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2004 National ASC Payment Rates
ASC payment group rates effective October 1, 2003 are as follows:
Group 1 - $340
Group 2 - $455
Group 3 - $520
Group 4 - $643
Group 5 - $731
Group 6 - $840 ($690 + $150 for intraocular lenses (IOLs));
Group 7 - $1015
Group 8 - $989 ($839 + $150 for IOLs).
Group 9 - $1366
The $150 payment allowance in groups 6 and 8 is for intraocular lenses.
The formula for creating ASC payment rates is as follows:
Payment group 1,2,3,4,5,7,9
(National ASC Payment Rate x .3445 (standardized labor related portion) x CMS wage index) +
(National ASC Payment Rate x .6555 (standardized non labor related portion))
Payment group 6 & 8
((National ASC Payment Rate - $150 (IOL Allowance))x .3445 (standardized labor related portion) x CMS wage index) +
((National ASC Payment Rate - $150 (IOL Allowance)) x .6555 (standardized non labor related portion)+
$150 (IOL Allowance)
Tutorial
The following is an tutorial is for providers/suppliers furnishing services/supplies to a Medicare carrier. This material is intended to
complement and not replace Medicare program requirements as set forth in statute, regulations and manual instructions. It is the responsibility of each provider/supplier submitting claims to a Medicare carrier to familiarize themselves with Medicare coverage requirements.
Ambulatory Surgical Centers (ASCs) Tutorial on Billing
An ASC is a distinct entity which operates exclusively to provide outpatient surgical services to patients by entering into an agreement with the Health Care Financing Administration (CMS). ASCs must be state licensed and Medicare certified. ASCs must also enter into a written agreement with CMS to accept assignment on Medicare claims. Any hospital, clinic, physician or physician group wishing to participate and establish a Medicare approved ASC should contact the state agency listed below:
An ASC may be either independent (i.e., not a part of any other facility) or hospital affiliated. Hospital affiliated ASCs are those operated by hospitals under common ownership, licensure or control. To be covered as an ASC operated by a hospital, a facility must meet the following requirements:
· Elect to participate in the Medicare Part B program as an ASC and continue as such unless CMS determines there is good cause to do otherwise. (The ASC may not opt to change at will to bill as an outpatient area of that hospital for purposes of reimbursement advantage.)
· Be a separate identifiable entity. This means it must be physically, administratively, and financially independent and distinct from other hospital operations. The hospital affiliated ASC must be set up as a non-reimbursable cost center to the hospital. (Under this restriction, ordinary hospital outpatient departments providing ambulatory surgery services are not eligible to receive reimbursement from the Part B Carrier.)
· Meet all requirements for health and safety standards, and agree to the assignment, coverage and reimbursement rules applied to an independent ASC. These requirements will be specifically outlined during the state licensure and CMS approval proceedings. Licensure and CMS certification must precede Medicare Part B billing.
Note: As an Ambulatory Surgical Center, assignment is mandatory for ASC facility services but Medicare participation is voluntary.
Coverage
Covered ASC facility services are defined as those furnished by an ASC in connection with a covered surgical procedure which are otherwise covered if furnished on an inpatient or outpatient basis in a hospital in connection with that procedure. The facility payment rate includes only the covered ASC facility services.
When an ASC is assigned a provider number for billing purposes, a list of eligible ASC procedure codes will be provided. This list of covered procedures merely indicates procedures that are covered and reimbursable if performed in the ASC setting. It does not require such procedures to be performed in such settings, nor is any out-of-the-ordinary justification or special review required if listed procedures are performed on a hospital inpatient basis. The choice of operating site remains a matter for the professional judgment of the patient's physician. Also, all the general coverage rules regarding the medical necessity of a given procedure are applicable to ASC services in the same manner as all other covered services.
c.1 Covered ASC Facility Services
Covered services which are included in the ASC facility rate are as follows:
· Nursing services, services of technical personnel, and other related services;
· Use of the ASC facilities by the patient;
· Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances and equipment;
· Diagnostic or therapeutic items and services (including simple preoperative laboratory tests, e.g., urinalysis, blood hemoglobin or hematocrit);
· Administrative, record keeping and housekeeping items and services;
· Blood, blood plasma, platelets, etc., except for those to which the blood deductible applies;
· Materials for anesthesia; and
· Intraocular lenses (IOLs).
