Johns Hopkins HealthCare LLC Policy Number CMS23.05 Medical … · Version 2.0.51 Policy Number CMS23.05 Effective Date 10/01/2019 Johns Hopkins HealthCare LLC Medical Policy Medical

Version 2.0.51

Policy Number CMS23.05

Effective Date 10/01/2019

Johns Hopkins HealthCare LLCMedical PolicyMedical Policy

Review Date 08/20/2019

Revision Date 08/20/2019Subject

Site of ServicePage 1 of 9

This document applies to the following Participating Organizations:

Priority Partners US Family Health Plan

Keywords: ASA, Site of Service

Table of Contents Page Number

I. ACTION 1II. POLICY DISCLAIMER 1III. POLICY 1IV. POLICY CRITERIA 2V. DEFINITIONS 4VI. BACKGROUND 5VII. CODING DISCLAIMER 5VIII. CODING INFORMATION 6IX. REFERENCE STATEMENT 6X. REFERENCES 6XI. APPROVALS 9Appendix A: Appendix A Site of Service Procedure Codes Click Here

I. ACTION New Policy

X Revising Policy Number CMS23.05

Superseding Policy Number

Archiving Policy Number

Retiring Policy Number

II. POLICY DISCLAIMERJohns Hopkins HealthCare LLC (JHHC) provides a full spectrum of health care products and services for Employer HealthPrograms, Priority Partners, Advantage MD and US Family Health Plan. Each line of business possesses its own uniquecontract and guidelines which, for benefit and payment purposes, should be consulted first to know what benefits are availablefor coverage.

Specific contract benefits, guidelines or policies supersede the information outlined in this policy.

III. POLICYA. The purpose of this policy is to provide clinical guidance for site of service redirection.B. This policy applies to PPMCO & USFHP members 18 years and older, and addresses site of service redirection for

network providers. For select ear nose & throat (ENT) procedures this policy is applicable to all ages.C. For applicable procedures codes refer to the Appendix A link above.

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D. Network providers will receive the required advance notification prior to inclusion of additional applicable procedurecodes to this policy. For advance notification of updates to applicable procedure codes also refer to JHHC ProviderCommunications.

E. It is the policy of Johns Hopkins HealthCare (JHHC) to apply criteria to determine whether an outpatient hospital site ofservice is medically necessary, or if a procedure may be safely and effectively performed at a network ambulatory surgerycenter.

F. This policy takes into consideration the individual needs of the member and the availability of services in the localdelivery system and their ability to meet the member’s needs.

IV. POLICY CRITERIAA. JHHC uses the following guidelines for PPMCO & USFHP members 18 years and older in the utilization review process

for surgeries and procedures when the requested site of service is in an outpatient hospital setting. 1. Surgery/Procedure Considerations

a. JHHC follows CMS guidelines when determining surgeries and procedures that may be appropriate forambulatory surgery center settings. Refer to the Addendum AA, BB, DD1, DD2 and EE file: CMS ASCRegulations and Notices

2. Medical Considerationsa. American Society of Anesthesiologists® Physical Status (ASA PS) score will be reviewed and members with

ASA® PS score III or higher will be considered for approval in a hospital-based setting.b. Certain medical conditions/comorbidities make outpatient surgery in an Ambulatory Surgery Center too high

risk. The outpatient hospital setting will be considered appropriate for members with any of the followingconditions/comorbidities including but not be limited to:i. Cardiovascular risk

• New York Heart Association (NYHA) Class III or IV or decompensated heart failure• Coronary Artery Disease

• Unstable coronary syndrome• Recent coronary intervention

• Plain angioplasty within 90 days• Bare metal stents (BMS) placed within 90 days• Drug eluting stents (DES) placed within 1 year• Myocardial infarction within 3 months

• Uncontrolled/difficult to control hypertension• Significant or new onset cardiac arrhythmia• Significant valvular heart disease• Implanted pacemaker/AICD

ii. Neurological Risk• Cerebrovascular accident (CVA) or transient ischemic attack (TIA) within 3 months• Preexisting dementia or cognitive impairment (increased risk of post-operative delirium with use of

psychoactive and sedative-hypnotic medications)iii. Endocrine risk

• Uncontrolled/difficult to control diabetes• Uncontrolled/difficult to control thyroid disease• Uncontrolled/difficult to control adrenal disease

