evekhm/cms_iom_500 huggingface dataset:
(Manual Name)
NOTE:  Effective for dates of service on or after January 1, 2009, for allowed ASC claims, if modifier = TC, contractors must ensure that either:    ordering physician name and NPI or   referring physician name and NPI   are presen t on electronic or paper claims.   If this information is missing, contractors shall return as unprocessable.   The contractor shall use the following remittance advice messages and associated codes when returning claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 16  RARC: N264, N265, N285 or N286 as appropriate  MSN: N/A  Definitions of ASC Facility Services:   Nursing Services, Services of Technical Personnel, and Other Related Serv ices  These include all services in connection with covered procedures furnished by nurses and technical personnel who are employees of the ASC.  In addition to the nursing staff, this category includes orderlies, technical personnel, and others involved i n patient care.   Use by the Patient of the ASC Facilities   This category includes operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use by the patients relatives in connection with s urgical services.   Drugs, Biologicals, Surgical Dressings, Supplies, Splints, Casts, Appliances, and Equipment   This category includes all supplies and equipment commonly furnished by the ASC in connection with surgical procedures.  See the following paragraphs for certain exceptions.  Drugs and biologicals are limited to those which cannot be self -administered. See the Medicare Benefit Policy Manual, Chapter 15, 50.2, for a description of how to determine whether drugs can be self -administered.
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Under Par t B, coverage for surgical dressings is limited to primary dressings, i.e., therapeutic and protective coverings applied directly to lesions on the skin or on openings to the skin required as the result of surgical procedures.  (Items such as Ace bandages,  elastic stockings and support hose, Spence boots and other foot coverings, leotards, knee supports, surgical leggings, gauntlets and pressure garments for the arms and hands are used as secondary coverings and therefore are not covered as surgical dressin gs.) Although surgical dressings usually are covered as incident to a physicians service in a physicians office setting, in the ASC setting, such dressings are included in the facilitys services.   However, surgical dressings may be reapplied later by others, including the patient or a member of his family.  When surgical dressings are obtained by the patient on a physicians order from a supplier, e.g., a drugstore, the surgical dressing is covered under Part B.  The same policy applies in the case of dressings obtained by the patient on a physicians order following surgery in an ASC; the dressings are covered and paid as a Part B service by the DME MAC.   Similarly, other supplies, splints, and casts include only those furnished by the ASC at the tim e of the surgery.  Additional covered supplies and materials furnished later are generally furnished as incident to a physicians service, not as an ASC facility service.  The term supplies includes those required for both the patient and ASC personnel , e.g., gowns, masks, drapes, hoses, and scalpels, whether disposable or reusable. Payment for these is included in the rate for the surgical procedure.   Beginning January 1, 2008, the ASC facility payment for a surgical procedure includes payment for drugs and biologicals that are not usually self -administered and that are considered to be packaged into the payment for the surgical procedure under the OPPS.  Also, beginning January 1, 2008, Medicare makes separate payment to ASCs for drugs and biologicals that are furnished integral to an ASC covered surgical procedure and that are separately payable under the OPPS.   Diagnostic or Therapeutic Items and Services
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Diagnostic or Therapeutic Items and Services   These are items and services furnished by ASC staff in connection with covered surgical procedures.  Many ASCs perform diagnostic tests prior to surgery that are generally included in the facility charges, such as urinalysis, blood hemoglobin, hematocrit l evels, etc.  To the extent that such simple tests are included in the ASC facility charges, they are considered facility services.  However, under the Medicare program, diagnostic tests are not covered in laboratories independent of a physicians office, r ural health clinic, or hospital unless the laboratories meet the regulatory requirements for the conditions for coverage of services of independent laboratories.  (See 42 CFR 416.49)  Therefore, diagnostic tests performed by the ASC other than those genera lly included in the facilitys charge are not covered under Part B and are not to be billed as diagnostic tests.  If the ASC has its laboratory certified, the laboratory itself may bill for the tests performed.   The ASC may make arrangements with an indepe ndent laboratory or other laboratory, such as a hospital laboratory, to perform diagnostic tests it requires prior to surgery.  In general, however, the necessary laboratory tests are done outside the ASC prior to scheduling of surgery, since the test resu lts often determine whether the beneficiary should have the surgery done on an outpatient basis in the first place.   Administrative, Recordkeeping and Housekeeping Items and Services  These include the general administrative functions necessary to run the facility e.g., scheduling, cleaning, utilities, and rent.  Blood, Blood Plasma, Platelets, etc., Except Those to Which Blood Deductible Applies   While covered procedures are not expected to result in extensive loss of blood, in some cases, blood or blood products are required.  Usually the blood deductible results in no expenses for blood or blood products being included under this provision.  However, where there is a need for blood or blood products beyond the deductible, they are considered ASC facility services and no separate charge is permitted to the beneficiary or the program.   Materials for Anesthesia   These include the anesthetic agents that are not paid separately under the OPPS, and any materials, whether disposable or re -usable, necessary for it s administration.   Intraocular Lenses (IOLs) and New Technology IOLs (NTIOLs)