c.2 ASC Services Not Included in the ASC Facility Rate
In general, an item or service separately covered under Medicare is not considered to be a covered ASC facility service. Services which are not considered ASC facility services, such as physician services and prosthetic devices other than intraocular lenses (IOLs), may be covered and billable under other Medicare provisions. Certain items and services such as those listed below are otherwise covered under Medicare and may be provided in the ASC, but are not included in the ASC facility rate:
· Physician services;
· The sale, lease or rental of durable medical equipment (DME) to ASC patients for use in their homes;*
· Prosthetic devices, except intraocular lenses (IOLs) and prosthetic implants; *
· Ambulance services;
· Leg, arm, back and neck braces;*
· Artificial legs, arms and eyes; and*
· Independent laboratory services.
*Claims for these items must be billed to the appropriate Durable Medical Equipment Regional Carrier (DMERC).
Note: An ASC wishing to provide laboratory services directly must have its laboratory certified as an independent clinical laboratory for the services to be covered. The services must then be billed by the laboratory rather than the ASC. Or, if the ASC has no laboratory facilities of its own, the ASC should contract with a hospital laboratory or independent clinical laboratory to provide services for them. The laboratory should then, under provisions of the law, bill Medicare directly. In general, however, the necessary laboratory tests are done outside the ASC prior to scheduling of surgery, since the test results often determine whether the beneficiary should have the surgery done on an outpatient basis.
Reimbursement
ASC facility services are reimbursed based on prospectively determined rates. These rates are not based on Diagnostic Related Groups (DRGs) as are hospital services. Rather, they are based upon the classifications of procedures into different payment groups which are based on surgical procedure complexity. Rates by payment group are established by CMS.
CMS updates and publishes the rate setting methodology and establishes wage index (WI) tables to use for either urban or rural areas. Each ASC's rates are calculated using CMS's rate and wage indices according to the ASC's location.
When changes are made to the WI or the facility base rate, rates will be recalculated as instructed by CMS and each ASC will be notified of its newly adjusted rate. The ASCs must ensure their charges are based upon the applicable rates in effect. That is, the billed amount should be equal to or greater than the applicable rate.
The carrier is required to pay these rates regardless of what is billed. Reporting less than the calculated facility group rate could cause problems with co-insurance collection.
Facility services are subject to the usual Medicare Part B 20 percent coinsurance and deductible requirements. Therefore, Medicare payment is 80 percent of the prospectively determined rate.
At no time should an ASC bill for anesthesiology, surgery or assistant at surgery services. The anesthesiologist, surgeon and assistant surgeon would be submitting separate claims for their professional reimbursement.
Exception: ASC employed CRNA services must be reported with the ASC's provider number in block 33 or the EMC equivalent and the rendering CRNA's number in block 24k or the EMC equivalent. Please refer to the claims completion chart for specifics on reporting.
Facility Reimbursement-Single Procedures
Approved surgical procedures are classified into eight payment groups for facility reimbursement purposes. All approved surgical procedures within the same payment group are reimbursed at a single rate. The standard, unadjusted* rates applicable to each of the payment groups for services are as follows:
*These are the ASC facility rates before the WI factor is applied. Each facility will receive its respective adjusted facility rates at the time they are approved.
Facility Reimbursement-Multiple Procedures
More than one surgical procedure may be performed in the same operative session. Special rules apply to this situation. When two or more procedures are performed, the ASC will be reimbursed at the full rate for the procedure classified in the highest payment group. Any other procedures performed during the same session are reimbursed at 50% of the procedure's applicable group rate. If the procedures are within the same group, the ASC should be reimbursed for the full rate for one procedure and at 50% of the rate for the others.
Payment for eligible bilateral procedures will be reimbursed at 150% of the applicable rate. Procedures eligible for the bilateral payment adjustment are determined by CMS.
For example, if sinusotomy, maxillary (antrotomy); intranasal (procedure code 31020) is performed bilaterally in one operative session, report it as 31020 with a 50 modifier (bilateral procedure). Payment for bilateral procedures is calculated by multiplying the wage adjusted payment rate by 150 percent.