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• Uncontrolled/difficult to control pituitary diseaseiv. Liver Risk

• Liver disease with Model for End-Stage Liver Disease (MELD) Score >8v. Pulmonary risk

• Severe chronic obstructive pulmonary disease (COPD) (FEV1<50%)• Uncontrolled asthma (active symptoms or FEV1 <80% despite treatment• Moderate to severe obstructive sleep apnea (OSA), or OSA with unmanaged comorbidities• Moderately severe to severe restrictive lung disease (e.g. pulmonary fibrosis) (TLC ≤ 60% of

predicted)vi. Renal risk

• Severe (Stage 4) renal disease (estimated GFR 15-29 mL/min per 1.73m2)• End stage (Stage 5) renal disease (on dialysis)

vii. Other medical conditions and situations• BMI > 50• BMI 40-50 with obesity-related condition or unmanaged comorbidities• Pregnancy• Bleeding disorder requiring replacement factor, blood products, or special infusion product

(excluding DDAVP/Desmopressin)• Alcohol dependence• Recent history of drug abuse• Anesthesia complications (personal or family history)• Arterial or venous thromboembolism within 1 month• Post-operative ventilation anticipated• Transfusion anticipated• Significant blood loss anticipated• Surgery >3 hours anticipated• Difficult airway anticipated• History of anaphylaxis to medication, latex or iodine• Significant geriatric frailty defined as 3 or more of the following:

• Unintentional weight loss # 10 lbs. in prior year or # 5% weight loss in prior year• Weakness (grip strength in the lowest 20% at baseline)• Poor endurance and energy • Slowness (slow walking speed)• Low physical activity level

c. Additional medical considerations (require secondary medical review with a medical director for approval foroutpatient hospital setting):i. Indications not listed, including other chronic unstable conditions affecting a major organ (heart, lung,

liver, kidney, brain) that may predispose the member to complications

B. For PPMCO & USFHP members younger than 18 years of age pediatric ENT procedures (e.g. Adenoidectomy,Tonsillectomy, Tympanostomy, Tympanoplasty, Myringotomy, Septoplasty) may be approved at outpatient hospital siteof service when any of the following conditions are present: 1. Members with the following comorbidities:

a. Craniofacial abnormities (e.g. Down syndrome, Pierre Robin syndrome, etc.)

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b. Mucopolysaccharoidosesc. Hemoglobinopathyd. Congenital neuromuscular disease e. Congenital cardiovascular diseasef. Congenital pulmonary diseaseg. Severe obstructive sleep apnea syndrome (OSAS) - apnea-hypopnea index of 10 or more obstructive events/

hour, oxygen saturation nadir less than 80%, or bothh. Morbid obesity - BMI above the 95th percentile

2. Presence of peritonsillar abscess or tonsillar malignancy3. The member was assigned ASA PS score of III or higher based on preoperative assessment4. ASC does not have adequate resources to provide safe and effective surgical care (as stated/ documented by the

surgeon or ASC)

C. Documentation requirements include but are not limited to: 1. Physician notes with all pertinent clinical information to support necessity for site of service in the outpatient

hospital setting.

V. DEFINITIONSAmerican Society of Anesthesiologists® Physical Status (ASA PS) Score (American Society of Anesthesiologists, 2018)

• ASA I: A normal healthy patient• ASA II: A patient with mild systemic disease• ASA III: A patient with severe systemic disease• ASA IV: A patient with severe systemic disease that is a constant threat to life• ASA V: A moribund patient who is not expected to survive without the operation• ASA VI: A declared brain-dead patient whose organs are being removed for donor purpose

Medical Necessity Review: A process to consider whether a covered service is clinically appropriate based on evidence-basedclinical standards of care. Medically necessary services are accepted health care services provided by health care entities,appropriate to evaluation and treatment of a disease, condition, illness or injury (NCQA).

