What is ASC and covered services - Surgical and Dental services

                   AMBULATORY SURGERY CENTERS BENEFIT COVERAGE STANDARD


BRIEF COVERAGE STATEMENT

Ambulatory Surgery Centers (ASCs) are facilities that operate exclusively for the purpose of furnishing outpatient surgical services that do not require hospitalization. An ASC may be independent or part of a hospital, but only if the building space used by the ASC is physically, administratively and financially independent and distinct from other operations of the hospital

SERVICES ADDRESSED IN OTHER BENEFIT COVERAGE STANDARDS

• None

ELIGIBLE PROVIDERS

Colorado Medical Assistance Program (Colorado Medicaid) enrolled ASC providers must be certified by the Centers for Medicare and Medicaid Services (CMS) to participate in the Medicare program as an ASC. The facility must also be licensed by the Colorado Department of Public Health and Environment.


ELIGIBLE PLACE OF SERVICE

• Ambulatory Surgery Centers

ELIGIBLE CLIENTS

Any client enrolled in Colorado Medicaid for whom a covered ASC service is medically necessary as defined in 10 CCR 2505-10 Section

COVERED SERVICES AND LIMITATIONS

ASC procedures include those that are commonly performed on an inpatient basis in hospitals but may be safely performed in an ASC. ASC procedures are limited to those requiring a dedicated operating room (or suite), and generally requiring a post-operative recovery room or short-term convalescent room. ASC covered procedures are listed in the annual ASC billing manual.


SURGICAL PROCEDURES

Limited to those that are not expected to exceed a total of 4 hours recovery or convalescent time. If the surgical procedures require anesthesia, the anesthesia must be:

1. Local or regional anesthesia; or

2. General anesthesia


DENTAL PROCEDURES

Clients who are less than 21 years of age, and qualifying adult clients, may receive covered dental services in an ASC when those services cannot be delivered safely and effectively in a private office.


PRIOR AUTHORIZATION REQUIREMENTS

The physician performing the surgery shall be responsible for obtaining all necessary Prior Authorizations for those procedures requiring pre-procedure approval by the Department.



NON-COVERED SERVICES AND GENERAL LIMITATIONS

Non-covered services include those that:

• Are not commonly performed in an ASC

• May safely be performed in a physician’s office

• Generally result in extensive blood loss

• Require major or prolonged invasion of body cavities

• Directly involve major blood vessels

• Are generally emergency or life-threatening in nature

• Pose a significant safety risk to clients or are expected to require active medical monitoring at midnight of the day on which the
surgical procedure is performed (overnight stay) when furnished in an ASC; or

• Are not listed in the annual ASC billing manual.

DEFINITIONS TERM  DEFINITION


Ambulatory Surgery Center (ASC)                                          

An entity that operates exclusively for the purpose of furnishing outpatient surgical services, which do not require hospitalization. An A SC may be independent or part of a hospital, but only if the building  space used by the ASC is physically, administratively and financially independent and distinct from other operations of the hospital.



Inpatient Hospital Service  

 Items and services ordinarily furnished by the hospital for the care and treatment of inpatients. These must be provided under the direction of either 1) a physician with privileges or 2) a dentist; in an institution  maintained primarily for treatment and care of patients with disorders other than mental disease.