CMS Pub. 100-04, ch. 14, § 10.2

Procedures List

(Rev. 11793; Issued:01-19-23; Effective: 02-21-23; Implementation: 02-21-23)

Covered ASC services are those surgical procedures that are identified by CMS on a

listing that is updated at least annually. Some surgical procedures are covered by

Medicare but are not on the list of ASC covered surgical procedures. For surgical

procedures that are performed but not covered in ASCs, the related professional services

may be billed by the rendering provider as Part B services and the beneficiary is liable for

the facility charges, which are non-covered by Medicare.

Under the ASC payment system, Medicare makes facility payments to ASCs only for the

specific ASC covered surgical procedures on the ASC list of covered surgical procedures.

In addition, Medicare makes separate payment to ASCs for certain covered ancillary

services that are provided integral to a covered ASC surgical procedure. All other non-ASC services, such as physician services and prosthetic devices may be covered and

separately billable under other provisions of Medicare Part B. The Medicare definition of

covered ASC facility services for a covered surgical procedure includes services that

would be covered if furnished on an inpatient or outpatient basis in connection with a

covered surgical procedure. This includes operating and recovery rooms, patient

preparation areas, waiting rooms, and other areas used by the patient or offered for use to

patients needing surgical procedures. It includes all services and procedures provided in

connection with covered surgical procedures furnished by nurses, technical personnel and

others involved in patient care. These do not include physician services or medical and

other health services for which payment may be made under other Medicare provisions

(e.g., services of an independent laboratory located on the same site as the ASC,

anesthetist professional services, non-implantable DME).

ASC services for which payment is included in the ASC payment for a covered surgical

procedure under 42 CFR 416.166 include, but are not limited to-

(a) Included facility services:

(1) Nursing, technician, and related services;

(2) Use of the facility where the surgical procedures are performed;

(3) Any laboratory testing performed under a Clinical Laboratory

Improvement Amendments of 1988 (CLIA) certificate of waiver;

(4) Drugs and biologicals for which separate payment is not allowed under

the hospital outpatient prospective payment system (OPPS);

(5) Medical and surgical supplies not on pass-through status under Subpart

G of Part 419 of 42 CFR;

(6) Equipment;

(7) Surgical dressings;

(8) Implanted prosthetic devices, including intraocular lenses (IOLs), and

related accessories and supplies not on pass-through status under Subpart

G of Part 419 of 42 CFR;

(9) Implanted DME and related accessories and supplies not on pass-through status under Subpart G of Part 419 of 42 CFR;

(10) Splints and casts and related devices;

(11) 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;

(12) Administrative, recordkeeping and housekeeping items and services;

(13) Materials, including supplies and equipment for the administration

and monitoring of anesthesia; and

(14) 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. ASCs must incorporate charges for packaged

services into the charges reported for the separately payable services with which they are

provided. Because contractors price ASC services based on the lower of submitted

charges or the ASC payment rate for the separately payable procedure, and because this

comparison is made at the claim line-item level, facilities may not be paid appropriately

if they unbundle charges and report those charges for packaged codes as separate line-item charges.

There is a payment adjustment for insertion of an IOL approved as belonging to a class of

NTIOLs, for the 5-year period of time established for that class, as set forth at 42 CFR

416.200

.

Covered ancillary items and services that are integral to a covered surgical procedure, as

defined in 42 CFR 416.61, and for which separate payment to the ASC is allowed

include:

(b) Covered ancillary services

(1) Brachytherapy sources;

(2) Certain implantable items that have pass-through status under the

OPPS;

(3) Certain items and services that CMS designates as contractor-priced,

including, but not limited to, the procurement of corneal tissue;

(4) Certain drugs and biologicals for which separate payment is allowed

under the OPPS;

(5) Certain radiology services for which separate payment is allowed

under the OPPS.

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 present 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 Services

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 in 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 patient’s relatives in

connection with surgical 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.

Under Part 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 dressings.)

Although surgical dressings usually are covered as “incident to” a physician’s service in a

physician’s office setting, in the ASC setting, such dressings are included in the facility’s

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

physician’s 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

physician’s 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 time of the surgery. Additional covered supplies and materials furnished later are

generally furnished as “incident to” a physician’s 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

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 levels,

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 physician’s office, rural 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 generally included in the

facility’s 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 independent 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 results 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 its administration.

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.)