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Where can I find a list of procedures and ancillary services that are payable in the Ambulatory Surgical Ce...- ASC covered surgical procedures and associated payment rates are published in Addendum AA of the hospital outpatient pro... (more)
- ASC covered surgical procedures and associated payment rates are published in Addendum AA of the hospital outpatient prospective payment system (OPPS)/ASC final rule for the relevant payment year and covered ancillary services are in Addendum BB. Both Addenda AA and BB for CY 2008 are available at http://www.cms.hhs.gov/ASCPayment/ASCRN/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1213395&intNumPerPage=10
Quarterly updates are available by accessing the "Addenda Updates" menu link at: http://www.cms.hhs.gov/ASCPayment/
The ASC list of covered procedures merely indicates procedures which are covered and paid if performed in the ASC setting. It does not require the covered surgical procedures to be performed only in ASCs. The decision regarding the most appropriate care setting for a given surgical procedure is made by the physician based on the beneficiary's individual clinical needs and preferences. Also, all 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. See the Medicare Claims Processing Manual, Chapter 14, Section 20.1.
(FAQ2377)
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What procedures and services are payable when performed in the Ambulatory Surgical Center (ASC) setting und...- Under the ASC payment system, Medicare will make facility payments to ASCs only for the specific ASC covered surgical pr... (more)
- Under the ASC payment system, Medicare will make facility payments to ASCs only for the specific ASC covered surgical procedures on the ASC list of covered surgical procedures published in Addendum AA of the hospital outpatient prospective payment system (OPPS)/ASC final rule for the relevant payment year. Addendum AA to the calendar year (CY) 2008 OPPS/ASC final rule is available at http://www.cms.hhs.gov/ASCPayment/ASCRN/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1213395&intNumPerPage=10. In addition, Medicare will make separate payment to ASCs for certain covered ancillary services that are provided integral to a covered ASC surgical procedure. Covered ancillary services include the following:
• Brachytherapy sources;
• Certain implantable items with pass-through status under the OPPS;
• Certain items and services that CMS designates as contractor-priced, including, but not limited to, the procurement of corneal tissue;
• Certain drugs and biologicals for which separate payment is allowed under the OPPS; and
• Certain radiology services for which separate payment is allowed under the OPPS.
Other non-ASC services such as physician services and prosthetic devices may be covered and separately billed under Medicare Part B. See the Medicare Claims Processing Manual, Chapter 14, Section 10.2 for more information.
(FAQ2305)
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Where can I find a list of procedures and ancillary services that are payable in the Ambulatory Surgical Ce...- ASC covered surgical procedures are published in Addendum AA of the outpatient prospective payment system (OPPS)/ASC fin... (more)
- ASC covered surgical procedures are published in Addendum AA of the outpatient prospective payment system (OPPS)/ASC final rule for the relevant payment year and covered ancillary services are in Addendum BB.
The ASC list of covered procedures merely indicates procedures which are covered and paid if performed in the ASC setting. It does not require the covered surgical procedures to be performed only in ASCs. The decision regarding the most appropriate care setting for a given surgical procedure is made by the physician based on the beneficiary's individual clinical needs and preferences. Also, all 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. See the Medicare Claims Processing Manual, Chapter 14, Section 20.1.
(FAQ2309)
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What Ambulatory Surgical Center (ASC) services are included in the ASC payment for a covered surgical proce...- ASC services for which payment is included in the ASC payment for a covered surgical procedure include, but are not limi... (more)
- ASC services for which payment is included in the ASC payment for a covered surgical procedure include, but are not limited to, the following:
• Nursing, technician, and related services;
• Use of the facility where the surgical procedures are performed;
• Any laboratory testing performed under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver;
• Drugs and biologicals for which separate payment is not allowed under the outpatient prospective payment system (OPPS);
• Medical and surgical supplies not on pass-through status under the OPPS;
• Equipment;
• Surgical dressings;
• Implanted prosthetic devices, including intraocular lenses, and related accessories and supplies not on pass-through status under the OPPS;
• Implanted durable medical equipment (DME) and related accessories not on pass-through under the OPPS;
• Splints and casts and related devices;
• Radiology services for which separate payment is not allowed under the OPPS, and other diagnostic tests or interpretive services that are integral to a surgical procedure;
• Administrative, recordkeeping, and housekeeping items and services;
• Materials, including supplies and equipment for the administration and monitoring of anesthesia; and
• Supervision of the services of an anesthetist by the operating surgeon.
