REGULATORY REVIEW


Medicare Payment Policy Overview How CMS sets ASC reimbursement rates BY KARA NEWBURY


The Centers for Medicare & Medicaid Services (CMS) introduced the system that it uses to set ASC payment rates today on January 1,


2008, in accordance with the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. At that time, Medicare began paying for facility services provided in ASCs using a system that is linked primarily to the hospital outpatient prospective payment system (OPPS). Under this system, as with the OPPS, Medicare pays ASCs a predetermined rate for all covered procedures.


Each summer Medicare proposes


ASC payment rates for the next year and then finalizes the rates in the fall.


What the Facility Fee Covers Medicare pays for surgical procedures in an ASC unless CMS determines that the procedures meet one of the criteria


surgical dressings, supplies, splints, casts, appliances and equipment; ■ administrative, recordkeeping housekeeping items and services;


■ and for exclusion that CMS has


established (for a complete list of those criteria go to www.ascassociation.org/ ExclusionCriteria). CMS also does not reimburse ASCs for “unlisted codes,” or services provided that are not accurately described by the CPT codes listed in the Healthcare Common Procedure Coding System (HCPCS) code book. Hospitals may provide documentation indicating why use of an unlisted code is necessary and may be reimbursed for those, but unlisted codes are not reimbursed in ASCs under any circumstances. An ASC’s facility fee pays for:


■


nursing services, services furnished by technical personnel and other related services;


■ patient use of the ASC facility; ■


drugs and biologicals for which separate payment is not made under the OPPS;


18 ASC FOCUS MARCH 2015


blood, blood plasma and platelets with the exception of those to which the blood deductible applies; ■ materials for anesthesia;


■


■ intraocular lenses (IOLs); and ■


implantable devices, with the excep- tion of those devices with pass- through status under the OPPS. Medicare also makes a separate


payment for certain drugs, services and supplies, including: ■


■


drugs and biologicals separately paid under the OPPS;


radiology services separately paid under the OPPS;


■ brachytherapy sources; ■


■


implantable devices with OPPS pass-through status; and


corneal tissue acquisition. These separately payable items and


services are considered ancillary ser- vices, and Medicare pays ASCs for them when they are provided in conjunction with a Medicare-covered procedure.


CMS produces primers on the var-


ious payment systems, including an ASC fact sheet that includes a helpful chart that provides examples of pay- ment and billing for items or services not included in ASC payments for cov- ered surgical procedures or ancillary services (see the chart on page 19). If you have questions regarding Medicare billing, contact your Medicare Administrative Contractor (MAC). You can find your MAC at: www.ascassociation.org/CMSReview ContractorDirectory.


How Payment Rates Are Determined The rate setting is sophisticated but, at a very basic level, starts with hospital cost reporting. Hospitals supply CMS with outpatient hospital cost data, and both the OPPS and the ASC payment systems use this cost data as a starting point to set payment rates. CMS compiles the cost data and takes out anomalies to try to derive accurate average costs in these outpatient settings for the HCPCS codes for which CMS reimburses. The ASC payment rates are increasingly lower than those of hospital outpatient


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