COVERAGE OF SERVICES IN AN ASC

COVERAGE OF SERVICES IN AN ASC WHICH ARE NOT ASC FACILITY SERVICES

• Ambulance Services
If the ASC furnishes ambulance services, the facility may obtain approval as an ambulance supplier to bill covered ambulance services.

• Artificial Legs, Arms and Eyes
Like non-implantable 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. If the ASC furnishes these items to patients, it is treated as a DME 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.

• Durable Medical Equipment (DME) (Implantable)
If the ASC furnishes items of implantable DME to patients, the ASC bills and receives a single payment from NHIC for the covered surgical procedure and the implantable device, as long as the implantable device does not have pass-through status under the OPPS. When the surgical procedure is not on the ASC list, the physician bills for his or her professional services and the ASC may bill the beneficiary for the facility charges associated with the procedure.

• Durable Medical Equipment (DME) (Non-implantable)
If the ASC furnishes items of non-implantable DME to patients, the ASC is treated as a DME supplier and all rules and conditions ordinarily applicable to DME are applicable. This includes obtaining a supplier number and billing the DME MAC where applicable.

•  Leg, Arm, Back and Neck Braces
These items of equipment, like non-implantable prosthetic devices, are covered under Part B, but are not included in the ASC facility payment amount. If the ASC furnishes these to patients, it is treated as a DME 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.

• Physicians’ Services
This category includes most covered services performed in ASCs which are not considered ASC facility services. Consequently, physicians who perform covered services in ASCs receive separate payment under Part B. Physicians’ services include the services of anesthesiologists administering or supervising the administration of anesthesia to ASC patients and the patients’ 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 which the individual physician usually includes in the fee for a given surgical procedure.

• Prosthetic Devices
Prior to January 1, 2008, an ASC was allowed to bill and receive separate payment for implantable prosthetic devices, other than intraocular lenses (IOLs) that were implanted, inserted, or otherwise applied by surgical procedures on the ASC list of approved procedures. The ASC billed NHIC and received payment according to the DMEPOS fee schedule. However, an intraocular lens (IOL) inserted during or subsequent to cataract surgery in an ASC was included in the facility payment rate.
Beginning January 1, 2008, payment for implantable prosthetic devices without OPPS pass-through status is included in the ASC payment for the covered surgical procedure. ASCs may not bill separately for implantable devices without OPPS pass-through status. 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 as directed by the jurisdiction list.

• Services of an Independent Laboratory
Only a very limited number and type of diagnostic tests are considered ASC facility services and these are 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 since §1861(s) of the statute 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. The ASC’s laboratory must be CLIA certified and will need to enroll with NHIC as a laboratory. Otherwise, the ASC makes arrangements with a covered laboratory or laboratories for laboratory services. If the ASC has a certified independent laboratory, the laboratory itself bills NHIC.