(Manual Name)

10.4 - Coverage of Services in ASCs That Are Not ASC Facility Services or Covered Ancillary Services  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  Physicians Services - This category includes most covered services performed in ASCs that are not considered ASC services.  Physicians who furnish services in ASCs may bill for and receive separate payment under Part B.  Physicians services include the services of anesthesi ologists administering or supervising the administration of anesthesia to beneficiaries in ASCs and the beneficiaries recovery from the anesthesia.  The term physicians services also includes any routine pre - or post - operative services, such as office v isits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other services which the individual physician usually includes in the fee for a given surgical procedure.   Implantable Durable Medical Equipment (DME) -  If the ASC furn ishes items of implantable DME to patients, the ASC bills and receives a single payment from the local contractor for the covered surgical procedure and the implantable device, as long as the implantable device does not have pass -through status under the O PPS.  When the surgical procedure is not on the ASC list, the physician bills for his or her professional services and the ASC may bill the beneficiary for the facility charges associated with the procedure.   Non-implantable Durable Medical Equipment  - If the ASC furnishes items of non-implantable DME to beneficiaries, it is treated as a DME supplier, and all the rules and conditions ordinarily applicable to DME are applicable, including obtaining a supplier number and billing the DME MAC where applic able.   Prosthetic Devices  Prior to January 1, 2008, an ASC was allowed to bill and receive separate payment for implantable prosthetic devices, other than intraocular lenses (IOLs) that were implanted, inserted, or otherwise applied by surgical procedure s on the ASC list of approved procedures. The ASC billed the A/B MAC (B) and received payment according to the DMEPOS fee schedule.  However, an intraocular lens (IOL) inserted during or subsequent to cataract surgery in an ASC was included in the facility payment rate.  Beginning January 1, 2008, payment for implantable prosthetic devices without OPPS pass- through status is included in the ASC payment for the covered surgical procedure.  ASCs may not bill separately for implantable devices without OPPS pas s-through status.  If the ASC furnishes non -implantable prosthetic devices to beneficiaries, the ASC is treated as a supplier, and all the rules and conditions ordinarily applicable to suppliers are applicable, including obtaining a supplier number and bil ling as directed by the jurisdiction list.   Ambulance Services - If the ASC furnishes ambulance services, the facility may obtain approval as an ambulance supplier to bill covered ambulance services.   Leg, Arm, Back and Neck Braces - These items of equipment, like non -implantable prosthetic devices, are covered under Part B, but are not included in ASC payment for ASC services.  If the ASC furnishes these to beneficiaries, it is treated as a supplier, and all the rules and conditions ordinarily applicable t o suppliers are applicable, including obtaining a supplier number and billing the DME MAC where applicable.   Artificial Legs, Arms and Eyes -  Like non- implantable prosthetic devices and braces, this equipment is not considered part of an ASC facility servi ce and so is not included in ASC payment for ASC services.  If the ASC furnishes these items to beneficiaries, it is treated as a supplier, and all the rules and conditions ordinarily applicable to suppliers are applicable, including obtaining a supplier number and billing the DME MAC where applicable.   Services of Independent Laboratory  - As noted in 10.2, only a very limited number and type of diagnostic tests are considered ASC facility services and these are included in the ASC payment for covered surg ical procedures.  In most cases, diagnostic tests performed directly by an ASC are not considered ASC facility services and are not covered under Medicare.  Section 1861(s)  of the Act limits  coverage of diagnostic lab tests in facilities other than physicians offices, rural health clinics, or hospitals to facilities that meet the statutory definition of an independent laboratory.  In order to bill for diagnostic tests as a laboratory, an ASC s laboratory must be CLIA certified and enrolled with the A/B MAC (B) as a laboratory and the certified clinical laboratory must bill for the services provided to the beneficiary in the ASC.  Otherwise, the ASC makes arrangements with a covered laboratory  or laboratories for laboratory services, as provided in 42 CFR 416.49.  20 - List of Covered Ambulatory Surgical Center Procedures  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  The complete lists of ASC  covered surgical procedures and ASC covered ancillary services, the applicable payment indicators, payment rates for each covered surgical procedure and ancillary service before adjustments for regional wage variations, and wage indices are available on t he CMS Web -site at:  https://www.cms.gov/Medicare/Medicare- Fee-for-Service -Payment/ASCPayment/ASC -Regulations -and-Notices.html.  .  20.1 - Nature and Applicability of ASC Covered Procedures List  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  The ASC list of covered procedures merely indicates procedures which are covered and paid for if performed in the ASC setting.  It does not require the covered surgical procedures to be performed only in ASCs.  The decision regar ding the most appropriate care setting for a given surgical procedure is made by the physician based on the beneficiarys individual clinical needs and preferences.  Also, all the general coverage rules requiring that any procedure be reasonable and necess ary for the beneficiary are applicable to ASC services in the same manner as all other covered services.   