Ambulatory Surgery Center Definition
"Ambulatory outpatient surgical center" means a public or private institution that meets the following conditions:
- Is established, equipped, and operated primarily for the purpose of performing surgical procedures and services
- Is operated under the supervision of at least one licensed physician or under the supervision of the governing board of the hospital if the center is affiliated with a hospital
- Permits a surgical procedure to be performed only by a physician, dentist, or podiatrist who meets the following conditions
- Is qualified by education and training to perform the surgical procedure
- Is legally authorized to perform the procedure
- Is privileged to perform surgical procedures in at least one hospital within the county or an Indiana county adjacent to the county in which the ambulatory outpatient surgical center is located
- Is admitted to the open staff of the ambulatory outpatient surgical center
- Requires that a licensed physician with specialized training or experience in the administration of an anesthetic supervise the administration of the anesthetic to a patient and remain present in the facility during the surgical procedure, except when only a local infiltration anesthetic is administered
- Provides at least one operating room and, if anesthetics other than local infiltration anesthetics are administered, at least one (1) post-anesthesia recovery room
- Is equipped to perform diagnostic x-ray and laboratory examinations required in connection with any surgery performed
- Does not provide accommodations for patient stays of longer than 24 hours
- Provides full-time services of registered and licensed nurses for the professional care of the patients in the post-anesthesia recovery room
- Has available the necessary equipment and trained personnel to handle foreseeable emergencies such as a defibrillator for cardiac arrest, a tracheotomy set for airway obstructions, and a blood bank or other blood supply
- Maintains a written agreement with at least one hospital for immediate acceptance of patients who develop complications or require postoperative confinement
- Provides for the periodic review of the center and the center's operations by a committee of at least three licensed physicians having no financial connections with the center
- Maintains adequate medical records for each patient
- Meets all additional minimum requirements as established by the state department for building and equipment requirements
- Meets the rules and other requirements established by the state department for the health, safety, and welfare of the patients
Excluded from the definition are birthing centers.
License Requirements
A license must be obtained before establishing, conducting, operating or maintaining an ambulatory outpatient surgical center.
ASC license fees are due upon initial application for and annual renewal of the ASCs license based upon total annual procedures performed as reported to the Indiana Department of Health. The fee schedule, based on procedure volume, is as follows:
- 0-799: $500
- 800-3,499: $1,000
- 3,500-6,999: $2,000
- 7,000 and above: $3,000
A person who operates an unlicensed institution or agency or advertises the operation of an unlicensed institution or agency commits a Class A misdemeanor.
Certificate of Need
Indiana's CON requirements do not apply to ASCs.
Length of Stay Restriction
An ASC may not provide accommodations for patient stays of longer than 24 hours.
Medical History and Physical Examination
All ASC patient records must document and contain appropriate medical history and results of a physical examination performed as follows:
- In accordance with medical staff requirements on history and physical examination consistent with the scope and complexity of the procedure to be performed
- On each patient admitted by a physician, dentist, or podiatrist who has been granted such privileges by the medical staff or by another member of the medical staff
- Within the time frame specified by the medical staff prior to date of admission and documented in the record with a durable, legible copy of the report and with an update and changes noted in the record on admission in accordance with center policy
Transfer Agreement
The governing body of an ASC shall ensure that the center maintains a written transfer agreement with one or more hospitals for immediate acceptance of patients who develop complications or require postoperative confinement, and that all physicians, dentists and podiatrists performing surgery in the center maintain admitting privileges at one or more hospitals in the same county or in an Indiana county adjacent to the county in which the center is located.
Price Transparency
Indiana imposes price transparency requirements on shoppable services and requires the provision of a good faith estimate to patients.
Shoppable Services: ASCs must post on their Internet website pricing and other information for the following:
- For as many of the 70 shoppable services specified in the final rule of the Centers for Medicare and Medicaid Services published in 84 FR 65524 that are provided by the ASC
- In addition to the services specified above:
- The 30 most common services that are provided by the ASC not included above
- Or if the ASC offers less than 30 services not included above, all of the services provided by the ASC.