Site of Service

• Office: Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center,State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provideshealth examinations, diagnosis, and treatment of illness or injury on an ambulatory basis (Place of Service Code, 11)(Centers for Medicare & Medicaid Services, 2018).

• Off Campus-Outpatient Hospital: A portion of an off-campus hospital provider based department which providesdiagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do notrequire hospitalization or institutionalization (Place of Service Code, 19) (Centers for Medicare & Medicaid Services,2018).

• On Campus-Outpatient Hospital: A portion of a hospital’s main campus which provides diagnostic, therapeutic (bothsurgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization orinstitutionalization (Place of Service Code, 22) (Centers for Medicare & Medicaid Services, 2018).

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• Ambulatory Surgery Center (ASC): A freestanding facility, other than a physician’s office, that operates for the purposeof providing surgical services to patients on an ambulatory basis, not requiring hospitalization and in which the expectedduration of services would not exceed 24 hours following an admission (Place of Service Code, 24) (Centers for Medicare& Medicaid Services, 2018).

VI. BACKGROUNDSince the early 1980s, there has been substantial growth in the prevalence of outpatient surgeries, with over 32.0 millionprocedures performed in 2005 (Munnich, 2014). Analysts at the CDC have suggested that medical advancements andtechnological advancements (including improvements in anesthesia and pain control methods, and the increased utilization ofless invasive procedures) were the two major drivers for this change (Hall, 2017).

As per the American Society of Anesthesiologists®, outpatient surgery is also referred to as “same-day, ambulatory, oroffice-based surgery” (American Society of Anesthesiologists, 2018). Ambulatory surgery can be performed in the hospitalsetting (referred to as “hospital outpatient department surgery”) or in facilities independent of the hospital setting (referredto as ambulatory surgery centers, or ASCs) (Hall, 2017). Differences between the two sites include services provided, as anoutpatient hospital department can provide additional services beyond outpatient surgery, while an ASC is structured to provideonly those services in support of the ambulatory procedure (Munnich, 2014).

Not all outpatient surgeries are identified as being appropriate for both sites of service (CMS.gov, 2018). Since the early 1980s,however, there has been considerable growth in the number of surgeries that can be performed in ambulatory surgery centers,and therefore an increase in the percentage of all outpatient surgeries that are performed in this site of service (Munnich, 2014).As of 2018, there were around 3,500 Healthcare Common Procedure Coding System (HCPCS) codes that Centers for Medicareand Medicaid Services (CMS) would cover in the ASC setting (MedPAC, 2018).

The appropriate site of service for outpatient procedures is dependent on multiple factors. These include, but are not limitedto, the procedure itself, the health status of the patient, and the accessibility of the site of service for both the provider andthe patient. It has been suggested in the literature that there is significant cost-saving potential for site of surgery in theambulatory surgery center as compared to the outpatient hospital setting, making this an important consideration (Munnich,2014; American Society of Anesthesiologists, 2018). Ultimately, site of service determination for outpatient surgery is animportant step in the provision of cost-effective, appropriate, high-quality medical care.

VII. CODING DISCLAIMERCPT Copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the AmericanMedical Association.

Note: The following CPT/HCPCS codes are included below for informational purposes and may not be all inclusive. Inclusionor exclusion of a CPT/HCPCS code(s) below does not signify or imply that the service described by the code is a covered ornon-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan documentand applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right toreimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

Note: All inpatient admissions require preauthorization.

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Compliance with the provision in this policy may be monitored andaddressed through post payment data analysis and/or medical review audits

Employer Health Programs(EHP) refer to specificSummary Plan Description(SPD). If there is no criteriain the SPD, apply theMedical Policy criteria.

Priority Partners (PPMCO)refer to COMAR guidelinesthen apply the MedicalPolicy criteria.

US Family Health Plan(USFHP), TRICAREMedical Policy supersedesJHHC Medical Policy.If there is no Policy inTRICARE, apply theMedical Policy Criteria.

