Every year, healthcare leaders review CMS updates to understand which procedures may be performed in the ambulatory surgery center setting. The proposed CY2027 rule has generated significant discussion due to the continued expansion of procedures eligible for ASC reimbursement.
When a procedure appears on a CMS list, many organizations immediately ask:
"Can we perform this procedure in our ASC?"
The better question is:
"Has our organization completed the analysis necessary to safely and appropriately offer this procedure?"
One of the most common misconceptions in healthcare is that CMS approval alone determines whether a procedure belongs in an ASC. In reality, CMS is only one consideration among several. We saw this firsthand with total joint procedures, where some facilities performed them successfully long before CMS reimbursement existed, because state regulations, payer coverage, facility capability, and governing body approval supported the service.
Adding a procedure is not a reimbursement decision.
It is a governance decision.
Before a procedure should be added to a facility's Delineation of Privileges (DOP) or operating schedule, it should successfully pass through four independent gates.
CMS establishes what Medicare will reimburse in the ASC setting.
This matters, particularly for facilities serving Medicare beneficiaries. However, CMS reimbursement is neither a clinical endorsement nor a determination that every ASC is capable of safely performing the procedure. CMS answers one question:
Will Medicare pay for this procedure in an ASC setting?
It does not answer whether your organization should perform it.
The next consideration is state law and facility licensure requirements.
A procedure may be clinically appropriate and financially viable, yet still fall outside a state's scope-of-service limitations, anesthesia regulations, licensure provisions, or other operational requirements.
When state requirements are more restrictive, the state standard controls
Payers have their own rules.
Coverage determinations, prior authorization requirements, site-of-service restrictions, reimbursement methodologies, implant carve-outs, and medical policies all impact whether a procedure makes financial sense for a facility.
A procedure that is medically appropriate and operationally feasible may still create significant financial exposure if payer requirements have not been fully evaluated.
Many facilities discover too late that a procedure allowed by CMS and permitted by the state is not covered by a key commercial payer within their market.
The final gate is often the most important.
The governing body must determine whether the facility is equipped, staffed, trained, and operationally prepared to perform the procedure safely.
This evaluation extends beyond the practitioner requesting the privilege. It includes questions such as:
Even when CMS, the state, and payers all say "yes," the governing body may appropriately determine the organization is not ready.
That is not a failure.
That is governance.
Many organizations make another mistake after passing the Four Gates.
They assume approval means implementation is complete.
In reality, approval is where the operational work begins.
Before the first case is ever scheduled, organizations should address:
Practitioner Qualifications
Facility Readiness
Employee Competency
Policies and Documentation
Financial Readiness
Quality and Safety Oversight
Each of these steps contributes to patient safety, operational readiness, and defensible governance.
As healthcare continues to evolve, ASC leaders will have more opportunities than ever to expand services, adopt new technologies, and introduce new procedures.
Those decisions should never be driven by reimbursement alone.
The strongest organizations recognize that adding a procedure is not simply a scheduling decision. It is a multidisciplinary governance process that requires regulatory review, financial analysis, operational readiness, quality oversight, and formal approval.
The Four Gates Framework helps ensure that decisions are viewed through all of these lenses before a patient ever enters the operating room.
Because at the end of the day, every privilege granted represents a commitment that the organization has evaluated not only whether a procedure can be performed, but whether it can be performed safely, competently, and responsibly within that facility.
And that is the foundation of patient safety.