The following information, to the extent applicable, must be included on the Internet web site by an ASC for the shoppable and common services described above:
- A description of the shoppable and common service
- The standard charge per item or service for each of the following categories:
- Any nongovernment sponsored health benefit plan or insurance plan provided by a health carrier in which the provider is in the network
- Medicare, including fee for service and Medicare Advantage
- Self-pay without charitable assistance from the ASC
- Self-pay with charitable assistance from the ASC
- Medicaid, including fee for service and risk based managed care.
"Standard charge" means the regular rate established by the ASC for an item or service provided to a specific group of paying patients. The term includes the following:
- Gross charge (defined as the charge for an individual item or service that is reflected on an ASC's chargemaster, absent any discounts)
- Payer-specific negotiated charge (defined as the charge that an ASC has negotiated with a third party payer for an item or service)
- De-identified minimum negotiated charge (defined as the lowest charge that an ASC has negotiated with any third party payer for an item or service)
- De-identified maximum negotiated charge (defined as the highest charge that an ASC has negotiated with any third party payer for an item or service)
- And discounted cash price (defined as the charge that applies to an individual who pays cash or the cash equivalent for an ASC item or service).
An individual for whom a nonemergency health care service has been ordered, scheduled or referred may request from the provider facility (defined to include ASCs) in which the nonemergency health care service will be provided a good faith estimate of the price that will be charged for the nonemergency health care service. A provider facility that receives such a request shall, not more than five business days after receiving relevant information from the individual, provide to the individual a good faith estimate of:
- The price that the provider facility in which the health care service will be performed will charge for:
- The use of the provider facility to care for the individual for the nonemergency health care service
- The services rendered by the employed or contracted staff of the provider facility in connection with the nonemergency health care service
- And medication, supplies, equipment and material items to be provided to or used by the individual while the individual is present in the provider facility in connection with the nonemergency health care service
- The price charged for the services of all practitioners, support staff and other persons who provide professional health services:
- Who may provide services to or for the individual during the individual’s presence in the provider facility for the nonemergency health care service
- And for whose services the individual will be charged separately from the charge of the provider facility.
Good Faith Estimate: An individual for whom a nonemergency health care service has been ordered, scheduled or referred may request from the provider facility in which the nonemergency health care service will be provided a good faith estimate of the price that will be charged for the nonemergency health care service. A facility that receives such a request shall, not more than two business days after receiving relevant information from the individual, provide to the individual a good faith estimate, by electronic mail or through a mobile application or other Internet web-based method, if available.
A good faith estimate provided by a provider facility must provide a summary of the services and material items that the good faith estimate is based on and include a total figure that is a sum of the estimated prices listed above.
Workers' Compensation
Medical service facilities (defined to include ASCs) must be reimbursed a reasonable amount, which is established by payment of one of the following:
- The amount negotiated at any time between the medical service facility and any of the following: the employer; the employer's insurance carrier; a billing review service on behalf of the employer or their insurance carrier; a direct provider network that has contracted with the employer or their insurance carrier
- 200% of the amount that would be paid to the medical service facility on the same date for the same service or product under the medical service facility's Medicare reimbursement rate, if after conducting the negotiations described in the first bullet point, an agreement has not been reached
For additional information, visit the Worker's Compensation Board's provider information page.
Patient Safety Reporting Requirements
ASCs are required to document and report information on specified Adverse Incidents. Indiana makes this information available to the public. More information on criteria and reporting requirements can be found here.
Charity Care
Indiana does not impose charity care requirements on ASCs.
Surgical Smoke
Indiana does not impose surgical smoke evacuation requirements on ASCs.
Advance Directives
Living Wills and Life Prolonging Procedures: Certification of Qualified Patient; Procedure Where Physician Refuses to Honor Declaration
For Full Act: § 16-36
Advance Directive Form
Advance Directives Resource Center
State Regulator
Indiana Department of Health
Division of Acute & Continuing Care
2 North Meridian Street, 4A
Indianapolis, IN 46204
Randy Snyder, Director, Division of Acute Care & Continuing Care
rsnyder1@isdh.in.gov
317.233.1286
Statutory & Regulatory References
Indiana Code: § 16-21-2
Indiana Administrative Code: 410 § 15-2.1-2; 410 § 15-2.4-2.2