Page 248 - Medicare Benefit Policy Manual

If a hospital based surgery center is not certified as an ASC it continues under the
program as part of the hospital. In that case the applicable hospital outpatient payment
rules apply. This is the outpatient prospective payment system (OPPS), for most
hospitals, or may be provisions for hospitals excluded from OPPS. See Pub.100-04, the
Medicare Claims Processing Manual, chapter 4, for billing and payment requirements for
hospital outpatient services.

Indian Health Service (IHS) hospital outpatient departments are not certified as separate
ASC entities. The ASC indication merely means that CMS approved them to bill for
ASC services and be paid based on the ASC rates for services on the ASC list. In order
to bill for ASC services, the hospital outpatient department must meet the conditions of
participation for hospitals defined at 42 CFR, Part 482. See Pub. 100-04, the Medicare
Claims Processing Manual, chapter 19, sections 40.2.1, and 80.9 for more information on
IHS hospital outpatient departments billing for ASC services.

260.2 - Ambulatory Surgical Center Services
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)

The ASC facility services are services furnished in an ASC in connection with a covered
surgical procedure that are otherwise covered if furnished on an inpatient or outpatient
basis in a hospital in connection with that procedure. Not included in the definition of
facility services are medical and other health services, even though furnished within the
ASC, which are covered under other portions of the Medicare program, or not furnished
in connection with covered surgical procedures. This distinction between covered ASC
facility services and services which are not covered ASC facility services is important,
since the facility payment rate includes only the covered ASC facility services. Services,
which are not covered ASC facility services such as physicians’ services and prosthetic
devices other than intraocular lenses (IOLs), may be covered and billable under other
Medicare provisions.

Since there is no uniformity among ASCs as to what items and services they include in
their facility fee or charge, the Medicare definition of covered facility services is both
inclusive and exclusive. The regulations specify what are and are not facility services.
Facility services are items and services furnished in connection with listed covered
procedures, which are covered if furnished in a hospital operating suite or hospital
outpatient department in connection with such procedures. These do not include
physicians’ services, or medical and other health services for which payment may be
made under other Medicare provisions (e.g., services of an independent laboratory
located on the same site as the ASC, anesthetist professional services, non-implantable
DME).

Examples of covered ASC facility services include:

Nursing Services, Services of Technical Personnel, and Other Related Services