CMS Pub. 100-04, ch. 19, § 40.2.1

Services

(Rev. 1325; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)

For dates of service prior to January 1, 2008, IHS providers that want to bill for surgeries

on the ambulatory surgical center (ASC) list and receive the ASC rate must contact their

designated A/B MAC (A). IHS providers are certified by one of several national

accrediting organizations recognized by the Centers for Medicare and Medicaid Services

(CMS) and meet the conditions for performing ASC procedures.

The IHS hospital outpatient departments are not certified as separate ASC entities. The

ASC indication merely means that CMS approved them to bill for ASC services and be

paid based on the ASC rates for services on the ASC list. In order to bill for ASC

services, the hospital outpatient department must meet the conditions of participation for

hospitals defined in 42 CFR, Part 482.

Authority for Medicare to pay IHS hospital outpatient departments using the freestanding

ASC rates was incorporated into Public Health Service regulations on December 27,

1989. The first IHS hospital requested to bill separately for ASC procedures at the

appropriate ASC group payment amounts in March 1987. HCFA (now CMS) approved

payment of the ASC group payment amounts for dates of service on or after October 1,

1987. Previously, the hospital was reimbursed for ASC procedures at the Office of

Management and Budget (OMB) negotiated all inclusive rate (AIR) for outpatient

hospital services. The rationale for approving this request was that the hospital was

already JCAHO certified, encompassing the ability to perform outpatient surgical

procedures, and that acute care hospitals providing surgical inpatient or outpatient

services can perform any surgical procedures within their capacity and capability.

For dates of service prior to January 1, 2008, in order for IHS providers to bill for ASC

procedures and receive payment based on the ASC rates published in the Federal

Register, the designated A/B MAC (A) must update the IHS/ASC cert indicator on the

provider file to ‘Y’. A ‘Y’ in this field indicates that the IHS provider or ASC is certified

under IHS and their claims should be processed through ASC Pricer, ensuring the IHS

provider is paid based on the ASC price rather than the AIR. Reimbursement is made

based on the AIR until the A/B MAC (A) updates the IHS/ASC cert indicator to a ‘Y’.

See §§100.6 and 100.6.1 of this chapter for information on the payment policy and claims

processing for ASC services.

NOTE: Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no

longer processes claims for IHS ASCs. All IHS ASC providers, including hospital

outpatient departments requesting payment based on freestanding ASC rates and ASCs

affiliated with a hospital but operating as a distinct entity for the purpose of performing

outpatient surgical services must enroll with and submit their claims to the designated

A/B MAC (B).