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 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 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.
4.5 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 Waiver
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.
4.10 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.