(Medicare Benefit Policy Manual)

The A/B MAC (B) determines whether the item or service falls into the categories described in the following section.  If it determines the item or service does fall into one of those categories, it makes payment following the applicable rules for such items and services found elsewhere in this chapter.  If the item or service does not fall into one of the categories described, the A/B MAC (B) denies the claim.   Covered ASC surgical procedures are those surgical procedures that are identified by CMS on an annually updated ASC listing.  Some surgical procedures covered by Medicare are not on the ASC list of covered surgical procedures.  Under the revised ASC payment system, Medicare makes facility payments to ASCs only for the specific ASC covered surgical procedures and covered ancillary services that are provided integral to a covered ASC surgical procedure.  See chapter 14, section 10 of Pub. 100-04, Medicare Claims Processing Manual for examples of covered ASC services for which payment is included in the ASC payment for a covered surgical procedure under 42CFR416.65.  There is a payment adjustment for insertion of an IOL approved as belonging to a class of NTIOLs, for the 5 -year period of time established for that class, as set forth at 42CFR416.200.  260.3 - Services Furnished in ASCs Which are Not ASC Facility Services  (Rev. 1, 10-01-03) B3-2265.3  A single payment is made to an ASC that encompasses all facility services furnished by the ASC in connection with a covered procedure.  However, a number of items and services covered under Medicare may be furnished in an ASC which are not considered facility services, and which the ASC payment does not include.  These non- ASC services are covered and paid for under the applicable provisions of Part B.  In addition, the ASC may be part of a medical complex that includes other entities, such as an independent laboratory, supplier of durable medical equipment, or a physicians office, which are covered as separate entities under Part B.  In general, an item or service separately covered under Medicare is not considered an ASC service.  Examples of services payable in addition to ASC services are found in 260.4.  260.4 - Coverage of Services in ASCs, Which are Not ASC Services  (Rev. 77; Issued: 08-29- 07; Effective: 01 -01-08; Implementation:  01-07-08)  Physicians Services   This category includes most covered services performed in ASCs, which are not considered ASC facility services.  Physicians services were covered before coverage of ASC services, and the ASC amendment did not change this.  Consequently, physicians who perform covered services in ASCs receive payment under the existing Part B system.  Physicians services include the services of anesthesiologists 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 visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other services that the individua l physician usually includes in the fee for a given surgical procedure..  The contractor applies the same criteria, limits and understandings to physicians services for procedures furnished in the ASC that are applied to the procedures furnished by the same physicians on an inpatient hospital basis.  The Sale, Lease, or Rental of Durable Medical Equipment (DME) to ASC Patients for Use in Their Homes   Non-implantable Durable Medical Equipment (DME)  - 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   Prosthetic devices, other than intraocular lenses (IOLs), whether implanted, inserted, or otherwise applied by covered surgical procedures, are covered, but are not included in the ASC facility payment amount.  However, 4063(b) of P.L. 100-203 amended 1833 (i)(2)(A) of the Act to mandate that payment for an intraocular lens (IOL) inserted during or subsequent to cataract surgery in an ASC be included in the facility payment rate.  This bundling of the payment for an IOL with the facility fee is effective for services furnished on or after March 12, 1990.  More information on coverage of prosthetic devices may be found in 120 .  Further information on the coverage of IOLs may be found in 260.2 .  Non-Implantable Prosthetic Devices  - 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 billing the DME MAC where applicable.  Ambulance Services   If the ASC furnishes ambulance services, they are covered as ambulance services pursuant to the terms and conditions of the Medicare Benefit Policy Manual, Chapter 10, Ambulance Services, 10.  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 prosthetic devices, are covered under Part B, but are not included in the ASC facility payment amount.  Coverage of these items is described in 130.  If the ASC furnishes these 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.  Artificial Legs, Arms, and Eyes   Like prosthetic devices and braces, this equipment is not considered part of an ASC facility service and so is not included in the ASC facility payment rate.  Information regarding the coverage of these items is set out in 130.  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 260.2, only a very limited number and type of diagnostic tests are considered ASC facility services and included in the ASC facility payment rate.  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.  (See 80.1  for a description of independent laboratories and covered services.)  In order to bill for diagnostic tests as a laboratory, an ASCs laboratory must be CLIA certified and enrolled with the contactor as a laboratory and the certified clinical laboratory m ust 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 .  