Medicare Payments
Medicare pays for surgical procedures in an ASC unless the Centers for Medicare & Medicaid Services (CMS) determine that the procedures meet any of the following criteria for exclusion.
Covered Procedures
The facility fee is designed to pay for the use of the ASC, including:
- Nursing
- Technician and related services
- Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure
- Administrative, recordkeeping and housekeeping items and services
- The operating surgeon’s supervision of the services provided by an anesthetist
As a general rule, the facility fee also covers:
- The drugs
- Biological
- Surgical dressings
- Supplies
- Splints
- Casts
- Appliances and equipment that are directly related to the provision of surgical procedures
- Anesthesia materials and implants, including intraocular lenses (IOLs)
Medicare does, however, make a separate payment for certain drugs, including:
- Some anesthetic agents
- Biologics
- Radiologic services
These separately payable items and services are considered ancillary services, and Medicare pays ASCs for them when they are provided in conjunction with a Medicare-covered procedure.
In addition, Medicare makes an additional $50 payment for interocular lenses (IOLs) that have been designated as “New Technology” IOLs (NTIOLs). Currently, no IOLs are classified as NTIOLs. CMS, however, may designate certain IOLs as being NTIOLs in the future.
Payment System
In 2008, CMS implemented a substantially revised payment system for ASCs based on Medicare’s hospital outpatient department payment system. Under the revised system, Medicare pays ASCs a prospectively determined rate for covered procedures. These rates are updated annually.
Each summer Medicare proposes rates for the next year and then finalizes the rates in the fall.
ASCA’s Medicare Payment Resources
2013 Final Payment Rule
2013 Medicare Rate Calculator
This calculator shows your national and local payment rates for 2013. Simply look up your local wage index from the easy to use chart and type it into the calculator and the calculator does the rest.
2013 Separately Payable Procedures
This document provides the list of procedures that are payable in an ASC in 2013 and for which there is a separate payment made. The CPT code and the 2013 national ASC rate are provided. This list does not include packaged procedures.
2013 Packaged Procedures
This chart lists the procedures that are on the 2013 ASC list, but for which there are no separate payments because payments for these packaged procedures are included in the payments made for other procedures.
2013 Ancillary Services
This chart provides the list of covered ancillary services for 2013. ASCs may bill for ancillary services when provided in conjunction with covered surgical procedures. This list will be updated quarterly to reflect changes made by Medicare.
2013 Device Intensive Procedures
This chart lists the procedures classified as device intensive in 2013 and their 2013 ASC payment rate.
2013 Office Based Procedures
This chart lists the procedures classified as office based for 2013, their 2013 payment rates, and whether the rates are based on the hospital outpatient department rates or on the physician's practice expense rates.
2013 Multiple-Procedure Discounting Exempt
This chart shows the procedures exempt from multiple-procedure discounting in 2013 and their 2013 ASC payment rate.
2013 Patient Cost Sharing Waived Services
This chart shows the services for which the patient copayment and deductible are waived for 2013.
2013 ASC List Changes
This chart lists codes that have been added to and deleted from the ASC list of payable procedures and the reason for addition/deletion.
Click on the heading tabs below to find out more information.
2013 Proposed Payment Rule
2013 Proposed Medicare Rate Calculator
This calculator shows your proposed national and local payment rates for 2013. Simply look up your local wage index from the easy to use chart and type it into the calculator and the calculator does the rest.
2013 Proposed Separately Payable Procedures
This document provides the proposed list of procedures that are payable in an ASC in 2013 and for which there is a separate payment made. The CPT code and the 2013 proposed national ASC rate are provided. This list does not include packaged procedures.
2013 Proposed Packaged Procedures
This chart lists the procedures that are on the proposed 2013 ASC list, but for which there are no separate payments because payments for these packaged procedures are included in the payments made for other procedures.
2013 Proposed Ancillary Services
This chart provides the proposed list of covered ancillary services for 2013. ASCs may bill for ancillary services when provided in conjunction with covered surgical procedures. This list will be updated quarterly to reflect changes made by Medicare.
2013 Proposed Device Intensive Procedures
This chart lists the proposed procedures classified as device intensive in 2013 and their 2013 ASC payment rate.
2013 Proposed Office Based Procedures
This chart lists the proposed procedures classified as office based for 2013, their proposed 2013 payment rates, and whether the rates are based on the hospital outpatient department rates or on the physician's practice expense rates.
2013 Proposed Multiple-Procedure Discounting Exempt
This chart shows the proposed procedures exempt from multiple-procedure discounting in 2013 and their proposed 2013 ASC payment rate.
2013 Proposed Patient Cost Sharing Waived Services
This chart shows the proposed services for which the patient copayment and deductible are waived for 2013.
2012 Final Payment Rule
2012 Final Medicare Rate Calculator
This calculator shows your local payment rates for 2012. Simply look up your local wage index from the easy to use chart and type it into the calculator and the calculator does the rest.
Updated incorporating CMS's April 24, 2012 correction. Corrected rates are retroactive to January 1, 2012.
2012 Separately Payable Procedures
This document provides the list of procedures that are payable in an ASC in 2012 and for which there is a separate payment made. The CPT code and the 2012 national ASC rate are provided. This list does not include packaged procedures.
2012 Packaged Procedures
This chart lists the procedures that are on the 2012 ASC list, but for which there are no separate payments because payments for these packaged procedures are included in the payments made for other procedures.
2012 Ancillary Services
This chart provides the list of covered ancillary services for 2012. ASCs may bill for ancillary services when provided in conjunction with covered surgical procedures. This list will be updated quarterly to reflect changes made by Medicare.
2012 Device Intensive Procedures
This chart lists the procedures classified as device intensive in 2012 and their 2012 ASC payment rate.
2012 Office Based Procedures
This chart lists the procedures classified as office based for 2012, their proposed 2012 payment rates, and whether the rates are based on the hospital outpatient department rates or on the physician's practice expense rates.
2012 Multiple-Procedure Discounting Exempt
This document lists the procedures that are exempt from multiple-procedure discounting in 2012.
2012 Patient Cost Sharing Waived Services
This chart shows the services for which the patient copayment and deductible are waived for 2012.