Thursday, June 30, 2016

Payment for ASC Facility services - covered and non covered


FCHP does reimburse for ambulatory surgical day procedures as follows:

Outpatient surgery procedures:

• Outpatient surgeries are reimbursed per contractual agreement.

Facility services

• Facility services that are directly related to the procedure performed including but not limited to anesthesia, operating room, recovery room, implantable device, pharmacy and supplies. Operative notes may be requested for facility charges which are $2,500 or more.

• Bilateral surgeries are typically reimbursed at 150% of the contracted allowable rate for the both procedures when billed on one line with the -50 modifier appended to the procedure code. 100% to be paid for first procedure, 50% to be paid for second procedure. Special situations occasionally apply when other reimbursement will be paid.

• Facilities reimbursed according to the Medicare ASC fee schedule will follow the payment methodology in the CMS Ambulatory Surgical Center Billing Guide.

FCHP does not reimburse:

• Ambulatory surgical day procedures if they are deemed:

** Not medically necessary

** Those services that require prior authorization by the Plan when authorization was not obtained. The member may not be billed for non-authorized services when performed by contracted providers at contracted facilities

** Services provided by residents.

• Services resulting in inpatient admission. Reimbursement for these services will be included in the inpatient reimbursement.
• Observation services related to an ambulatory surgical procedure. These are considered part of the routine recovery period for the procedure and are included in the reimbursement for the ambulatory surgical procedure

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