OAR 436-009-0023: Ambulatory Surgery Center (ASC)

(1) Billing Form. (a) The ASC must submit bills on a completed, current CMS 1500 form (see OAR 436-009-0010 (3)) unless the ASC submits medical bills electronically. Computer-generated reproductions of the CMS 1500 form may also be used. (b) The ASC must add a modifier “SG” in box 24D of the CMS 1500 form to identify the facility charges. (2) ASC Facility Fee. (a) The following services are included in the ASC facility fee and the ASC may not receive separate payment for them: (A) Nursing, technical, and related services; (B) Use of the facility where the surgical procedure is performed; (C) Drugs and biologicals designated as packaged in Appendix D, surgical dressings, supplies, splints, casts, appliances, and equipment directly related to the provision of the surgical procedure; (D) Radiology services designated as packaged in Appendix D; (E) Administrative, record-keeping, and housekeeping items and services; (F) Materials for anesthesia; (G) Supervision of the services of an anesthetist by the operating surgeon; and (H) Packaged services identified in Appendix C or D. (b) The payment for the surgical procedure (i.e., the ASC facility fee) does not include physician’s services, laboratory, X-ray, or diagnostic procedures not directly related to the surgical procedures, prosthetic devices, orthotic devices, durable medical equipment (DME), or anesthetists’ services. (3) ASC Billing. (a) The ASC should not bill for packaged codes as separate line-item charges when the payment amount says “packaged” in Appendices C or D. (b) When the ASC provides packaged services (see Appendices C and D) with a surgical procedure, the billed amount should include the charges for the packaged services. (c) For the purpose of this rule, an implant is an object or material inserted or grafted into the body. When the ASC’s cost for an implant is $100 or more, the ASC may bill for the implant as a separate line item. The ASC must provide the insurer a receipt of sale showing the ASC’s cost of the implant. (4) ASC Payment. (a) Unless otherwise provided by contract, insurers must pay ASCs for services according to this rule. (b) Insurers must pay for surgical procedures (i.e., ASC facility fee) and ancillary services the lesser of: (A) The maximum allowable payment amount for the HCPCS code found in Appendix C for surgical procedures, and in Appendix D for ancillary services integral to a surgical procedure; or (B) The ASC’s usual fee for surgical procedures and ancillary services. (c) When more than one procedure is performed in a single operative session, insurers must pay the principal procedure at 100 percent of the maximum allowable fee, and the secondary and all subsequent procedures at 50 percent of the maximum allowable fee. A diagnostic arthroscopic procedure performed preliminary to an open operation is considered a secondary procedure and should be paid accordingly. The multiple surgery discount described in this section does not apply to codes listed in Appendix C with an “N” in the “Subject to Multiple Procedure Discounting” column. (d) The table below lists packaged surgical codes that ASCs may perform without any other surgical procedure. In this case do not use Appendix C to calculate payment, use the rates listed below instead. [See attached table.] (e) When the ASC’s cost of an implant is $100 or more, insurers must pay for the implants at 110 percent of the ASC’s actual cost documented on a receipt of sale and not according to Appendix D or E. (f) When the ASC’s cost of an implant is less than $100, insurers are not required to pay separately for the implant. An implant may consist of several separately billable components, some of which may cost less than $100. For payment purposes, insurers must add the costs of all the components for the entire implant and use that total amount to calculate payment for the implant. (g) The insurer does not have to pay the ASC when the ASC provides services to a patient who is enrolled in a managed care organization (MCO) and: (A) The ASC is not a contracted facility for the MCO; (B) The MCO has not pre-certified the service provided; or (C) The surgeon is not an MCO panel provider. [ED. NOTE: To view attachments referenced in rule text, click here to view rule.]