(Manual Name)

ASCs should use HCPCS code Q1003 to bill for a Category 3 NTIOL. HCPCS code Q1003, along with one of the approved surgical procedure codes (CPT codes 66982, 66983, 66984, 66985, 66986) are to be used on all NTIOL Cat egory 3 claims associated with reduced spherical aberration from February 27, 2006, through February 26, 2011.  The payment adjustment for the NTIOL is subject to beneficiary coinsurance but is not  wage -adjusted.  Any subsequent IOL recognized by CMS as having the same characteristics as the first NTIOL recognized by CMS for a payment adjustment as a Category III NTIOL (those of reduced spherical aberration) will receive the same adjustment for the remainder of the 5 -year period established by the first r ecognized IOL.   40.4 - Payment for Terminated Procedures  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)   The following criteria determine the appropriate ASC facility payment for a scheduled  surgical procedure that is termin ated due to medical complications which increase the surgical risk to the patient   A. Contractors deny payment when an ASC submits a claim for a procedure that is terminated before the patient is taken into the treatment or operating room.  For example, payment is denied if scheduled surgery is canceled or postponed because the patient on intake complains of a cold or flu.   B. Contractors pay 50 percent of the rate if a surgical procedure is terminated due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating room but before anesthesia has been induced or the procedure initiated (use modifier 73).  For example, 50 percent is paid if the patient develops an allergic reaction to a drug administered by the ASC prior to surgery or if, upon injection of a retrobulbar block, the patient experiences a retrobulbar hemorrhage which prevents continuation of the procedure.  Although some supplies and resources are expended, they  are not consumed to the same ex tent had anesthesia been fully induced and the surgery completed.  Facilities use a 73 modifier to indicate that the procedure was terminated prior to induction of anesthesia or initiation of the procedure.   C. Contractors make full payment of the surgical  procedure if a medical complication arises that causes the procedure to be terminated after anesthesia has been induced or the procedure initiated (use modifier -74).  For example, A/B MACs (B) make full payment if, after anesthesia has been accomplished and the surgeon has made a preliminary incision, the patients blood pressure increases suddenly and the surgery is terminated to avoid increasing surgical risk to the patient.  In this case, the resources of the facility are consumed in essentially the same manner and to the same extent as they would have been had the surgery been completed.  Facilities use a 74 modifier to indicate that the procedure was terminated after administration of anesthesia or initiation of the procedure.   An ASC claim for payment for terminated surgery must include an operative report kept  on file by the ASC, and made available, if requested by the contractor.  The operative report should specify the following:    Reason for termination of surgery;   Services actually performed;   Supplies actually provided;   Services not performed that would have been performed if surgery had not been terminated;   Supplies not provided that would have been provided if the surgery had not been terminated;   Time actually spent in each stage, e.g., pre -operative, operative, and post -operative;   Time that would have been spent in each of these stages if the surgery had not been terminated; and   HCPCS code for procedure had the surgery been performed.   D. Prior to January 1, 2008, contract ors deducted the allowance for an unused IOL prior  to calculating payment for a terminated IOL insertion procedure.    E. Beginning January 1, 2008, payment for the IOL is included in payment for the surgical procedure to implant the lens.   F. Beginning Ja nuary 1, 2008, contractors apply a 50 percent payment reduction for discontinued radiology procedures and other procedures that do not require anesthesia.  Facilities use the - 52 modifier to indicate the discontinuance of these applicable procedures.   G. Beginning January 1, 2008, ASC surgical services billed with the -52 or - 73 modifier are not subject to the multiple procedure discount.  40.5 - Payment for Multiple Procedures  (Rev. 11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  When more than one surgical procedure is performed in the same operative session, special payment rules apply, even if the procedures have the same HCPCS code.   When the ASC performs multiple surgical procedures in the same operative session that are subject to the multiple procedure discount, contractors pay 100 percent of the highest  paying surgical procedure on the claim, plus 50 percent of the applicable payment rate(s) for the other ASC covered surgical procedures subject to the multiple procedure disc ount  that are furnished in the same session.  The OPPS/ASC final rule for the relevant payment year specifies whether or not a surgical procedure is subject to multiple procedure discounting for that year.  Final payment is subject to the usual copayment and  deductible provisions.   The multiple procedure payment reduction is the last pricing routine applied to applicable ASC procedure codes.  In determining the ranking of procedures for application of the multiple procedure reduction, contractors shall us e the lower of the billed charge or the ASC payment amount.  The ASC surgical services billed with modifier - 73 and - 52 shall not be subjected to further pricing reductions. (i.e., the multiple procedure price reduction  rules do not apply).  Payment for a n ASC surgical procedure billed with modifier - 74 may be subject to the multiple procedure discount if that surgical procedure is subject to the multiple procedure discount.   A procedure performed bilaterally in one operative session is reported as two procedures, either as a single unit on two separate lines or with 2 in the units field on one claim line.  The multiple procedure reduction of 50 percent applies to all bilateral procedures subject to multiple procedure discounting.  