Ambulatory Surgical Centers

Revised: September 11, 2020

· Eligible Providers

· Eligible Members

· Covered Services

· Billing

· Definitions

· Legal References

Overview

An Ambulatory Surgical Center (ASC) is a facility licensed and certified as an outpatient surgical center to provide surgical procedures that do not require overnight inpatient hospital care, including nonprofessional or facility services.

Eligible Providers

A freestanding ASC that meets ASC requirements is eligible to be a provider.

Eligible Members

Minnesota Health Care Programs (MHCP) members may be eligible to receive services from an ASC, depending on the enrolled member’s major program.

Covered Services

Services rendered in an ASC are subject to all applicable MHCP coverage rules including:

· Consent

· Medical necessity

· Request for authorization

· Second medical opinion

The following facility services and supplies are covered as ASC services and are included in the MHCP ambulatory surgery procedure payment: (These services and supplies may not be separately billed.)

· Use of facility (operating and recovery rooms, member preparation areas, waiting rooms, all other areas used by the member, or offered for use by persons accompanying the member)

· Nursing and technician services rendered by employees of the ASC (for example, nurses, technicians, orderlies)

· Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment. This category includes all supplies and equipment commonly furnished by the ASC in connection with surgical procedures. Secondary coverings (ace bandages, elastic stockings, spence boots, etc.) are included in the facility services

· Urinary supplies, such as collection devices, indwelling and external catheters, any type drainage bags, leg straps, external urethral clamps, irrigation supplies (bulbs, syringes, tubing, sterile saline or water), insertion trays, and perianal fecal collection pouches

· Primary surgical dressings that are therapeutic and protective coverings directly applied to the skin or on openings to the skin and required as a result of a surgical procedure

· Routine laboratory, X-ray, or other diagnostic tests routinely provided prior to surgery (for example, urinalysis, hemoglobin, hematocrit), as required by ASC protocol

· Administrative, record keeping and housekeeping services necessary to operate the facility (for example, scheduling, cleaning, utilities, rent)

· Blood, blood plasma, and platelets. Covered procedures are limited to those not expected to result in extensive loss of blood.

· Anesthetic and any supplies, whether disposable or reusable, necessary for its administration

Non-ASC Covered Services

The following services and supplies are not covered as ASC services, nor included in the MHCP ambulatory surgery procedure payment. Bill separately for the following services:

· Professional services: physician, anesthesiologist (administration or supervision of administration of anesthesia), and certified registered nurse anesthetists (CRNA) services

· Laboratory, X-rays, or diagnostic procedures other than those directly related to the performance of the surgical procedure

· Prosthetic devices, except intraocular lenses, including leg, arm, back and neck braces, and artificial limbs

· Ambulance services

· Durable medical equipment for use in the member’s home

· Take home supplies and medications not furnished at the time of surgery with a written physician’s order from a supplier

· Pathology services

· Secondary dressings applied over a primary dressing. Examples of secondary dressings are ace bandages, elastic stockings, support hose, spence boots and other foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for arms and hands.

Terminated Procedures

Surgical procedures terminated after a member was prepped and taken to the operating room, but before the induction of anesthesia, will receive partial ASC payment for the procedure(s).

Surgical procedures terminated after the induction of anesthesia, due to medical complication(s), will receive full ASC payment for the procedure(s).

Billing

Bill all ASC facility claims on the 837I.

The type of claim billed includes the following:

· 0831: Original or initial claim

· 0837: A replacement claim

· 0838: Void the claim

· The appropriate CPT code

Refer to the following for information about modifiers approved for ASC hospital outpatient:

· Bill terminated procedures with the appropriate modifier

· If more than one procedure was performed, use the appropriate modifier(s) as described in the CPT or the HCPCS manual for subsequent surgeries requiring modifiers

· Use CPT Level I

· Level II (use HCPCS codes, or the appropriate national modifiers or both)

List primary procedures first, followed by any subsequent procedures with appropriate modifiers.

When billing for anesthesia used during outpatient dental procedures, refer to the Outpatient Dental Surgery Services table in the Dental Benefits for Non-Pregnant Adults section of the MHCP Provider Manual.

Definitions

Ambulatory Surgical Center (ASC): A facility licensed and certified as an outpatient surgical center to provide surgical procedures that do not require overnight inpatient hospital care.

Facility Services: Items and services provided by an ASC in connection with a covered surgical diagnostic procedure.

Legal References

Minnesota Rules, 4675.0100 to 4675.2800 (facility licensure)
Minnesota Rules, 9505.0240 (Ambulatory Surgical Centers)
Minnesota Rules, 9505.0445 (payment information)
Code of Federal Regulations, title 42, section 416 (ASC guidelines)