(Manual Name)

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)  CMS performs the functions and calculations described above and publishes a list of covered surgical procedures and  covered ancillary services for which an ASC may be paid each year, as well as quarterly updates via Medicare contractor instructions.  Regulations pertaining to Medicare rates for ASC facility services are contained in Part 416 of the Code of Federal Regulations, at http://www.ecfr.gov/cgi -bin/text -idx?tpl=/ecfrbrowse/Title42/42tab_02.tpl  ASC services are subject to the usual Medicare Part B deductible and coinsurance requirements.  An exception to this is screening flexible sigmoidoscopies and screening colonoscopies, regardless of the code that is billed for the establishment of a diagnos is 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. There is no deductible and the co insurance will be gradually reduced until it is completely waived for dates of service on or after January 1, 2030.  Prior to the revised ASC payment system implemented January 1, 2008, the ASC facility payment rate was a standard overhead amount based on CMSs estimate of a fair fee and the costs incurred by the ASCs providing the procedures.  HCPCS codes for procedures covered in the ASC were compiled into 9 groups with a separate rate set for each group. Beginning January 1, 2008, CMS updates payment rat es and codes for covered surgical procedures and covered ancillary services on a calendar year basis.  Payable services are updated on a quarterly basis.  Also, CMS calculates and makes available to the claims processing contractors CBSA -specific wage- adjusted payment rates for each of the ASC payable codes to which geographic adjustment applies.  The complete lists of ASC covered surgical procedures and ASC covered ancillary services, the applicable payment indicators, payment rates for each covered surgic al procedure and ancillary service before  adjustments for regional wage variations, and wage indices are available on the CMS Web -site at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service -Payment/ASCPayment/11_Addenda_Updates.html  and available to co ntractors on the CMS mainframe.    40 - Payment for Ambulatory Surgery  (Rev. 11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)   Prior to 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. The HCPCS codes for procedures covered in the ASC were grouped into 9 groups and a rate was set for each group.  In CY 2007, the ASC payment rate for each ASC covered procedure was based  on the payment rates for the 9 groups, but capped at  the OPPS payment rate for the procedure.   Beginning January 1, 2008, with implementation of the revised ASC payment system, the payment rates for most covered ASC surgical procedures and covered ancill ary services are established prospectively, based on a percentage of the OPPS payment rates.  For more information on where to locate these prospective payment rates, see 30.1.  There are a small number of covered ancillary services that are contractor -priced.  These include OPPS pass -through devices, which are paid separately and are contractor -priced  based on acquisition cost or invoice .  Medicare pays the same amount for drugs and biologicals that are paid separately under the OPPS when those drugs and biologicals are provided integral to covered surgical procedures.  New drugs and biologicals for which product -specific HCPCS cod es do not exist and are billed by ASCs using HCPCS code C9399 (unclassified drug or biological), are also contractor -priced at 95 percent of the average wholesale price (AWP).  Medicare pays the same amount for brachytherapy sources under the revised ASC p ayment system as it pays hospitals under the OPPS if prospective rates are available.  If prospective rates for brachytherapy sources are not available under the OPPS, ASC payment for brachytherapy sources is made at contractor -priced rates.   Under the revised ASC payment system effective January 1, 2008, Medicare makes separate payment to ASCs for corneal tissue acquisition (which is billed using V2785).  Contractors pay for corneal tissue acquisition based on acquisition cost or invoice.  In  addition, co ntractors make payment adjustments for new technology intraocular lenses (NTIOLs).  The NTIOL payment adjustment is an unadjusted payment subject to beneficiary coinsurance but not subject to the wage index adjustments.  Beginning January 1, 2008, Medicare payment for implantable durable medical equipment is included in the payment for the covered surgical procedure.  The ASC payment for the surgical procedure is a bundled payment which includes the payment for  the implantable items previously paid separat ely under the DMEPOS fee schedule.  The one exception to this is OPPS pass -through devices, which are paid separately.   Medicare contractors calculate payment for each separately payable procedure and service based on the lower of 80 percent of actual charges or the ASC payment rate.  The  charge -to-payment rate comparison occurs at the line- item level.  ASCs should not rep ort separate line -item HCPCS codes or charges for items that are packaged into payment for covered surgical procedures and therefore, are not paid separately (e.g., nonpass- through implantable devices).  Instead, it is important that ASCs incorporate charg es for packaged services into the charges reported for the separately payable services with which they are provided.  