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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Ambulatory Surgery Centers (ASCs)
Chapter 9
Section 2
Ambulatory Surgical Center (ASC) Reimbursement For Service On Or After October 1, 2023
Issue Date:  August 1, 2023
Authority:  32 CFR 199.14(d)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  C-71, August 1, 2023
1.0  APPLICABILITY
1.1  The contractor shall follow this policy for reimbursing services provided by either network or non-network providers. However, the contractor may use alternative network reimbursement methodologies when approved by the Defense Health Agency (DHA) and the contractor specifically includes them in the network provider agreement.
1.2  This reimbursement policy applies to covered surgical procedures performed in freestanding Ambulatory Surgical Centers (FASCs).
1.3  The contractor shall not exempt ambulatory surgery services provided by FASCs in Maryland from this system and shall reimburse these services using the procedures set forth in this section.
2.0  DESCRIPTION
2.1  An FASC is any distinct entity that is classified by the Centers for Medicare and Medicaid Services (CMS) as an ASC under 42 CFR part 416, and has an active participation agreement with both Medicare and TRICARE. FASCs that specifically serve pediatric populations and do not have a Medicare participation agreement, meet TRICARE’s ASC requirements when the facility:
•  Is accredited by the Joint Commission or the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC); and
•  Enters into a participation agreement with TRICARE.
2.2  The contractor shall ensure FASCs do not bill TRICARE beneficiaries for non-covered procedures, unless the beneficiary agreed in advance in writing to pay for the services.
3.0  POLICY
3.1  Effective for service dates on or after October 1, 2023, TRICARE is adopting the Medicare ASC reimbursement system including their ASC fee schedule rules, payment rates, payment indicators, list of covered procedures and ancillary services, and wage indices.
3.2  The payment rates established under this system shall apply only to the facility charges for ambulatory surgery in an FASC. The contractor shall make facility payments to FASCs only for covered services listed on Medicare’s ASC list, except for Current Procedural Terminology (CPT) code 41899 and certain dental procedures. For covered dental procedures (e.g., CPT procedure code 41899), the contractor shall reimburse the ASC facility at the Outpatient Prospective Payment System (OPPS) rate. Refer to TRICARE Policy Manual (TPM), Chapter 8, Section 13.2 for dental care covered in an ASC. Additional services, which are not otherwise packaged into the OPPS payment for a covered dental procedure, and provided on a claim with covered a dental procedures will be subject to the payment methodology as described in this section.
3.3  The facility rate is a standard overhead amount that includes nursing and technician services; use of the facility; drugs, biologicals, and radiology services, for which separate payment is not allowed under OPPS; surgical dressings, splints, casts and equipment directly related to provision of the surgical procedure; materials for anesthesia; Intraocular Lenses (IOLs); and administrative, recordkeeping and housekeeping items and services.
3.4  This facility rate does not include items such as physicians’ fees (or fees of other professional providers authorized to render the services and to bill independently for them); certain laboratory, X-rays or diagnostic procedures for which separate payment is allowed under OPPS; orphan drugs; prosthetic devices (except IOLs); corneal acquisition tissue; brachytherapy services; certain implantable devices with pass-through status under OPPS; ambulance services; leg, arm, and back braces; artificial limbs; and Durable Medical Equipment (DME) for use in the patient’s home.
4.0  REIMBURSEMENT OF AMBULATORY SURGERY
4.1  Reimbursement
The contractor shall ensure payment to an FASC for covered services and items are the lower of the ASC payment rate or the billed charge. For surgical procedures which are covered under TRICARE, but are not on Medicare’s ASC list of covered surgical procedures, the contractor shall reimburse the rendering provider related professional services bill under the allowable charge method, and shall not make a separate payment for the facility charges. Refer to Chapter 3, Section 1 and Chapter 5 for payment of individual professional services.
4.2  Wage Index
The contractor shall base the reimbursement rates for covered procedure on the national rates established in Medicare’s ASC list, and wage-adjusted for geographic wage variations. To adjust for wage differences, the contractor shall apply the wage adjustment factor to the labor-related portion of the national rate (currently 50%), using the Core-Based Statistical Area (CBSA) value. The contractor shall also apply wage adjustments to covered dental procedures (e.g., CPT procedure code 41899).
4.2.1  The contractor shall not adjust for geographic wage differences for the following: corneal tissue acquisition; drugs and devices with pass-through status under OPPS; brachytherapy sources; IOLs and New Technology IOLs; and separately payable drugs and biologicals.
4.2.2  The contractor shall implement any future changes made by Medicare to the labor-related share, the items and services subject to wage adjustments, and the methodology by which wage adjustments are made.
4.3  Multiple Surgeries
When multiple procedures are performed in the same operative session, the contractor shall reimburse the highest paying surgical procedure at 100% of the allowable, plus 50% for the other ASC-covered surgical procedures. In determining the ranking of the procedures, the contractor shall use the lower of the billed charge or the ASC payment amount.
4.4  Discounting for Bilateral Procedures
The contractor shall apply discounts for bilateral procedures based on the discounting formulas in Chapter 13, Section 3, paragraphs 3.1.5.3.6 and 3.1.5.3.7.
4.5  Payment Indicators
Payment indicators identify whether a procedure code is covered, packaged, or separately payable. The contractor shall follow Medicare guidelines for packaged and bundled items/services. The contractor shall not make a separate payments for such items/services.
4.6  Unbundling of Procedures
The contractor shall ensure that reimbursement for claims involving multiple procedures conforms to the unbundling guidelines as outlined in Chapter 1, Section 3.
4.7  Subsequent Hospital Admission
If a beneficiary is admitted to a hospital subject to the DRG-based payment system as a result of complications, etc. of ambulatory surgery, the contractor shall reimburse ambulatory surgery procedures separately from the hospital inpatient services. The contractor shall apply the same rules to Emergency Room (ER) services.
4.8  State Waivers
Ambulatory surgery services provided by FASCs in Maryland are not exempt from this system and the contractor shall reimburse them using the procedures set forth in this section.
4.9  Cost-Shares
The contractor shall cost-share all surgical procedures performed in an FASC setting at the ASC cost-sharing levels. This includes covered dental procedures (e.g., CPT procedure code 41899). Refer to Chapter 2, Section 1, paragraph 1.3.3.7 and Chapter 2, Section 2, paragraph 2.7.9.
4.10  Pricing Files
The contractor shall download and implement the full list of ASC covered surgical procedures and ASC covered ancillary services, the applicable payment indicators, payment rates for each covered surgical procedure and ancillary service before adjustments for geographic wage variations, the wage adjusted payment rates, and wage indices posted on the CMS website at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/ascpayment. The contractor shall implement the latest ASC pricing files, including correction files, within 21 days of publication on CMS’ website.
5.0  EXCLUSIONS
5.1  Facilities without a valid TRICARE participation agreement.
5.2  Facilities without a valid participation agreement with Medicare. This exclusion does not apply to facilities that only service pediatric patients.
5.3  Services and items not listed on Medicare’s ASC coverage list, except for certain dental procedures described in paragraph 3.2.
6.0  EFFECTIVE DATE
The provisions of this policy are effective for ambulatory surgery procedures rendered in FASCs with dates of service on or after October 1, 2023.
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