If the ASC has a certified independent laboratory, the laboratory itself bills the A/B MAC (B) , pursuant to 80 .  260.5 - List of Covered Ambulatory Surgical Center Procedures  (Rev. 77; Issued: 08-29- 07; Effective: 01 -01-08; Implementation:  01-07-08)  The law ties coverage of ambulatory surgical center (ASC) services under Part B to specified surgical procedures, which are contained in a list revised and published periodically by CMS.  Groupings and related prices are also published periodically.  These are published in the Federal Register and on the CMS Web site.   Beginning January 1, 2008, under the revised ASC payment system, CMS will update the list of covered surgical procedures, relative payment weights and national unadjusted payment rates, annually.  The updates will be proposed and finalized in the Federal Register concurrent with updates to the hospital outpatient prospective payment system.  260.5.1 - Nature and Applicability of ASC List  (Rev. 77; Issued: 08- 29-07; Effective: 01 -01-08; Implementation:  01- 07-08)  The ASC list of covered surgical procedures indicates procedures that are covered and may be paid for if performed in the ASC setting.  There is no requirement that the covered surgical procedures be performed only in ASCs.  The decision regarding the most appropriate car e 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 necessary for the beneficiary are applicable to ASC services in the same manner as all other covered services.   260.5.2 - Nomenclature and Organization of the List  (Rev. 77; Issued: 08- 29-07; Effective: 01 -01-08; Implementation:  01- 07-08)  The listed procedures are all considered surgical procedures for coverage purposes under the ASC provision, regardless of the specific use to which the procedure is put.  For example, many of the oscopy procedures listed -  bronchoscopy, laryngoscopy, e tc., may be employed for either diagnostic or therapeutic purposes, or both at the same time, such as when the oscopy permits both detection and removal of a polyp.  Those procedures are considered surgical procedures within the context of the ASC provision.  Also, surgical procedures are commonly thought of as those involving an incision of some type, whether done with a scalpel or (more recently) a laser, followed by removal or repair of an organ or other tissue.  In recent years, the development of f iber optics technology, together with new surgical instruments utilizing that technology, has resulted in surgical procedures that, while invasive and manipulative, do not require incisions.  Instead, the procedures are performed without an incision through various body openings.  Those procedures, some of which include the oscopy procedures mentioned above, are also considered surgical procedures for purposes of the ASC provision, and several are included in the list of covered procedures.   Beginning January 1, 2008, 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 Category I CPT codes within the surgical range of CPT codes, 10000 through 69999.  Also considered to be included within that code range are Level II HCPCS and Category III CPT codes that crosswalk to or are clinically similar to the Category I CPT codes in the range.   The surgical codes that are included on the ASC list of covered surgical procedures are those that have been determined to pose no significant safety risk to Medicare beneficiaries when furnished in ASCs and that are not expected to require active medical monitoring at midnight of the day on which the surgical procedure is performed (overnight stay).   Procedures that are included on the inpatient list used under Medicares hospital outpatient prospective payment system and procedures that can only be reported by using an unlisted Category I CPT code are deemed to pose significant safety risk to benefici aries in ASCs and are not eligible for designation and coverage as covered surgical procedures.   260.5.3 - Rebundling of CPT Codes  (Rev. 1, 10- 01-03) B3-2266.3  Instructions regarding the Correct Coding Initiative apply to coverage of ASC facility services.   270 - Telehealth Services  (Rev. 221, Issued: 03- 11-16, Effective: 01 -01-15, Effective: 04 -11-16)  For information on telehealth services, see Pub. 100- 04, Medicare Claims Processing Manual, chapter 12, section 190.  280  Preventive and Screening Services  (Rev. 11355; Issued:04- 14-22; Effective: 05 -16-22; Implementation: 05 -16-22)  See section 50.4.4.2 for coverage requirements for PPV, hepatitis B vaccine,  Influenza Virus Vaccine, and COVID -19 vaccines.   See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 18, Preventive and Screening Services, for coverage requirements for the following:    40 for screening pelvic examinations,   50 for prostate cancer screening test and procedures,    60 for colorectal cancer screening, and,    70.4 for glaucoma screening.  280.1  Glaucoma Screening  (Rev. 194, Issued: 09- 03-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  A.  Conditions of Coverage   The regulations implementing the Benefits Improvements and Protection Act of 2000, 102, provide for annual coverage for glaucoma screening for beneficiaries in the following high risk categories:    Individuals with diabetes mellitus;   Individuals with a family history of glaucoma; or   African -Americans age 50 and over.   In addition, beginning with dates of service on or after January 1, 2006, 42 CFR 410.23(a)(2), revised, the definition of an eligible beneficiary in a high- risk category is expanded to include:    Hispanic -Americans age 65 and over.