ASCs - Citations and Description

2210 - ASCs - Citations and Description (Rev. 1, 05-21-04) Section 1832(a)(2)(F) of the Social Security Act (the Act) provides that, as an adjunct to outpatient surgical services, ASC facility services can be paid under Part B of the Medicare program. Though it is a supplier, an ASC must be certified and approved to enter into a written agreement with CMS. The Conditions for Coverage of ASC services are found in 42 CFR 416. Interpretive guidelines and surveyor procedures are in Appendix L. Participation as an ASC is limited to any distinct entity that operates exclusively for purposes of providing surgical services to patients not requiring hospitalization (i.e., an inpatient stay in a hospital). The regulatory definition of an ASC (42 CFR 416.2) does not allow the ASC and another entity to mix functions and operations in a common space during concurrent or overlapping hours of operations. Our current regulations and policy do not allow an entity to function both as an ASC and an Independent Diagnostic Testing Facility (IDTF), mixing unrelated functions and operations in a common space during concurrent or overlapping hours of operation. That is, the two facilities must be separated by time (different hours of operation) or the other entity may operate in the ASCs space when the space is not operating in that space. An exception to this rule is when there is a need for imaging services during the course of a procedure in progress at an ASC, the IDTF sharing the space with the ASC (but a different time), may conduct the required service outside of its normal business hours, as needed, and receive Medicare payment for those services. In this situation, our regulations and regulations and policy allow the IDTF to bill and receive Medicare payment for imaging and guidance services (such as angiography, venography, fluoroscopy, and ultrasonic needle guidance) that are reasonable and necessary and directly related to the performance of a surgical procedure and furnished in conjunction with a surgical procedure despite being conducted during the ASC’s designated hours. The operating room(s) and recovery room(s) are to be used only for patients having surgery. The ASC must also have a separate recovery room and waiting area. (See 42 CFR 416.44(a)(2)). An ASC may be either hospital-operated or independent. The hospital-operated ASC must be a separately identified entity. It must be physically and administratively distinct from other operations of the hospital and be able to identify its costs separately from other hospital costs. A hospital ASC’s agreement is made effective prospectively at the start of the hospital’s next cost reporting year. (See 42 CFR 416.30(f)(1).) The ASC may not perform a surgical procedure on a Medicare beneficiary when, before surgery, an overnight hospital stay is anticipated. There may, however, arise unanticipated medical circumstances that warrant a beneficiary’s hospitalization after an ASC surgical procedure. The ASC must have procedures for the immediate transfer of these patients to a hospital (42 CFR 416.41). Such situations should be infrequent. ASC covered procedures (see 42 CFR 416.65) are those that generally do not exceed 90 minutes in length and do not require more than four hours recovery or convalescent time. Therefore, ASC patients generally do not require extended care as a result of ASC procedures. An unanticipated medical circumstance may arise that would require an ASC patient to stay in an overnight health care setting. Such situations should also be infrequent. When extended care in a non-hospital health care setting is anticipated as a result of a particular procedure, that procedure would not be a covered ASC procedure for beneficiaries. The SA follows standard procedures for identifying interested ASCs and certifying them. If the ASC operates other activities as part of the same enterprise, the SA forwards a request for certification, Form CMS-377, (Exhibit 64) with a Certification and Transmittal, Form CMS-1539, to the RO, together with any evidence covering the activities operated. Copies of the ASC Health Insurance Benefits Agreement, Form CMS- 370 (Exhibit 65) are signed and processed in the same manner as provider agreements. Rural Health Clinics (RHCs)