospitals for these services resulted in hospital
closure of their interventional pain management centers. In August 2000, CMS implemented the
HOPD payment system in which interventional pain management ambulatory payment
classifications (APCs) were inconsistent with the mandate that the groups include services that
are alike clinically and in resource utilization. This resulted in hospitals refusing to schedule
necessary interventional pain management procedures in their operating rooms. ASIPP testified
before the APC panel, and presented new APC groupings for interventional pain management
procedures. ASIPP reclassification of APC groups for interventional pain procedures has resulted
in 2 APC groups including the above 9 codes. These include APC group 0206 and 0207.
ASIPP proposed a new classification for HOPD payments, which increased payments from $149
to $181 for interventional techniques in 2001 to $391 in 2007 for the 9 codes covered (APC
groups 0206 and 0207).
Impact Of CMS Proposed Rule On Interventional Pain Management
For 2008, CMS currently estimates that the revised ASC rates would be 62% of the
corresponding OPPS payment rates. Interventional pain management (IPM) treatments will be
particularly hard hit under this new system. Despite the fact that IPM accounts for only 15% of
all ASC procedures and 7% of all payments, 9 top IPM procedures will face a permanent
reduction of approximately 27% starting in 2009 (135% over five years). Most IPM treatments
would see a cut of at least 20% for 2008 and 2009 and as high as a 40% cut for 2009 onwards.
The top 9 procedures of the top 50 from 2004 ASC utilization data for interventional pain
management procedures include epidural injections (CPT 62310, 62311, 64483, 64484), facet
joint injections (CPT 64470, 64472, 64475, 64476), and sacroiliac joint injection (CPT 27096).
These constitute only 9 procedures of the top 50 and less than 0.3% of total expanded ASC list of
3,300 procedures.
Economically, the payments for these procedures of 642,058 in 2004 constituted approximately
$161 million. With a 10% increase on a yearly basis by 2010, these procedures will constitute
approximately 1.1 million with payments of approximately $285 million.
Even if ASCs are paid at 80% of the present HOPD payment rate, it will reduce the payments for
interventional procedures. The break even point would be at 90% of HOPD payment rate.
However, payment rates of 90% of HOPD will increase the ASC budget substantially.
Negative Effect On Patient Care
Even if the decision were made to pay ASCs 80% of the payment rates paid for hospital
outpatient department services, all IPM services would be paid well below current ASC rates, in
fact, less than it costs to purchase the supplies to perform the procedure.
Doctors will no longer perform these procedures in an ASC and patients seeking help for chronic
pain would be forced to receive care in the hospital outpatient setting. Using the HOPD for these
procedures will ultimately drive up overall costs in the Medicare program – the exact opposite
effect that CMS was hoping to ensure.
Recommendation
As CMS completes the final rule, we need to ensure that those patients suffering from chronic
and severe pain continue to have access to the procedures necessary to lead full and productive
lives. We would ask CMS to reevaluate its proposed rule to ensure that IPM procedures can
continue to be available in an ASC setting.
Contact Information
Thank you for your consideration. If you have any questions, please feel free to contact:
Tim Hutchinson
Senior Advisor (US House 93-96; US Senate 97-02)
Dickstein Shapiro LLP
1825 Eye Street NW
Washington DC 20006
HutchinsonT@dicksteinshapiro.com
Kathy Kulkarni
The Monument Group
1455 Pennsylvania Ave. NW, Suite 400
Washington, DC 20004
Tel (202) 652-2289
kk@monumentgroupdc.com
Randi Fredholm Hutchinson, Esq.
Dickstein Shapiro LLP
1825 Eye Street NW | Washington, DC 20006
Tel (202)420-5179 | Fax (202)420-2201
HutchinsonR@dicksteinshapiro.com
Laxmaiah Manchikanti, MD
Chief Executive Officer, ASIPP and SIPMS
Medical Director, Pain Management Center of Paducah
Associate Clinical Professor
Anesthesiology and Perioperative Medicine
University of Louisville, Kentucky
2831 Lone Oak Road
Paducah, KY 42003
Ph: 270-554-8373 ext. 101
Fax: 270-554-8987
E-mail: drm@apex.net.
Table 1. Top 9 Procedures from ASC 2004 Utilization data for IPM
HCPC
Short Description
ASC
ASC 2008
%
ASC 2009
%
2004
2007
Proposed
change
Proposed
change
Total
2004 Total
Allowed
Payment
Payment
from
Payment
from
Allowed
Charges
Rate
(with 50/50
2007
2007
Services
-27%
36388
(62% of
Transition)
2007 HOPD
final Rate)
62310
Inject spine c/t
$333
$293.08
-12%
$242.39
62311
Inject spine l/s (cd)
$333
$293.08
-12%
$242.39
-27%
230413
64483
Inj foramen
$333
$293.08
-12%
$242.39
-27%
107713
Inj foramen
$333
$293.08
-12%
$242.39
-27%
47094
64470
Inj paravertebral c/t
$333
$293.08
-12%
$242.39
-27%
13718
64472
Inj paravertebral c/t
$333
$276.51
-17%
$218.19
-34%
23379
$30,447,8
$7,932,48
$3,389,32
6
$3,614,97
6
add-on
Inj paravertebral l/s
66
7
epidural add-on
64476
42
$70,249,4
49
epidural l/s
64484
$11,081,6
$333
$276.51
-17%
$218.19
-34%
100563
$14,686,3
52
add-on
64475
Inj paravertebral l/s
$333
$293.08
-12%
$242.39
-27%
63126
27096
Inj for sacroiliac
$333
$276.51
-17%
$218.19
-34%
19664
joint anesth
$14,675,1
92
$4,706,29
0
(G0260)
Total
642,058
$160,783,
580
APC CPT/ HCPCS
Description
0206 G0260
Inj for sacroiliac jt anesth
0206 61791
Treat trigeminal tract
0206 62273
Inject epidural patch
0206 64410
N block inj, phrenic
0206 64412
N block inj, spinal accessor
0206 64421
N block inj, intercost, mlt
0206 64446
N blk inj, sciatic, cont inf
0206 64472
Inj paravertebral c/t add-on
0206 64476
Inj paravertebral l/s add-on
0206 64630
Injection treatment of nerve
0206 64640
Injection treatment of nerve
0207 62280
Treat spinal cord lesion
0207 62281
Treat spinal cord lesion
0207 62282
Treat spinal canal lesion
0207 62310
Inject spine c/t
0207 62311
Inject spine l/s (cd)
0207 62318
Inject spine w/cath, c/t
0207 62319
Inject spine w/cath l/s (cd)
0207 64470
Inj paravertebral c/t
0207 64475
Inj paravertebral l/s
0207 64479
Inj foramen epidural c/t
0207 64480
Inj foramen epidural add-on
0207 64483
Inj foramen epidural l/s
0207 64484
Inj foramen epidural add-on
0207 64510
N block, stellate ganglion
0207 64520
N block, lumbar/thoracic
0207 64530
N block inj, celiac pelus
0207 64623
Destr paravertebral n add-on
0207 64627
Destr paravertebral n add-on
0207 64680
Injection treatment of nerve