★ Premium Resource

Medicare Reimbursement for the ASC

Topic: ASC

Sponsor: Corcoran Consulting Group

Updated: 01/13/2020

Corcoran Consulting Group

The delivery of eye care services has undergone many changes in recent years. In particular, ophthalmic surgeons now perform major procedures in an ambulatory surgery center (ASC) more often than in a hospital outpatient department (HOPD). Within the Medicare system, eye surgery ranks in the top three groupings of ASC services; the other two popular services are gastroenterology and pain management. For the future, the Centers for Medicare & Medicaid Services (CMS) expects an increase in the number of procedures performed in ASCs.

In addition to other requirements, as discussed in this monograph, it is critical for the ASC to maintain documentation of medical necessity for procedures performed in its facility. While the surgeon makes the determination (with the patient) to proceed with a surgical procedure, it is unwise for the ASC to assume that the surgeon’s medical record will automatically support the claim for the facility fee.

An efficiently run ASC provides significant benefits to patients, surgeons and society. Patient satisfaction is high due to convenience and a friendly atmosphere. Surgeons appreciate the rapid turnover time for cases. Surgeon-owners also enjoy an additional revenue source when the ASC is profitable. Finally, society benefits from lower cost of health care in an ASC compared with a HOPD.

Since 2008, CMS uses a payment system for ASCs that relies heavily on the current methodology for HOPD reimbursement. This monograph describes the system in detail as well as related practice management and compliance issues.