evekhm/cms_iom_500 huggingface dataset:
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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
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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.
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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.
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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.
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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)
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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:
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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
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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.
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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)
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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)
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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)
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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.