Understanding the 2024 CMS ASC Covered Procedures List: Total Shoulders and Beyond
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By: Paul Cadorette, CPC, COC, CPC-P, COSC, CASCC, Director of Education, nimble solutions
Big news for the ambulatory surgery industry: starting January 1, 2024, Medicare and Medicaid beneficiaries requiring Total Shoulders (Total Shoulder Arthroplasty) can receive care in the ASC setting.
Traditionally, the Centers for Medicare & Medicaid Services (CMS) restricted these surgeries to hospitals or hospital outpatient departments (HOPDs). But come next year, Total Shoulder Arthroplasty has finally made its way onto the ASC Covered Procedures List (ASC-CPL), as well as Total Ankle and eight other surgical procedures.
The ASC setting became an increasingly popular choice for total joints after outpatient Total Knee replacements were eligible for Medicare in 2020, followed by Total Hip replacements in 2021. While most industry experts were surprised to see that Total Shoulders were not included in the ASC-CPL in 2022 or 2023, CMS didn’t offer any indication that Total Shoulders would be considered in 2024.
Why the Sudden Shift in CMS Policy?
CMS didn’t provide any details regarding the decision to approve Total Shoulders for the ASC setting; however, the move seems to indicate an effort to:
1. Control healthcare costs,
2. Recognize the safety and effectiveness of the ASC setting,
3. Acknowledge the use of new surgical technology and techniques that speed up recovery time on what once was an overnight procedure.
This blog post dives deeper into these factors, exploring the impact of the 2024 ASC-CPL as a whole in terms of what this means for patients, ASCs, and the 2024 healthcare landscape.
The Rising Cost of Total Shoulders
The overall increased volume of Total Shoulder procedures in the United States certainly factors into today’s healthcare costs. Back in 2017, the U.S. Agency for Healthcare Research and Quality estimated about 53,000 shoulder replacement surgeries were performed annually in the U.S., and more than 900,000 hip and knee replacement surgeries were being performed each year.
Fast forward to today, and those numbers are shifting. Total Shoulder replacements are becoming more prevalent, outnumbering Total Hip replacements by twofold and even surpassing Total Knee replacements by threefold.
Tens of thousands of patients with commercial insurance have been opting for safe, effective Total Shoulder surgeries in ASCs every year. This decision can save patients and their commercial insurers thousands of dollars per surgery, ultimately encompassing millions of dollars of savings when compared to costs incurred in HOPDs and in-patient settings.
It’s reasonable to assume CMS may have approved Total Shoulders for the ASC-CPL to control healthcare expenses on a high-volume procedure that’s becoming more and more common.
Why ASCs are Safe and Effective Options for Total Joints
Consumer surveys have shown 78% of orthopedic patients prefer ASCs over hospital or hospital outpatient (HOPD) settings due to lower costs and higher quality of care.
For example, ASCs provide one-to-one nursing care, which is often not possible in the hospital setting.
Additionally, patients experience a lower infection rate in ASCs, and research has demonstrated the safety and effectiveness of ASCs for Total Shoulders, even for patients with glenoid bone loss.
ASC surgeons also evaluate patient health risks with a critical lens. They screen all potential patients to determine if in-patient or outpatient is a better setting due to existing health conditions.
For instance, ASCs have been performing Rotator Cuff repairs and replacements on CMS beneficiaries, and the Total Shoulder Arthroplasty patient population and demographic is much the same: half are under 75 years of age, and one-third do not have chronic health conditions, making them ideal candidates for the lower cost, better value, more efficient ASC setting.
For the patients that do opt for surgery in the hospital setting, 80% are going home on the same day from hospital, which equates to a higher cost for same-day surgery.
Advancements in Pain Management
The reason why patients are able to return home from the hospital the same day, even when they were originally scheduled for an overnight inpatient stay, is due to new pain management techniques.
For example, using ultrasound-guided nerve blocks (UGNBs) for pain blocks improves efficacy, efficiency, and safety when compared to the blind approach. In fact, this method decreases the amount of medication typically prescribed for joint replacement procedures.
ASCs utilize UGNBs and long-acting local anesthetics that can last up to 72 hours to get patients through the most painful part of the surgery without relying on narcotics. This avoids potentially dangerous and adverse side effects with opioid medications, non-opioid adjuncts, and procedural sedation. Plus, most patients can be prescribed Motrin for pain management at home due to advancements in anti-inflammatory medication.
In terms of shoulder surgery, or upper extremity procedures, patients have better mobility compared to hip or knee replacements because they can get up and walk after surgery.
Between the improved safety, efficiency, and cost-effectiveness of outpatient settings, there’s not much of a reason for CMS to restrict patients to the hospital setting for Total Shoulder Arthroplasty.
CMS’s 2024 CPT Codes for Total Shoulders and Newly Added Procedures
With new ASC procedures comes new Current Procedural Terminology (CPT) codes for 2024. Accurate coding is essential for proper billing and reimbursement.
Notably, CMS added two codes — CPT 23470 and 23472 — for Total Shoulder replacements as well as codes for total ankle replacement, hip tendon incision, meniscal knee replacement, and repeat thyroid surgery.
Here are the 11 new surgical codes for 2024:
CPT Code 21194: Reconstruction of lower jaw with graft
CPT Code 21195: Reconstruction of lower jaw without fixation
CPT Code 23470: Reconstruction of shoulder joint
CPT Code 23472: Reconstruction of shoulder joint
CPT Code 27006: Incision of hip tendons
CPT Code 27702: Reconstruction of ankle joint
CPT Code 29868: Meniscal transplant knee with scope
CPT Code 33289: TCAT implantation of wireless pulmonary artery pressure sensor
CPT Code 37192: Insertion of intravascular vena cava filter
CPT Code 60260: Repeat thyroid surgery
CPT Code C9734: Ultrasound ablation/therapeutic intervention, other than uterine leiomyomata
Access the Medicare ASC Final Rule to learn more about these codes and other important updates, including the latest requirements for the ASC Quality Reporting (ASCQR) Program.
Final Thoughts on Total Shoulders
ASCs have been able to implement efficient processes that facilitate patients’ quick and safe recovery after total joint surgeries such as specialized pre-operative assessments, optimized anesthesia protocols, and dedicated post-operative care.
Due to these factors, orthopedic surgeons are currently performing a majority of their total hip, total knee, and/or total shoulder replacements as outpatient same-day surgeries. Experts project that 51% of joint replacements will be performed on an outpatient basis by 2026.
Now that CMS beneficiaries are eligible for additional total joint procedures in the ASC setting, the volume of cases migrating to the outpatient setting could potentially increase. Adding total joint replacements such as Total Shoulders your ASC’s service line can prove be a smart investment in 2024 and beyond.
To improve your knowledge of shoulder procedures, including when to report CPT code 29826 versus 29824, join us for clarification in our on-demand 2023 Shoulders coding course, which includes shoulder updates from the AMA.
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