Advantage MD, LCDand NCD Medical Policysupersedes JHHC MedicalPolicy. If there is no LCDor NCD, apply the MedicalPolicy Criteria.

VIII. CODING INFORMATIONCPT CODES DESCRIPTION

Multiple Codes - Refer to Appendix A for applicable codes

IX. REFERENCE STATEMENTAnalyses of the scientific and clinical references cited below were conducted and utilized by the Johns Hopkins HealthCareLLC (JHHC) Medical Policy Team during the development and implementation of this medical policy. The Medical PolicyTeam will continue to monitor and review any newly published clinical evidence and revise the policy and adjust the referencesbelow accordingly if deemed necessary.

X. REFERENCESAmerican Society of Anesthesiologists. (2018). Clinical information physical status classification system. Retrieved: https://www.asahq.org

American Society of Anesthesiologists. (2014). Practice Guidelines for the Perioperative Management of Patients withObstructive Sleep Apnea: An Updated Report by the American Society of Anesthesiologists Task Force on PerioperativeManagement of Patients with Obstructive Sleep Apnea. Anesthesiology, 120, 268-286. https://anesthesiology.pubs.asahq.org

American Society of Anesthesiologists. (2018). Preparation-outpatient surgery. Retrieved: AHQ https://www.asahq.org

Ambulatory pediatric otolaryngologic procedures in the United States: characteristics and perioperative safety.

Bhattacharyya. N. (2010). Ambulatory pediatric otolaryngologic procedures in the United States: characteristics andperioperative safety. Laryngoscope, 120(4), 821-825. https://www.ncbi.nlm.nih.gov/

Bhattacharyya. N. (2011). Benchmarks for the durations of ambulatory surgical procedures in otolaryngology. Annals ofOtology, Rhinology & Laryngology, 120(11), 721-731. https://www.ncbi.nlm.nih.gov

Brack, T., Jubran, A., Tobin, M. J. (2002). Dyspnea and Decreased Variability of Breathing in Patients with Restrictive LungDisease. American Journal of Respiratory and Critical Care Medicine. Vol. 165, No. 9. Retrieved: https://www.atsjournals.org

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Caronia, J. R. Restrictive Lung Disease. (2018). Medscape. Retrieved: https://emedicine.medscape.com

Centers for Medicare & Medicaid Services. Place of Service Code Set. [Accessed September 26, 2018]. Retrieved: https://www.cms.gov.

Collins, C. (2015). Ambulatory anesthetic care in pediatric tonsillectomy: challenges and risks. Ambulatory Anesthesia, 2.121-129. https://www.dovepress.com/ambulatory-anesthesia.

CMS.gov. (2018) ASC Regulations and Notices, https://www.cms.gov

Dabu-Bondoc, S., Shelley, K.H. (2015). Management of comorbidities in ambulatory anesthesia: a review. AmbulatoryAnesthesia. 2015(2): 39-51. Retrieved: https://www.dovepress.com

Dweik, R.A. (2011). Interpretation of Common Lung Function Tests. Cleveland Clinic. Retrieved: http://www.clevelandclinicmeded.com

Fong, R., Sweitzer, B.J. (2014). Preoperative Optimization of Patients Undergoing Ambulatory Surgery. CurrentAnesthesiology Reports. 4: 303-315. Retrieved: https://link.springer.com

Fong, T. G., Davis, D. Growdon, M. E., et al. (2015). The interface of Delirium and Dementia in Older Persons. The Lancet,Neurology. Vol. 14, Issue 8. p. 823-832. Retrieved: https://www.ncbi.nlm.nih.gov

Fried, L. P., Tangen, C. M., Walston, J. et al. (201). Frailty in Older Adults: Evidence of Phenotype. The Journals ofGerontology: Series A, Vol. 56, Issue 3, p. M146-M157. Retrieved: https://academic.oup.com

Goldfarb, C.A., Bansal, A., Brophy, R.H. (2017). Ambulatory Surgical Centers: A Review of Complications and AdverseEvents. J Am Acad Orthop Surg. 25: 12-22. Retrieved: https://insights.ovid.com

