|  | Healthcare Industry | Medicare

Medicare ASC Regulations

Ambulatory Surgery Centers, or ASCs, provide a convenient and cost-effective alternative for patients who need certain types of surgery. An ASC, or surgicenter, is a non-hospital facility where patients receive surgery that does not require hospital admission. As with hospitals, ASCs are regulated by various bodies, one of which is Medicare. Since many of these facilities treat Medicare beneficiaries, they must abide by the regulations found in 42 CFR part 416.

  1. Subpart A: General Provisions and Definitions

    • The scope of the regulations broadly covers the conditions that an ASC must meet in order to participate in the Medicare program, the scope of covered services and the conditions for payment by Medicare. Each topic is expanded upon within individual the regulations.

    Subpart B: General Conditions and Requirements

    • There are basic requirements for ASCs to participate in the Medicare program, including accreditation, legal agreements and compliance. An ASC must meet the definition of such as written by Medicare. They must also be accredited by a national accrediting body that is recognized by Medicare. In addition, an ASC must contractually agree to comply with Medicare coverage and payment conditions.

    Subpart C: Specific Conditions for Coverage

    • Specific conditions for Medicare coverage include proper staffing, laboratory and pharmacy services, infection control, patient rights, medical record standards and compliance with licensure laws. An ASC must obtain and maintain any license required by the state in which they operate. Staffing on all levels must be sufficient in not only number but qualification of employees. Centers must follow a standard infection control procedure and maintain safety through defined environmental standards, such as the proper placement of alcohol-based hand rub dispensers and emergency equipment. Patients must be notified of their rights before receiving any service, and their medical records must be kept according to procedure.

    Subpart D: Scope of Benefits for Services

    • Services payable include: administrative services, nursing and technician services; drugs used before, during and after surgery; and appliances and equipment used during surgery. Surgical procedures that meet the following standards are considered payable: procedures that are commonly performed on an outpatient basis in hospitals, not in a physician's office, and generally require less than 90 minutes operating time, followed by no more than 4 hours recovery time.

    Subpart E: Prospective Payment System for Facility Services

    • Payment for services performed before January 1, 2008 are subject to a standard overhead rate per procedure. The payment rate is derived from an estimate of the costs incurred by the center in providing services furnished in connection with the procedure. The payment must be less than what would have been paid if the service were performed as a hospital inpatient.

    Subpart F: Coverage, Scope and Payment System

    • ASC services performed after January 1, 2008 are subject to a revised payment system, which includes ancillary items and services such as implanted devices, radiology, supervision of anesthesia staff and brachytherapy. Revision of the payment system involves using conversion factors against a statutory relative payment amount.

    Subpart G: Adjustment in Payment for Intraocular Lenses

    • Interested parties may request that CMS (Medicare) review fees for the insertion of intraocular lenses (IOL). The review determines whether payment for the lens is reasonable and falls under the class of new technology IOLs. In order to be considered for review, a provider must submit a request that provides medical and scientific proof that the IOL is within an acceptable technology class. If the procedure is accepted for reimbursement, specific billing codes must be used.

Medicare - Related Articles