Facilities may not be paid appropriately if they unbundle charges and report those charges for packaged codes as separate line -item charges.   Beginning January 1, 2008, covered ancillary items and services, such as pass -through devices, brachytherapy sources, separately payable drugs and biologicals, and radiology procedures, should be billed on the same claim as the related ASC surgical procedure(s).  If an ASC bills for an ancillary service(s) separately (i.e., not on the same claim as the related surgical procedure) or a claim is split so that the ancillary service and related ASC  surgical service(s) are on separate claims, the contractor checks claims history to determine if there is an approved surgical procedure for the same beneficiary, same provider, and same date.  If there is no approved ASC surgical procedure on the same claim or in history for the same date, the ancillary service( s) shall be returned as unprocessable.   40.1 - Payment to Ambulatory Surgical Centers for Non- ASC Services  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  ASCs may furnish and be paid under other parts of Medicare Part B for certain services  that are not considered ASC facility services.  The usual Part B coverage and payment rules apply to such services.  For more information, see 10.3.  40.2 - Wage Adjustment of Base Payment Rates  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  Prior to January 1, 2008, the payment rates established for ASC procedures (see 30) are standard base rates that have been adjusted to remove the effects of regional wage variations.  When contractors process claims for ASC services, they adjust the base rates for services subject to geographic adjustment to reflect the wage index value applicable to the area in which the ASC is located.  The Medicare payment for ASC services is equal to 80 percent of the wage -adjusted standard payment rate.  Beneficiaries are responsible for a 2 0 percent coinsurance payment for ASC services once their deductible is satisfied.  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 resu lt 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. There is no deductible and the coinsurance wi ll be gradually reduced until it is completely waived for dates of service on or after January 1, 2030.   The wage index includes the wage and salary levels of certain health care professionals in both urban and nonurban locations, compared to a national n orm of 1.0.  Areas with above average wage levels have index numbers greater than 1.0, while areas with below average wage levels have index numbers below l.0.  Each Core -Based Statistical Area (CBSA) within a State has a separate index.  If a specific cit y or county does not have a CBSA value, the default is to the overall state wage index.   For dates of service on or after January 1, 2008, the ASC payment rates are geographically wage adjusted based on the wage index for the CBSA.  Beginning January   1, 2008, CMS calculates and makes available to the contractors CBSA -specific ASC payment rates for services subject to geographic adjustment.  The wage index values for urban and rural areas that CMS applies to all non- acute providers are used in the calculat ion of the ASC wage adjusted payment rates.  With the implementation of the ASC revised payment system, the labor related portion of the payment rate is 50 percent and the remaining non -labor related portion is 50 percent.   There is no adjustment for geogr aphic wage differences for the following:    Corneal tissue acquisition;   Drugs and devices that have pass- through status under the OPPS;   Brachytherapy sources;   Payment adjustment for NTIOLs; or   Separately payable drugs and biologicals.   40.3 - Payment for Intraocular Lens (IOL)  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  Prior to January 1, 2008, payment for facility services furnished by an ASC for IOL insertion during or subsequent to cataract surgery includes an allowance for the lens.  The   procedures that include insertion of an IOL are:   Payment Group 6:  CPT -4 Codes 66985 and 66986  Payment Group 8:  CPT -4 Codes 66982, 66983 and 66984  Physicians or suppliers are not paid for an IOL furnished to a bene ficiary in an ASC after July 1, 1988.  Separate claims for IOLs furnished to ASC patients beginning March 12, 1990, are denied.  Also, effective March 12, 1990, procedures 66983 and 66984 are treated as single procedures for payment purposes.   Beginning January 1, 2008, the Medicare payment for the IOL is included in the Medicare ASC payment for the associated surgical procedure.  Consequently, no separate  payment for the IOL is made, except for a payment adjustment for NTIOLs established accor ding to the process outlined in 42 CFR 416.185.  ASCs should not report separate charges for conventional IOLs because their payment is included in the Medicare payment for the associated surgical procedure.  The ASC payment system logic that excluded $150 for IOLs for purposes of the multiple surgery reduction in cases of cataract surgery prior to January 1, 2008, no longer applies, effective for dates of service on or after January 1, 2008.  Effective for dates of service on and after February 27, 2006, t hrough February 26, 2011, Medicare pays an additional $50 for specified Category 3 NTIOLs that are provided in association with a covered ASC surgical procedure.  The list of Category 3 NTIOLS is available at:  https://www.cms.gov/Medicare/Medicare- Fee-for-Service -Payment/ASCPayment/NTIOLs.html   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)