Under the revised ASC payment system, the above items and services fall within the scope of ASC facility services, and payment for them is packaged into the ASC payment for the covered surgical procedure. See the Medicare Claims Processing Manual, Chapter 14, Section 10.2 for more information.
(FAQ2307)
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Will CMS adjust Ambulatory Surgical Center (ASC) payment for multiple procedures performed during the same ...- When the ASC performs multiple surgical procedures in the same operative session that are subject to the multiple proced... (more)
- 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 procedures on the claim, plus 50 percent of the applicable wage adjusted payment rate(s) for the other ASC covered surgical procedures subject to the multiple procedure discount that are furnished in the same session. In determining the ranking of procedures for application of the multiple procedure reduction, contractors shall use the lower of the billed charge or the ASC payment amount. The multiple procedure reduction is the last pricing routine applied to applicable ASC procedure codes.
ASC surgical procedures billed with modifier -73 or -52 shall not be subjected to further pricing reductions (i.e., the multiple procedure price reduction rules will not apply). The hospital outpatient prospective payment system (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. For more information, see the Medicare Claims Processing Manual, Chapter 14, Section 40.5.
(FAQ2303)
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What are the requirements for reporting the –TC modifier under the revised Ambulatory Surgical Center (ASC)...- ASCs are required to report the -TC modifier when billing for facility charges associated with HCPCS codes that have bot... (more)
- ASCs are required to report the -TC modifier when billing for facility charges associated with HCPCS codes that have both a technical (-TC) component and a professional component (e.g., radiology services) under the Medicare Physician Fee Schedule (MPFS). ASCs may access their local Medicare contractors’ websites for additional information regarding the Healthcare Common Procedure Coding System (HCPCS) codes that must be billed with the -TC modifier.
(FAQ2379)
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Does CMS adjust Ambulatory Surgical Center (ASC) payment under the revised ASC payment system for geographi...- Starting in 2008, CMS adjusts for geographic differences in wages using the Core Based Statistical Area (CBSA) geographi... (more)
- Starting in 2008, CMS adjusts for geographic differences in wages using the Core Based Statistical Area (CBSA) geographic locality definitions established in 2003 by the Office of Management and Budget (OMB). These geographic locality definitions replace the Metropolitan Statistical Area (MSA) definitions that were used as the basis for ASC wage adjustments prior to January 1, 2008. Adopting the CBSA geographic definitions is consistent with wage index policy under other CMS payment systems. The ASC payment system is one of the last to adopt the CBSA definitions. The wage index assigned to a specific ASC reflects the geographic labor area where an ASC is physically located. ASCs may not appeal for wage index reclassification as this process is specific to hospitals.
Additionally, starting in 2008 the wage index values used to adjust payment for procedures under the revised ASC payment system are based on the applicable annually updated pre-reclassification wage index that CMS uses to pay almost all non-acute providers. These wage indices do not include acute inpatient specific adjustments, including reclassification, floor provisions, or occupational mix adjustments. The pre-reclassification wage index by CBSA is available on CMS's website in the Federal Register ASC final rulemaking. These final changes are published annually. The ASC final rules are accessible online at: http://www.cms.hhs.gov/ASCPayment/ASCRN/list.asp#TopOfPage
Payment rates for each ASC covered surgical procedure and ancillary service before adjustment for regional wage variations and wage indices are updated quarterly as appropriate, and available on the CMS web site at: http://www.cms.hhs.gov/ASCPayment/11_Addenda_Updates.asp#TopOfPage See the Medicare Claims Processing Manual, Chapter 14, Section 40.2 for more information.
(FAQ2375)
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Prior to implementation of the revised Ambulatory Surgical Center (ASC) payment system, ASCs received separ...- CMS uses a modified payment methodology to establish the ASC payment rates for procedures that are designated as “device... (more)
- CMS uses a modified payment methodology to establish the ASC payment rates for procedures that are designated as “device-intensive.” Device-intensive procedures are specified ASC covered surgical procedures that, under the outpatient prospective payment system (OPPS), are assigned to certain device-dependent ambulatory payment classification groups (APCs, the payment groups used under the OPPS). Device-dependent APCs are groups of procedures that require the insertion or implantation of expensive devices. Payment for the high cost devices is packaged into the procedure payments under the OPPS. For the device-dependent APCs, CMS develops estimates of the “device offset percentage,” the proportion of the procedures’ costs that are attributable to the cost of the device. Under the revised ASC payment system, CMS identifies the covered surgical procedures for which the device offset percentage of the APC to which they are assigned under the OPPS is greater than 50 percent of the APC’s median cost and designates those surgical procedures as device-intensive. CMS pays the same amount for the device-related portion of the procedure under the revised ASC payment system as under the OPPS. However, payment for the service portion of the ASC rate will be adjusted by the ASC conversion factor.