Goyal, S.S., Shah, R., Roberson, D.W., Schwartz, M.L. (2013). Variation in post-adenotonsillectomy admission practices in 24pediatric hospitals. Laryngoscope, 123(10), 2560-2566. https://www.ncbi.nlm.nih.gov/pubmed/23907959/

Hall, M.J., Schwartzman, A., Zhang, J., Liu, X. (2017). Ambulatory Surgery Data From Hospitals and Ambulatory SurgeryCenters: United States, 2010. National Health Statistics Report. 102: 1-15. Retrieved: https://www.cdc.gov

Han, J.K., Stringer, S.P., Rosenfeld, R.M., Archer, S.M., Baker, D.P., Brown, S.M....Nnacheta, L.C. (2015). Clinical consensusstatement: Septoplasty with or without inferior turbinate reduction. Otolaryngology - Head and Neck Surgery. 153(5), 708-720.https://www.ncbi.nlm.nih.gov/pubmed/26527752

Inker, L. A., Astor, B. C., Fox, C. H. (2014). KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for theEvaluation and Management of CKD. American Journal of Kidney Disease. Vol. 63. Issue 5, p. 713-735. Retrieved: https://www.ajkd.org

InterQual® Procedures Criteria. (2018.2). Subset: Adenoidectomy (Pediatric).

InterQual® Procedures Criteria. (2018.2). Subset: Septoplasty (Adolescent).

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InterQual® Procedures Criteria. (2018.2). Subset: Tonsilectomy (Pediatric).

InterQual® Procedures Criteria. (2018.2). Subset: Tympanoplasty (Pediatric).

InterQual® Procedures Criteria. (2018.2). Subset: Tympanostomy Tube (Pediatric).

Joshi, G,P., Ahmad, S., Riad, W., Eckert, S., Chung, F. (2013). Selection of obese patients undergoing ambulatory surgery: asystematic review of the literature. Anesthesia & Analgesia. 117(5):1082-91. Retrieved: https://insights.ovid.com

Kaiser Permanente. (2012). KPCO Guidelines for Determining Appropriate Ambulatory Surgery Venue. Retrieved: http://info.kaiserpermanente.org

Kataria, T., Cutter, T.W., Apfelbaum, J.L. (2013). Patient Selection in Outpatient Surgery. Clinics Plastic Surg. 40(3): 371-382.Retrieved: https://www.plasticsurgery.theclinics.com

Lam, D.J., Jensen, C.C., Mueller, B.A., Starr, J.R., Cunningham, M.L., Weaver, E.M. (2010). Pediatric sleep apneaand craniofacial anomalies: A population-based case-control study. Laryngoscope, 120(10), 2098-2105. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4826142/

Mathews, D.M., Twersky, R.S. (2008) Adult Clinical Challenges. In: Twersky R.S., Philip B.K. (eds) Handbook ofAmbulatory Anesthesia. Springer, New York, NY.

MedPAC. Medicare Payment Policy (2018). [Accessed September 12, 2018] Report to the Congress. Available at: http://www.medpac.gov

Mohanty, S., Rosenthal, R. A., Russell, M. M. et al. (2016). Optimal Perioperative Management of the Geriatric Patient: ABest Practices Guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. Journal of theAmerican College of Surgeons. Vol. 222, Issue 5, p. 930-947. Retrieved: https://www.journalacs.org

Munnich, E.L., Parente, S.T. (2014). Procedures take less time at ambulatory surgery centers, keeping costs down and ability tomeet demand up. Health Affairs. 33(5): 764-769. Retrieved: https://www.healthaffairs.org

National Committee for Quality Assurance (NCQA). (2018). Standards and Guidelines for the Accreditation of Health Plans,Definition - Medical Necessity Review. Citation:

National Heart, Lung, and Blood Institute of the National Institute of Health. (2007). The Expert Panel Report 3: Guidelines forthe Diagnosis and Management of Asthma. Retrieved: https://www.nhlbi.nih.gov

Pasternak, L.R. (2008). Preanesthesia Evaluation and Testing. In: Twersky R.S., Philip B.K. (eds) Handbook of AmbulatoryAnesthesia. Springer, New York, NY. Retrieved: https://the-eye.eu

Pennsylvania Patient Safety Authority. (2009). Patient Screening and Assessment in Ambulatory Surgical Facilities.Pennsylvania Patient Safety Advisory. 6(1): 3-9. http://patientsafety.pa.gov.