Reimbursement of Physicians' Professional Services Provided In Connection With Covered ASC Surgical Procedures
Physician reimbursement for ASC approved procedures are subject to the 20% coinsurance and deductible provisions. Payment is made at 80% of the Medicare physician fee schedule. Fees for approved procedures in an ASC setting (place of service 24) are noted on the fee schedule as a facility fee.
The Medicare global fee policies which are applied to the procedure when performed by the physician on an inpatient hospital basis will be applied to physician services provided in an ASC.
Reporting Instructions for ASC Facility Services
· The ASC and the surgeon should both report the surgical procedure code which accurately reflects the service provided.
· Report the place of service as 24 (ambulatory surgical center).
· Report procedure code modifier SG (ambulatory surgical center facility services). Physicians should not report this modifier when billing for their professional service.
· Report referring physician name and UPIN.
Note: ASCs are required to report referring physician information for three procedures codes: 66983, 66984, 66985 and 66986.
Refer to claims completion chart for complete reporting information.
ASC Special Instructions
Molteno Valve
Effective with dates of service on or after March 1, 1991, Medicare Part B will separately reimburse ASCs for Molteno valves (L8612) implanted during covered glaucoma surgery. Molteno valves are considered prosthetic devices and are generally implanted into the eyes of patients with advanced glaucoma in order to preserve their sight. Report procedure code L8612 with a separate charge in addition to the charge for the facility service. Attach a complete legible copy of the actual invoice for the Molteno valve to the facility claim. The invoice must indicate the actual or acquisition cost of the Molteno valve, any handling or dispensing fees involved, and any discounts the ASC receives.
Report the individual acquisition cost. Refer to the claims completion chart.
Note: Invoices must be kept on file and available for carrier review in the provider's office for verification purposes.
Corneal Tissue Acquisition
Reimbursement may be made for the "processing, preserving and transporting of corneal tissue" (code V2785), associated with keratoplasty procedures performed in an Ambulatory Surgical Center. Claims for code V2785 must be supported by an invoice from the supplying eye bank showing the actual cost incurred to acquire the corneal tissue. Code V2785 may be reimbursed as an add-on to the ASC facility fee.
Report the individual acquisition cost. Refer to the claims completion chart.
Note: Invoices must be kept on file and available for carrier review in the provider's office for verification purposes.
Implantable Venous Access Portals
Payment may be made for implantable venous access portals (procedure code A4300) furnished by Medicare participating ASCs in conjunction with insertion of implantable venous access port, with or without subcutaneous reservoir (procedure code 36533).
Report procedure codes A4300 and A4301 with a separate charge in addition to the facility services.
Note: Invoices must be kept on file and available for carrier review in the provider's office for verification purposes.
Prosthetic Implants
Medicare Part B will separately reimburse ASCs for prosthetics (procedure codes L8600 - L8690) implanted during the specified covered surgeries. Ambulatory Surgical Centers should use these codes when reporting implant procedure services. Report the specific prosthetic code and applicable charge on a separate line on the facility claim. All these prosthetics are related to procedures that are on the current ASC list.
Code Terminology
Integumentary System
L8600 Implantable breast prosthesis, silicone or equal
Head (skull, facial bones and temporomandibular joint)
L8610 Ocular
L8612 Aqueous shunt
L8613 Ossicula
L8614 Cochlear device/system
Upper extremity
L8630 Metacarpophalangeal joint
Lower extremity (joint: knee, ankle, toe)
L8641 Metatarsal joint
L8642 Hallux implant
Miscellaneous muscular-skeletal
L8658 Interphalangeal joint
Cardiovascular system
L8670 Vascular graft material, synthetic
Intraocular Lens (IOLs)
IOLs are "bundled" into facility payment groups 6 and 8. Do not bill separately for IOLs since the facility payment includes this item.
Note: The referring physician name and Unique Physician Identification (UPIN) Number must be reported for group 6 (procedure code 66985, 66986) and group 8 (procedure codes 66983 and 66984) facility services.
Payment for Terminated Procedures
An ASC claim for payment of terminated surgery must be accompanied by an operative report that specifies 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
· CPT-4 code for procedure had the surgery been performed.
Peer Review Organization (PRO) Prior Authorization
Assistant-at-cataract surgery for procedures 66852, 66920, 66940, requires a PRO prior authorization number. |