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Intraocular Lenses (IOLs) and New Technology IOLs (NTIOLs)   The ASC facility services include IOLs (effective for services furnished on or after March 12, 1990), and NTIOLs (effective for services furnished on or after May 18, 2000), approved by the Food and Drug Administration (FDA) for insertion during or subsequent to cataract surgery.   FDA has classified IOLs into the following categories, any of which are included:   1. Anterior chamber angle fixation lenses;   2. Iris fixation lenses;   3. Irido -capsular fixation lenses; and   4. Posterior chamber lenses.   5. NTIOL Category 1 (as defined in Federal Register  Notice, VOL 65, dated May 3, 2000).  Note: This category expired May 18, 2005  6. NTIOL Category 2 (as defined in Federal Register  Notice, VOL 65, dated May 3, 2000).  Note:  This category expired May 18, 2005  7. NTIOL Category 3 (as defined in Federal  Register  Notice, 71 FR 4586, dated January 27, 2006):  This category will expire on February 26, 2011.  Note that while generally no separate charges for intraocular lenses (IOLs) are allowed, approved NTIOLS may be billed separately and an adjustment to the facility payment will be made for those lenses that are eligible.  (See 40.3.)   10.3 - Services Furnished in ASCs Which Are Not ASC Facility Services or Covered Ancillary Services  (Rev.  11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  A single payment is made to an ASC for facility services furnished by the ASC in connection with a covered surgical procedure.  Additional payments may be made to the ASC for covered ancillary services, specifically brachytherapy  sources, certain implantable devices with pass- through status under the OPPS, corneal tissue acquisition, drugs and biologicals for which separate payment is allowed under the OPPS, radiology services for which separate payment is allowed under the OPPS, and certain other integral services not included in the primary procedure payment.  To be covered ancillary services for which separate payment is made, these items and services must be provided integral to covered surgical procedures, that is, immediately  before, during, or immediately after the covered surgical procedure.
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However, a number of items and services covered under Medicare may be furnished in an ASC that are not considered ASC services, and which payment for ASC services does not include.  The se 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 phys icians office, which are covered as separate entities under Part B.  In general, an item or service provided in a separate part of the complex is not considered an ASC service, except as defined above.   Examples of payment and billing for items or service s that are not ASC services:   Items not included in payment for ASC services  Who may receive payment  Submit bills to:  Physicians services (including surgical procedures excluded from ASC payment)  Physician  A/B MAC (B)  The purchase or rental of non-implantable durable medical equipment (DME) to ASC patients for use in their homes  Supplier - An ASC can be a supplier of DME if it has a supplier number from the National Supplier Clearinghouse. DME MAC, or A/B MAC (B) as directed by the current DME jurisdiction list  Non-implantable prosthetic devices  Supplier.  An ASC can be a supplier of non- implantable prosthetics if it has a supplier number from the National Supplier Clearinghouse.  DME MAC, or A/B MAC (B), as directed by the current DME jurisdictio n list Ambulance services  Certified Ambulance supplier  A/B MAC (B)  Leg, arm, back and neck braces  Supplier  DME MAC, or A/B MAC (B), as directed by the current DME jurisdiction list  Artificial legs, arms, and eyes Supplier  DME MAC, or A/B MAC (B), as directed by the current DME jurisdiction list  Services furnished by an independent laboratory  Certified lab.  ASCs can receive lab certification and a CLIA number.  A/B MAC (B)  Facility services for surgical procedures excluded from the ASC list  ASC  ASC bills beneficiary for facility charges associated with the non -covered procedure
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Examples of payment and billing for items or services that are included in payment for ASC facility services beginning January 1, 2008  Items included in payment for ASC facility services beginning January 1, 2008 Who may receive payment beginning January 1, 2008 Submit bills to: Implantable DME and accessories without OPPS pass -through status  ASC  A/B MAC (B) Implantable nonpass -through prosthetic devices (except NTIOLs), and accessories without OPPS pass -through status  ASC  A/B MAC (B) Radiology services for which there is no separate OPPS payment  ASC  A/B MAC (B) Drugs and biologicals for which there is no separate OPPS payment  ASC  A/B MAC (B)  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.
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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.
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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)
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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).
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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.
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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.
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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)