Saga of Payment Systems of Ambulatory
Surgery Centers for Interventional Techniques:
An Update
Authors: Manchikanti Laxmaiah 
Published: March 2021

The health care system in the United States has been criticized for skyrocketing expenditures and
quality deficits. Simultaneously, health care providers and systems are under pressure to provide
better and more proficient care. The landscape of the US health care system is shaped by federal
and private payers which continue to develop initiatives designed to curtail costs. These include
value-based reimbursement programs; cost-shifting expenses to the consumer and reducing
reimbursement of providers and facilities. Moreover, there is an underlying thought to steer
provision of health care to theoretically more efficient settings. Many of these initiatives are based
on affordable health care reform.
The major aspects of curtailing health care costs include hospital and other facility payments as well
as physician payments and reductions in the approved services. Consequently, ambulatory surgery
centers (ASCs) are not immune to these changes. Until 1970, all surgery was performed in hospitals
The development of ASCs and site of service differential payments for in-office procedures have
changed the dynamics of surgical trends with outpatient surgeries outpacing inpatient surgeries
by as early as 1989. By 2008, approximately 65% of procedures were performed in all outpatient
settings including hospital outpatient departments. ASCs claim that improved efficiency in health
care delivery allows patients to spend less time in the health care setting with quicker turn over,
improving the productivity of the health care team. However, since the majority of the ASCs are
owned, in part, by the physicians who staff them, the financial incentives related to ownership
have been alleged to potentially alter provider behavior.
The number of Medicare certified ASCs and total Medicare payments from 1999 to 2010 increased
significantly, but more recent year-to-year changes are far less substantial when compared to
previous years. Net percent revenue growth from 2008 to 2009 was 3.2% and from 2009 to
2010 was 6.2% with an overall increase from 1999 of 183% over a period of 11 years. Similarly,
the number of Medicare certified ASCs increased from 2,786 in 1999 to 5,316 in 2010, 1.1%
increased from 2009 to 2010, however, a 91% increase from 1999 over a period of 11 years.
Interventional pain management is one of the fastest growing specialties with a footprint in multiple
disciplines. Interventional pain management in ASC settings has come a long way since June 1998
proposed Health Care Financing Administration’s ASC rule which seriously compromised interventional
pain management in the ASC setting. There are many payment challenges facing interventional pain
management (IPM) in 2012. Significant changes continue to occur in the payment systems with policies
of paying a certain percent of hospital outpatient department payments to ASCs which declined from
63% in 2008 to 56% in 2011, with substantial reductions for add-on codes. The Centers for Medicare
and Medicaid Services (CMS) evaluation of IPM codes also consists of multiple misvalued codes.
In conclusion, overall the future of ASCs may appear optimistic, but in the near perspective,
specifically in 2012 to 2014, there will be challenging times specifically for interventional pain
management centers with the regulatory environment and rapid changes taking place with or
without implementation of Affordable Care Act.
Key words: Outpatient prospective payment system, ambulatory surgery center payment system,
Government Accountability Office, Medicare Modernization and Improvement Act, interventional
techniques