ASC billing Payment and Reimbursement - ASC fee schedule

Effective January 1, 2008
The standard ASC payment for most ASC covered surgical procedures is calculated as the product of the estimated ASC conversion factor and the ASC relative payment weight (set based on the OPPS relative payment weight) for each separately payable procedure. Per Section 626 of the MMA, contractors will pay ASCs based on the lesser of the actual charge or the standard ASC payment rate. Payment rates for surgical procedures that are commonly performed in physicians’ offices and the technical component of covered ancillary radiology procedures cannot exceed the MPFS non-facility Practice Expense (PE) amount. Payments to ASCs for covered surgical procedures and certain covered ancillary services are geographically adjusted using the Inpatient Prospective Payment System (IPPS) pre-reclassification wage index values, with 50 percent as the labor-related factor. There is an annual adjustment of the payment rates for inflation. The update for inflation begins with the CY 2010 ASC payment rates when the statutory requirement for a zero update no longer applies.

CMS adjusts for geographic differences in wages using the Core-Based Statistical Area (CBSA) geographic locality definitions established in 2003 by the Office of Management and Budget (OMB). CBSA is a statistical geographic unit consisting of a county or counties associated with at least one core (urbanized area or urban cluster) of at least 10,000 in population, plus adjacent counties having a high degree of social and economic integration with the core as measured through ties with counties containing the core. Metropolitan and micropolitan statistical areas are the two categories of CBSAs.

The calculation adjusts the national ASC rate to a rate that applies to the ASC location. TrailBlazer Health EnterprisesSM will make necessary calculation adjustments based on various CBSAs and post the ASC fee schedule to the TrailBlazer Web site.

Payment is made to ASCs under Part B for all surgical procedures except those that CMS determines may pose a significant safety risk to beneficiaries or that are expected to require an overnight stay when furnished in an ASC.

Each January 1, CMS publishes updates to the list of procedures for which an ASC may be paid for that year. In addition, CMS publishes quarterly updates to the lists of covered surgical procedures and covered ancillary services to establish payment indicators and payment rates for newly created Level II HCPCS and Category III CPT codes. The complete lists of ASC-covered surgical procedures and ASC-covered ancillary services, applicable payment indicators, payment rates for each covered surgical procedure and ancillary service before adjustments for regional wage variations, the wage adjusted payment rates, and wage indices are available on the CMS Web site at http://www.cms.hhs.gov/ascpayment/.

ASC Fee Schedule
The ASC fees can be accessed from the TrailBlazer ASC specialty Web page at:
http://www.trailblazerhealth.com/Tools/Fee%20Schedule/ASCFEESchedule.aspx
The current year, the state, region and procedure code must be entered to obtain the current ASC payment rate. The online fee schedule will provide the allowed amount,