Page 254 - Medicare Benefit Policy Manual

periodically by CMS. Groupings and related prices are also published periodically.
These are published in the Federal Register and on the CMS Web site.

Beginning January 1, 2008, under the revised ASC payment system, CMS will update the
list of covered surgical procedures, relative payment weights and national unadjusted
payment rates, annually. The updates will be proposed and finalized in the Federal
Register concurrent with updates to the hospital outpatient prospective payment system.

260.5.1 - Nature and Applicability of ASC List
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)

The ASC list of covered surgical procedures indicates procedures that are covered and
may be paid for if performed in the ASC setting. There is no requirement that the
covered surgical procedures be performed only in ASCs. The decision regarding the
most appropriate care setting for a given surgical procedure is made by the physician
based on the beneficiary’s individual clinical needs and preferences. Also, all the general
coverage rules requiring that any procedure be reasonable and necessary for the
beneficiary are applicable to ASC services in the same manner as all other covered
services.

260.5.2 - Nomenclature and Organization of the List
(Rev. 77; Issued: 08-29-07; Effective: 01-01-08; Implementation: 01-07-08)

The listed procedures are all considered “surgical procedures” for coverage purposes
under the ASC provision, regardless of the specific use to which the procedure is put.
For example, many of the “oscopy” procedures listed - bronchoscopy, laryngoscopy, etc.,
may be employed for either diagnostic or therapeutic purposes, or both at the same time,
such as when the “oscopy” permits both detection and removal of a polyp. Those
procedures are considered “surgical procedures” within the context of the ASC provision.
Also, surgical procedures are commonly thought of as those involving an incision of
some type, whether done with a scalpel or (more recently) a laser, followed by removal
or repair of an organ or other tissue. In recent years, the development of fiber optics
technology, together with new surgical instruments utilizing that technology, has resulted
in surgical procedures that, while invasive and manipulative, do not require incisions.
Instead, the procedures are performed without an incision through various body openings.
Those procedures, some of which include the “oscopy” procedures mentioned above, are
also considered surgical procedures for purposes of the ASC provision, and several are
included in the list of covered procedures.

Beginning January 1, 2008, the ASC list of covered surgical procedures is comprised of
surgical procedures that CMS determines do not pose a significant safety risk and are not
expected to require an overnight stay following the surgical procedure.

Surgical procedures are defined as Category I CPT codes within the surgical range of
CPT codes, 10000 through 69999. Also considered to be included within that code range