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
and Bilateral ProceduresThe contractor
shall follow Medicare rules for discounting of multiple surgeries
and bilateral procedures performed in freestanding ASCs.
4.4 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.
4.5 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.
4.6 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.
4.8 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.