For example, if lavage by cannulation; maxillary sinus (antrum puncture by natural ostium) (CPT code 31020) is performed bilaterally in one operative session, report 31020 on two separate lines or with 2 in the units field.  Depending on whether the claim includes other servic es to which the multiple procedure discount applies, the contractor applies the multiple procedure reduction of 50 percent to  the payment for at least one of the CPT code 31020 payment rates.   40.6 - Payment for Extracorporeal Shock Wave Lithotripsy (ESWL)  (Rev. 11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  A ninth ASC payment group was established in a Federal Register notice (56 FR 67666) published December 31, 1991.  The ninth payment group amount ($1,150) was assigned to onl y one procedure, CPT code 50590, extracorporeal shock wave lithotripsy (ESWL).  However, a court order issued March 12, 1992, has stayed the Group 9 payment rate until the Secretary publishes all information relevant to the setting of the ESWL rate, receiv es comments, and publishes a subsequent final notice.  This has not yet been completed.   CMS advised contractors to make payment to ASCs for ESWL services furnished after January 29, 1992, and through the date when the ASC received notice from the contract or of the court order staying the Group 9 payment rate.  This was a temporary measure to avoid penalizing ASCs that furnished ESWL services in accordance with the December 31, 1991, Federal Register notice and that could not have been expected to know that the March 12, 1992, court order set aside the ESWL provisions of that notice.    Contractors did not make Medicare payment for ESWL as an ASC procedure when such services were furnished after the date that the carrier advised an ASC of the court order.  However, contractors were instructed to retain all ASC claims for ESWL with a service date after January 29, 1992, and before the date when they were notified about the court order.  It may be necessary to retrieve these clams for further action at some later date.   Beginning January 1, 2008, with the revised ASC payment system, contractors may pay for any of the ESWL services that are included on the ASC list of covered surgical procedures.   40.7 - Payment and Offset for Pass- Through Devices Beginning Janu ary 1, 2008  (Rev.  11927; Issued: 03 -24-23; Effective: 04 -01-23; Implementation: 04 -03-23)  Under the revised payment system, there can be situations where contractors must reduce (cut back) the approved payment amount for specifically identified procedures when provided in conjunction with a specific pass -through device.  This reduction would only be applicable when services for specific pairs of codes are provided on the same day by the same provider. The device offset amount is the device portion included in Addendum FF of the quarterly addenda file. To determine the payment rate for the approved surgical procedure that is billed with an OPPS pass- through device, subtract the device portion from the ASC payment rate in Addendum AA.  The ASC addenda are accessible on the CMS website at: https://www.cms.gov/medicare/medicare -fee-for-service-payment/ascpayment     Code pairs subject to this policy would be updated on a quarterly basis.  CMS will inform contractors of the code pairs and the percent reduction removed from the procedure payment rate through a look- up table.  As an example, contractors  would perform the procedure percent reduction as follows:  If the example code pair Cxxxx (device) and 2xxxx (procedure) were on the code pair file with a procedure percent reduction of 0.008, contractors would remove 0.008 device offset amount from the payment rate assigned to the ASCs jurisdictional CBSA, and therefore effectively pay 0.992 of the payment rate.  Paying 0.992 of the payment rate, in this example, is equivalent to implementing the 0.008 procedure percent reduction.  The contractors would then pay Cxxxx according to the ASCFS, including current payment and claims processing instructions.  No code pair file related calculation or offset is performed on the device.  Calculations to implement the co de pair file procedure percent reductions, im pact only the CBSA procedure payment rate.   To process a claim i n the unlikely event that two procedures appearing on the ASC code pair file with the same device are billed in the same encounter, contractors should check the claim and history for each code  pair on the ASC code pair file or look -up table, in the order they are listed in the file . If one pass through device could pair with multiple procedures on the look -up table, the contractor should apply the offset  to the first code pair it identifies by going through the look -up table sequentially, in the order that they appear. If there is more than 1 unit of a pass -through device on the claim, the contractor should take an offset for each code pair. No code pair should be offset more than once and the number of code pairs receiving an offset should be no more than the units of a pass-through device.  40.8 - Payment When a Device is Furnished With No Cost or With Full or Partial Credit Beginning January 1, 2008  (Rev. 11793; Issued:01- 19-23; Effective: 02- 21-23; Implementation: 02 -21-23)  Contractors pay ASCs a reduced amount for certain specified procedures when a specified device is furnished without cost or for which either a partial or full credit is received (e.g., device recall).  For specified pro cedure codes that include payment for a device, ASCs are required to include modifier FB on the procedure code when a specified device is furnished without cost or for which full credit is received.  If the ASC receives a partial credit of 50 percent or m ore of the cost of a specified device, the ASC is required to include modifier FC on the procedure code if the procedure is on the list of specified procedures to which the -FC reduction applies.  A single procedure code should not be submitted with both modifiers FB and - FC.  The pricing determination related to modifiers   FB and - FC is made prior to the application of multiple procedure payment reductions.  Contractors adjust beneficiary coinsurance to reflect the reduced payment amount.  Tables listing the procedures and devices to which the payment adjustments apply, and the full and partial adjustment amounts, are available on the CMS Web- site.