CMS Pub. 100-02, ch. 15, § 260.4

Physicians’ Services

This category includes most covered services performed in ASCs, which are not

considered ASC facility services. Physicians’ services were covered before coverage of

ASC services, and the ASC amendment did not change this. Consequently, physicians

who perform covered services in ASCs receive payment under the existing Part B system.

Physicians’ services include the services of anesthesiologists administering or

supervising the administration of anesthesia to beneficiaries in ASC’s and the

beneficiaries’ recovery from the anesthesia. The term physicians’ services also includes

any routine pre- or post-operative services, such as office visits, consultations, diagnostic

tests, removal of stitches, changing of dressings, and other services that the individual

physician usually includes in the fee for a given surgical procedure.. The contractor

applies the same criteria, limits and understandings to physicians’ services for procedures

furnished in the ASC that are applied to the procedures furnished by the same physicians

on an inpatient hospital basis.

The Sale, Lease, or Rental of Durable Medical Equipment (DME) to ASC Patients

for Use in Their Homes

Non-implantable Durable Medical Equipment (DME) - 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 applicable.

Prosthetic Devices

Prosthetic devices, other than intraocular lenses (IOLs), whether implanted, inserted, or

otherwise applied by covered surgical procedures, are covered, but are not included in the

ASC facility payment amount. However, §4063(b) of P.L. 100-203 amended §1833

(i)(2)(A) of the Act to mandate that payment for an intraocular lens (IOL) inserted during

or subsequent to cataract surgery in an ASC be included in the facility payment rate.

This bundling of the payment for an IOL with the facility fee is effective for services

furnished on or after March 12, 1990. More information on coverage of prosthetic

devices may be found in §120. Further information on the coverage of IOLs may be

found in §260.2.

Non-Implantable Prosthetic Devices - 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 billing the DME MAC where applicable.

Ambulance Services

If the ASC furnishes ambulance services, they are covered as ambulance services

pursuant to the terms and conditions of the Medicare Benefit Policy Manual, Chapter 10,

“Ambulance Services,” §§10. 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 prosthetic devices, are covered under Part B, but are not

included in the ASC facility payment amount. Coverage of these items is described in

§130. If the ASC furnishes these 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.

Artificial Legs, Arms, and Eyes

Like prosthetic devices and braces, this equipment is not considered part of an ASC

facility service and so is not included in the ASC facility payment rate. Information

regarding the coverage of these items is set out in §130. 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 §260.2, only a very limited number and type of diagnostic tests are

considered ASC facility services and included in the ASC facility payment rate. 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. (See

§§80.1 for a description of independent laboratories and covered services.) In order to

bill for diagnostic tests as a laboratory, an ASC’s laboratory must be CLIA certified and

enrolled with the contactor 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. If the ASC has a certified independent laboratory, the

laboratory itself bills the A/B MAC (B), pursuant to §§80.