20.2 - Types of Services Included on the ASC Covered Procedures List  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  The ASC list of covered surgical procedures is comprised of surgical procedures that CMS determines do not pose a significant safety risk and are not expected to require an overnight stay following the surgical procedure.   Surgical procedures are defined as C ategory I CPT codes within the surgical range of CPT codes, 10000 through 69999.  Also considered to be included within that code range are procedures that are described by Level II HCPCS, Category I CPT codes, or Category III CPT codes that directly cross walk to or are clinically similar to the Category I CPT codes in the surgical range that we have determined do not pose a significant safety risk, would not expect to require an overnight stay when performed in an ASC, and are separately paid under the OPP S.  The surgical codes that are included on the ASC list of covered surgical procedures are separately paid under the OPPS, have been determined to pose no significant safety risk to Medicare beneficiaries when furnished in ASCs, and for which standard medical practice dictated that the beneficiary  would not typically be expected to require active medical monitoring and care at midnight following the procedure (overnight stay).   Additionally, covered surgical procedures do not include those surgical procedures that: (1) generally result in extensive blood loss; (2) require major or prolonged invasion of body cavities; (3) directly involve major blood vessels; (4) are generally emergent or life threatening in nature; (5) commonly require systemic thrombolytic therapy; (6) are designated as requiring inpatient care under 419.22(n); (7) can only be reported using a CPT unlisted surgical procedure code; or (8) are otherwise excluded under 411.15.   Procedures that are included on the inpatient list used under Medicares hospital outpatient prospective payment system are deemed to pose significant safety risk to beneficiaries in ASCs and are not eligible for designation and coverage as ASC covered surgical procedures.  Procedures that can only be reported by using an unlisted Category I  CPT code are excluded from consideration because there are no specifically descriptive codes that can be evaluated for safety risk.   20.3 - Rebundlin g of CPT Codes  (Rev. 1, 10- 01-03)  The general CCI rebundling instructions apply to processing claims from ASC facilities services.  In general, if an ASC bills a CPT code that is considered to be part of another more comprehensive code that is also billed for the same beneficiary on the same date of service, only t he more comprehensive code is covered, provided that code is on the list of ASC approved codes.   Refer to Chapter 23 for a description of these instructions.   30 - Rate -Setting Policies  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  Generally, there are two primary elements in the total cost of performing a surgical  procedure:    The cost of the physicians professional services for the performing the procedure; and   The cost of services furnished by the facility where the procedure is performed (for example, surgical supplies and equipment and nursing services).   For ASC covered surgical procedures, the professional fee is paid to the physician; payments for facility costs are paid to the ASC.   Prior to the revised ASC paym ent system implemented January 1, 2008, the ASC payment rate was a standard overhead amount based on CMSs estimate of a fair fee and the costs incurred by the ASCs providing the procedure.  To estimate this cost, CMS surveyed audit costs incurred by a sam ple of ASCs.  There is an annual adjustment for inflation based on the percentage increase in the consumer price index for urban consumers in years when the ASC payment rates are not updated by a survey or otherwise.  Over a number of years, there have been statutory requirements reducing or eliminating the inflation adjustment on a year by year basis.  For example, the statute requires that the CPI adjustment factor be zero percent in FY 2005, the last quarter of CY  2005, and each CY from 2006 through 2009.  Beginning January 1, 2008, the revised ASC payment system includes the following features:   ASC payment rates for most services are based on a percentage of the hospital outpatient prospective payment system (OPPS) rates.  Unless statutorily prohibited , there is annual adjustment of the payment rates for inflation based on the CPI -U.  The update for inflation begins with the CY 2010 ASC payment rates when the statutory requirement for a zero update no longer applies. For CYs 2019 through 2023, the annua l adjustment of ASC payment rates for inflation is based on the hospital market basket update.    In general, the Medicare program pays ASCs 80 percent of the lesser of the actual charge or the ASC facility payment rate for the covered services performed.  The beneficiary pays 20 percent of the lesser of the submitted charge or the ASC facility payment rate for the covered services performed.  An exception to this is screening flexible sigmoidoscopies and screening colonoscopies, regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure, that is furnished in connection with, as a result of, and in the same clinical encounter as the colorectal cancer screening test. The coinsurance will be gradually reduced until it is completely waived for dates of service on or after January 1, 2030.  Beginning with the implementation of the 2008 revised payment system, the labor related adjustments to the ASC payment rat es are based on the Core- Based Statistical Area (CBSA) methodology.  Payment rates for most services are geographically adjusted using  the pre -reclassification wage index values that CMS uses to pay non -acute providers.  The adjustment for geographic wage  variation will be made based on a 50 percent labor related share.   Detailed information on both the OPPS and ASC payment methodologies is available in  the hospital outpatient and ASC final rules.   30.1 - Where to Obtain Current Rates and Lists of Covered Services  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)