Polaner, D.M., Houck, C.S. (2015). Critical elements for the pediatric perioperative anesthesia environment. Pediatrics 136(6).https://pediatrics.aappublications.org

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Premera Blue Cross. (2018). Utilization Management Guideline 11.01.524, Site of Service: Select Surgical Procedures.Retrieved: https://www.premera.com

Qaseem, A., Snow, V., Fitterman, N., Hornbake, E.R., Lawrence, V.A., Smetana, G.W., et al. (2006). Risk Assessment forand Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: AGuideline from the American College of Physicians. Annals of Internal Medicine ;144:575–580. Retrieved: http://annals.org

Raman, V.T., Jatana, K.R., Elmaraghy, C.A. Tobias, J.D. (2014). Guidelines to decrease unanticipated hospital admissionfollowing adenotonsillectomy in the pediatric population. International Journal of Pediatric Otorhinolaryngology, 78(1), 19–22. https://www.ncbi.nlm.nih.gov/pubmed/2423902

Rao, A., Polanco, A., Qiu, S., Kim, J., Chin, E.H., Divino, C.M., Nguyen, S.Q. (2013). Safety of outpatient laparoscopiccholecystectomy in the elderly: analysis of 15,248 patients using the NSQIP database. Journal of the American College ofSurgeons. 217(6):1038-43. Retrieved: https://www.journalacs.org

Rodman, R., Boehnke, M., Venkatesan, N., Pine, H. (2013). Discharge after tonsillectomy in pediatric sleep apnea patients.International Journal of Pediatric Otorhinolaryngology, 77(5), 682-685. https://www.ncbi.nlm.nih.gov/pubmed/23433995

Roland, P.S., Rosenfeld, R.M., Brooks, L.J., Friedman, N.R., Jones, J., Kim, T.W....Roberson, P. (2011). Clinical practiceguideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngology Head NeckSurgery 145(1), S1-15. https://www.ncbi.nlm.nih.gov/pubmed/21676944

Shah, R.K., Welborn, L., Ashktorab, S., Stringer, E., Zalzal, G.H. (2008). Safety and outcomes of outpatient pediatricotolaryngology procedures at an ambulatory surgery center. Laryngoscope, 118(11) 1937-1940. https://www.ncbi.nlm.nih.gov/.

Sweitzer, B.J. (2018). Preanesthesia evaluation for noncardiac surgery. In M Crowley (Ed.), UpToDate. Retrieved: August 22,2018 from https://www.uptodate.com.

Tweedie, D.J., Bajaj, Y., Ifeacho, S.N., Jonas, N.E., Jephson, C.G., Cochran, L.A....Wyatt, M.E. (2012). Peri-operativecomplications after adenotonsillectomy in a UK pediatric tertiary referral centre. International Journal PediatricOtorhinolaryngology, 76(6), 809-815. https://www.ncbi.nlm.nih.gov/pubmed/22469495

United Healthcare. (2018). Site of Service Guidelines for Certain Outpatient Surgical Procedures. URG-11.03. Retrieved:https://www.uhcprovider.com

Xue, Q-L. (2011). The Frailty Syndrome: Definition and Natural History. Clinics in Geriatric Medicine. Volume 27, Issue 1, P.1-15. Retrieved: https://www.geriatric.theclinics.com

Whippey, A., Kostandoff, G., Paul, J., Ma, J., Thabane, L., Ma, H.K. (2013). Predictors of unanticipated admission followingambulatory surgery: a retrospective case-control study. Canadian Journal of Anesthesia. 60:675–683. Retrieved: https://link.springer.com

XI. APPROVALSHistorical Effective Dates: 01/02/2019, 10/01/2019

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