CMS may drop four urologic procedures from ASC coverage

March 1, 2005

Washington—Officials at the Centers for Medicare & Medicaid Services have recommended that several urologic procedures be ineligible for reimbursement if they are performed in ambulatory surgical centers.

According to AUA President Brendan M. Fox, MD, what CMS has in mind is a bad idea and indicates that bureaucrats were looking at numbers and "site-of-service data" rather than the actual needs of pa-tients, including the basic "anatomic differences" between men and women.

With that in mind, Dr. Fox, on behalf of AUA, questioned whether the changes proposed by CMS should even be considered.

"We urge CMS to consider whether it is appropriate to disrupt the current Medicare ASC payment system to such a great degree by deleting urology codes and other procedures from the list when reform is imminent within the next 3 years," Dr. Fox said in a letter to CMS Administrator Mark McClellan, MD, PhD.

The changes were proposed late last November, some as a result of recommendations made in January 2003 by the De-partment of Health and Human Services Office of Inspector General. On its web site, AUA urges members to contact CMS to explain why the proposed deletions would be inadvisable and, in some cases, would actually result in higher costs to Medicare if patients must visit hospital outpatient departments instead of an ASC.

Dr. Fox noted that the "site-of-service data" relied upon by CMS "is not an appropriate basis for making payment decisions because it does not account for practice patterns that vary by patient gender."

"Anatomical differences between men and women affect site-of-service decisions," he said. "Male patients, due to anatomic differences and the increased frequency of bladder outlet obstruction due to enlarged prostates, are likely to incur more discomfort from cystoscopic procedures; are more likely to require anesthesia than women; and are more likely to undergo cystoscopy in a facility.

"CMS data does not distinguish based on patient gender, and female cystoscopies skew the site-of-service data."

Dr. Fox noted that CMS proposed to delete the codes from the ASC list in 1993 but agreed not to do so on the advice of medical staff and consultants.

"We urge CMS to once again retain these procedures on the ASC list for the same reasons," he said, adding that Medicare statistics indicate that "there is a core group of beneficiaries for whom the facility setting is necessary."

Dr. Fox also noted that ASCs with urologic experience may not be available in some communities, while in others, local outpatient departments may lack urologic specialization. In some communities, he added, physician offices may not be equipped to do certain procedures or local laws may preclude physicians from performing certain office surgeries unless they are certified.