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How ASC Payment Amounts For Your Location Are Determined

In accordance with the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, the Centers for Medicare & Medicaid Services (CMS) implemented a revised ASC payment system using the Outpatient Prospective Payment System (OPPS) relative payment weights as a guide.

Medicare makes a single payment to ASCs for covered surgical procedures, which includes ASC facility services furnished in connection with the covered procedure. Examples of covered ASC facility services paid through the payment for covered surgical procedures include:

  • Nursing services, services furnished by technical personnel, and other related services
  • Drugs and biologicals for which separate payment is not made under the OPPS, surgical dressings, supplies, splints, casts, appliances, and equipment
  • Blood, blood plasma, and platelets, with the exception of those to which the blood deductible applies
  • Intraocular lenses
  • Radiology services for which payment is packaged under the OPPS
  • Patient use of ASC facilities
  • Administrative, recordkeeping, and housekeeping items and services
  • Materials for anesthesia
  • Implantable devices, with the exception of those devices with pass-through status under the OPPS
  • Diagnostic or therapeutic items and services

Additional payments may be made to the ASC for covered ancillary services integral to a covered surgical procedure that you bill, specifically certain services furnished immediately before, during, or immediately after the covered surgical procedure. Covered ancillary services include:

  • Drugs and biologicals separately paid under the OPPS
  • Brachytherapy sources
  • Corneal tissue acquisition
  • Radiology services separately paid under the OPPS
  • Implantable devices with OPPS pass-through status

ASC payment policy and addenda updatesExternal Site are posted quarterly on the CMS web site.

In order to determine your local ASC payment, you will need to know the national payment rate and your local wage index. Use the formula below to calculate the specific payment for your county.

(National Group ASC Rate x .5) + [(National Group ASC Rate x .5) x Wage Index]

Example

Date of Service: September 29, 2014

Procedure: Cataract Removal with Insertion of IOL (CPT code 66984)

ASC Location: Toledo, Ohio

(National Group ASC Rate x .5) + [(National Group ASC Rate x .5) x Wage Index]

(975.58 x .5) + [(975.58 x .5) x 0.9013]

487.79 + 487.79 x 0.9013

487.79 + 439.645

927.435

927.44

References:

Updated: 10.14.14


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