Non ASC services coverage guidelines

Coverage of Services in ASCs Which Are Not ASC Facility Services or Covered Ancillary Services 

Physicians’ Services - This category includes most covered services performed in ASCs which are not considered ASC services. Physicians who furnish services in ASCs may bill for and receive separate payment under Part B. Physicians’ services include the services of anesthesiologists administering or supervising the administration of anesthesia to beneficiaries in ASCs and the beneficiaries’ 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.

Implantable Durable Medical Equipment (DME) - If the ASC furnishes items of implantable DME to patients, the ASC bills and receives a single payment from the local contractor 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.

Non-implantable Durable Medical Equipment - If the ASC furnishes items of non-implantable DME to beneficiaries, it is treated as a DME supplier, and all the rules and conditions ordinarily applicable to DME are applicable, including obtaining a supplier number and billing the DME MAC where applicable.

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 the local Carrier 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.

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

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 ASC payment for ASC services. If the ASC furnishes these to beneficiaries, it is treated as a supplier, and all the rules and conditions ordinarily applicable to suppliers are applicable, including obtaining a supplier number and billing the DMERC where applicable.

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 ASC payment for ASC services. If the ASC furnishes these items to beneficiaries, it is treated as a supplier, and all the rules and conditions ordinarily applicable to suppliers are applicable, including obtaining a supplier number and billing the DMERC where applicable.

Services of Independent Laboratory - Only a very limited number and type of diagnostic tests are considered ASC facility services and these are included in the ASC payment for covered surgical procedures. In most cases, diagnostic tests performed directly by an ASC are not considered ASC facility services and are not covered under Medicare. Section 1861(s) of the Act 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. In order to bill for diagnostic tests as a laboratory, an ASC’s laboratory must be CLIA certified and enrolled with the carrier as a laboratory and the certified clinical laboratory must bill for the services provided to the beneficiary in the ASC. Otherwise, the ASC makes arrangements with a covered laboratory or laboratories for laboratory services,