For example: If the OPPS payment for a device-intensive procedure is $7,000 and the device offset percentage is 75 percent, the device portion is about $5,250. The remaining $1,750 is the service portion of the procedure, the nondevice cost that the facility incurs when the device is implanted. Under the revised ASC payment system, CMS will pay the same amount for the device portion of the procedure as under the OPPS but will adjust the service portion, just as will occur for other OPPS surgical procedures when ASCs are paid for performance of these procedures. Thus, the ASC rate will be calculated by adjusting the OPPS service portion by the ASC conversion factor and that will be added to the full device portion of the OPPS rate to establish the full ASC payment rate for the procedure.
Because payment for procedures is based on the OPPS, which packages payment for implantable devices in the payment for the surgical procedures to implant them, ASCs will no longer bill separately under the Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) fee schedule for any implantable prosthetic devices.
(FAQ2311)
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How should Ambulatory Surgical Centers (ASCs) report bilateral procedures under the revised ASC payment sys...- Bilateral procedures should be reported as a single unit on two separate lines or with “2” in the units field on one lin... (more)
- Bilateral procedures should be reported as a single unit on two separate lines or with “2” in the units field on one line, in order for both procedures to be paid. While use of the -50 modifier is not specifically prohibited according to CMS billing instructions, the modifier will not be recognized for payment purposes and may result in incorrect payment to ASCs. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting. See the Medicare Learning Network (MLN) Matters article SE0742, available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0742.pdf for billing examples illustrating this revised payment policy.
(FAQ2381)
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How should Ambulatory Surgical Centers (ASCs) report bilateral procedures under the revised ASC payment sys...- Bilateral procedures should be reported as a single unit on two separate lines or with “2” in the units field on one lin... (more)
- Bilateral procedures should be reported as a single unit on two separate lines or with “2” in the units field on one line, in order for both procedures to be paid. While use of the -50 modifier is not specifically prohibited according to CMS billing instructions, the modifier will not be recognized for payment purposes and may result in incorrect payment to ASCs. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting. See the MLN Matters article SE0742, available at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0742.pdf for billing examples illustrating this revised payment policy.
(FAQ2315)
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Under the revised Ambulatory Surgical Center (ASC) payment system, will ASCs receive separate payment for d...- Pass-through status under the OPPS is granted to new devices that will lead to substantial clinical improvement for bene... (more)
- Pass-through status under the OPPS is granted to new devices that will lead to substantial clinical improvement for beneficiaries. Under the OPPS, devices with pass-through status are paid separately for two to three years. CMS will provide separate payment to ASCs at contractor-priced rates for devices that are included in device categories with pass-through status under the OPPS when the devices are an integral part of a covered surgical procedure.
There can be situations where contractors must reduce the approved payment amount for a specifically identified procedure when provided in conjunction with a specific pass-through device. This occurs when the payment for the procedure in which the device is implanted already includes the cost of a different, predecessor device that can be implanted through the same procedure, and is intended to prevent contractors from paying twice for the device. This reduction would be applicable only when services for specific pairs of codes are provided on the same day by the same provider. Code pairs subject to this policy would be updated on a quarterly basis when a new pass-through device is approved under the OPPS. CMS will inform contractors of the code pairs and the percent reduction taken from the procedure payment rate through a "look-up" table on the ASC website at http://www.cms.hhs.gov/ASCPayment/. See the Medicare Claims Processing Manual, Chapter 14, Section 40.7.
(FAQ2313)
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If a beneficiary still needs post-op cataract eyewear following the insertion of a presbyopia-correcting IO...- Yes. Section 1861(s)(8) permits payment for one pair of eyeglasses or contact lenses following cataract surgery with in... (more)
- Yes. Section 1861(s)(8) permits payment for one pair of eyeglasses or contact lenses following cataract surgery with insertion of an IOL.
http://www.cms.hhs.gov/Rulings/downloads/CMSR0501.pdf
(FAQ1985)
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