Ambulatory Surgery Center (ASC) Payment Policy

Payment Policy for ASC Services in the Facility Payment.

OWCP pays the lesser of the billed charge (the ASC’s usual and customary fee) or the maximum allowed rate. Currently, the base maximum allowable rate for any ASC procedure is 175% of the maximum allowable rate for physician’s professional charge as determined from RVU and conversion factor values associated with each HCPCS code, and from GPCI values associated with site of service.

State waiver: Ambulatory surgery services provided in a hospital-based ambulatory surgical center in Maryland are exempt from this section. The Maryland Health Services Cost Review Commission establishes rates for hospital-based ambulatory surgery services in Maryland. Since Maryland hospitals are required to bill these rates, reimbursement for ambulatory services is to be based on the billed charge. Freestanding ambulatory surgical centers in the state of Maryland are not covered under the Maryland state waiver for hospital inpatient, hospital outpatient and hospital-based ambulatory surgical centers.

ASC Services Included in the Facility Payment.

Facility payments for ASCs include the following services which are not paid separately:

• Nursing services, services of technical personnel, and other related services;

• Use by the patient of ASC facilities including the operating room and the recovery room;

• Drugs, including take-home medications, biologicals, surgical dressings, supplies, splints, casts, appliances and equipment directly related to the surgical procedure;

• Diagnostic or therapeutic items and services directly related to the surgical procedure (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.;

• Materials for anesthesia; and

• Intraocular lenses (IOLs).

ASC Services Not Included in the Facility Payment.

Facility payments for ASCs do not include the following services which are paid separately:

• Professional services including physicians;

• Laboratory services;

• X-ray or diagnostic procedures other than those directly related to the performance of the surgical procedure;

• Prosthetics and implants except intraocular lenses;

• Ambulance services;

• Leg, arm, back and neck braces;

• Artificial limbs; and

• DME for use in the patient’s home.

ASC Procedures Covered for Payment.

All procedures covered by OWCP in an ASC are listed in the “List of surgical procedures allowable for facility fee payment to Ambulatory Surgical Center” available online at:

http://www.dol.gov/esa/regs/feeschedule/fee.htm

Note that inclusion in this list does not mean that a procedure is automatically payable. Prior authorization for elective procedures, appropriateness to the accepted condition, and other program requirements must also be met.

ASC Procedures Not Covered for Payment.

Procedures that are not included in the “List of surgical procedures allowable for facility fee payment to Ambulatory Surgical Center” are not covered in an ASC. This list does not include procedures that are currently performed on an ambulatory basis in a physician’s office and that do not generally require the more elaborate facilities of an ASC. Neither does the list include procedures that are appropriately performed in an inpatient hospital setting but would not be safely performed in an ASC. We recognize that there are some procedures that might be appropriately performed in ASC for the younger patient who is generally healthy. But for the larger number of FECA beneficiaries whose health is more likely to be compromised by disability and age, an ASC may be a questionable setting for those same procedures. Therefore, we are including in the list only those procedures that can be safely performed in an ASC on the general FECA population in at least a significant number of cases. The resulting list of procedures allows ASCs to furnish FECA beneficiaries with a broad range of surgical services that reflect the practice of contemporary surgery without compromising patient safety.

ASC Billing Information

Modifiers required for ASC.

Modifier –SG must accompany all CPT and HCPCS codes billed by an Ambulatory Surgery Center.

Modifiers accepted for ASC.

OWCP will accept all valid CPT and HCPCS modifiers, though only a few will affect payment.

Modifiers affecting payment for ASC.

Modifier -50, Bilateral modifier.

Modifier -50 identifies cases where a procedure typically performed on one side of the body is performed on both sides of the body during the same operative session. Providers must bill using separate line items for each procedure performed. Modifier -50 must be applied to the second line items for each procedure performed. The second line item will be paid at 50% of the allowed amount for that procedure.

Modifier -51, Multiple surgery modifier.

Modifier -51 identifies when multiple surgeries are performed on the same patient at the same operative session. Providers must bill using separate line items for each procedure performed. Modifier -51 should be applied to the second line item. The total payment equals the sum of

100% of the maximum allowable fee for the highest valued procedure according to the fee schedule, plus

50% of the maximum allowable fee for the subsequent procedures with the next highest values according to the fee schedule.

If the same procedure is performed on multiple levels the provider must bill using separate line items for each level.

Modifier -73, Discontinued procedure prior to the administration of anesthesia.

Modifier -73 is used when a physician cancels a surgical procedure due to the onset of medical complications subsequent to the patient’s preparation, but prior to the administration of anesthesia. Payment will be at 50% of the maximum allowable fee. Multiple and bilateral procedure pricing will not apply.

Modifier -74, Discontinued procedures after administration of anesthesia.

Modifier -74 is used when a physician terminates a surgical procedure due to the onset of medical complications after the administration of anesthesia or after the procedure was started. Payment will be at 85% of the maximum allowable fee. Multiple and bilateral procedure pricing may apply to this if appropriate to the circumstances.

Prosthetic Implants.

Implants must be billed on a separate line. Many implant items have maximum fees under the OWCP fee schedule. If no maximum allowable levels are set by the fee schedule, OWCP will pay acquisition cost for implants when the bill is accompanied by a copy of the original invoice clearly showing invoice cost less applicable discounts.

Exception: Intraocular Lenses

Intraocular lenses, including new technology lenses, are bundled into the fee for the associated procedure. Please include the cost of the lens in the charge for the procedure. It is permissible to include a line on the bill with the HCPCS code for an intraocular lens (i.e., V2630, V2631 and V2632) and its associated cost for information purposes only.

Acquisition Costs Policy.

Acquisition cost equals the wholesale cost plus shipping, handling and sales tax, net of all discounts. These items must be billed together as one charge. Wholesale invoices for all devices must be retained in the provider’s office files for a minimum of three years. A provider must submit a hard copy of the wholesale invoice when an individual device or supply costs $150.00 or more, or upon request. Payment of a provider’s bill may be delayed if this information is not submitted.

Spinal Injections.

Injection procedures are billed in the same manner as all other surgical procedures with the following considerations:

1. For purposes of multiple procedure discounting, each procedure in a bilateral set is considered to be a single procedure.

2. For injection procedures, which require the use of radiographic localization and guidance, ASCs must bill for the technical component of the radiological CPT code (e.g., 76005 –TC) to be paid for the operation of a fluoroscope or C-arm.

Exception: HCPCS Code G0260 cannot accept modifier -50 or any other multiple procedure modifier.