Highlights of the Florida Medicaid Ambulatory Surgical Center Services Coverage and Limitations Handbook

Transcription

1 Highlights of the Florida Medicaid Ambulatory Surgical Center Services Coverage and Limitations Handbook Agency for Health Care Administration July

2 Learning Objectives Provide an overview of the Ambulatory Surgical Center Services Coverage and Limitations Handbook. Improve knowledge about Provider Qualifications and Responsibilities. Increase understanding about covered services, limitations, exclusions and payment groups. Improve compliance with Florida Medicaid policy. 2

3 Rules that Govern Ambulatory Surgical Center Services 1) Florida Provider General Handbook describes the Florida Medicaid Program. 2) Florida Medicaid Provider Reimbursement Handbook, CMS-1500 describes how to complete and file claims for reimbursement from Medicaid. 3) Ambulatory Surgical Center Services describes service-specific policy information, which includes the Fee Schedule listing the services covered and the maximum fees for Medicaid recipients. 3

4 Purpose Ambulatory Surgical Center Services (ASC) The purpose of the ASC program is to enable all Medicaid recipients to receive single day outpatient surgical services. 4

5 Ambulatory Surgical Center (ASC) Definition of an ASC An ASC is a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization. 5

6 Covered ASC Services Medicaid covers most medically necessary procedures authorized by the Centers for Medicare and Medicaid Services (CMS) for performance in an ASC and published in the Federal Register. Procedures that are not covered under the Florida Medicaid Physician Services program are also not covered under the Florida Medicaid ASC Services program. Florida Medicaid also covers certain dental procedures furnished in an ASC. 6

7 Special Services for Children As required by federal law, Florida Medicaid provides services to eligible children under 21 years old, if such services are medically necessary to correct or ameliorate a defect, a condition, or a physical or mental illness. Included are diagnostic services, treatment, equipment, supplies, and other measures. See section 1905(a) of the Social Security Act, codified in 42 USC 1396d(a). Services requested in excess of limitations described within this handbook or the associated fee schedule for children under the age of 21 may be approved, if medically necessary, through the prior authorization process described in the Medicaid Provider General Handbook. 7

8 Service Exclusions The following services are not covered by the Medicaid ASC program: Any procedure not listed in Appendix A of this handbook. Surgical procedures incidental to the primary surgery. Such procedures are not separately reimbursable services. Incidental procedures are an integral component of a total service or procedure. Codes identified as separate procedure in the most recent Physician s Current Procedural Terminology (CPT) code book, copyright by the American Medical Association, must not be reported in addition to the code for the total procedure or service of which it is considered an integral component. 8

9 Service Exclusions All procedures in the through range referred to as unlisted. Unlisted codes end with any of these digits: 9, 99, 999, Their descriptor in the CPT code book begins with the words Unlisted procedure. Office-based procedures for which the more elaborate facility services of an ASC are not required. These services do not require surgical facilities, a dedicated operating room, or room for post-operative recovery. 9

10 Who is Eligible for ASC Covered Services? Medicaid recipients of all ages are eligible for covered ASC services. Recipients may obtain any covered and medically necessary service in an ASC when ordered by a Medicaid-participating physician. 10

11 Scope of Facility Services Ambulatory surgical facility services include the following: Nursing, technician, and related services. Use of the facilities where the surgical procedures are performed. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment directly related to the provision of surgical procedures. Diagnostic or therapeutic services performed by the ASC on the day of the surgical service or items directly related to the provision of a surgical procedure. 11

12 Scope of Facility Services, cont d Administrative, recordkeeping, and housekeeping items and services. Materials for anesthesia. Standard Intra-ocular lenses (IOLS) less than $150. Medicaid reimbursement for the items and services noted above is included in the payment made to the facility for the surgical procedure performed. The level of payment is based on the payment group for the procedure. 12

13 General Standards for Surgery Covered surgical procedures for ASCs are procedures that: Are commonly performed on an outpatient basis in hospitals, but may be safely performed, consistent with accepted medical practice, in an ASC. Are not commonly performed or cannot be safely performed in physicians offices. 13

14 General Standards for Surgery Covered surgical procedures for ASCs are procedures that: Require a dedicated operating room and generally require a post-operative recovery room or shortterm (not overnight) convalescent room. Are not otherwise excluded in this handbook. 14

15 Time Standard Covered surgical procedures are limited to those that do not generally exceed the following: A total of 90 minutes operating time. A total of four hours recovery or convalescent time. 15

16 Procedures Requiring Anesthesia If the covered surgical procedure requires anesthesia, the anesthesia must be either of the following: Local or regional anesthesia; Monitored anesthesia care; and General anesthesia of 90 minutes or less duration. 16

17 Specific Standards for Surgery Medicaid does not cover surgical procedures performed in an ASC that: Generally result in extensive blood loss. Require major or prolonged invasion of body cavities. Directly involve major blood vessels. Are generally emergency or life-threatening in nature. 17

18 Sterilizations Covered sterilization procedures may be reimbursed by Medicaid under the following circumstances: The recipient must be at least 21 years old at the time the Sterilization Consent Form is signed. The recipient must be mentally competent and not institutionalized in a correctional, penal, or rehabilitative facility or a facility for mental diseases. A Florida Medicaid Sterilization Consent Form must be correctly completed at least 30 days but no more than 180 days prior to sterilization. 18

19 Sterilizations A copy of the form must be attached to the ASC facility claim form for reimbursement. Consent for sterilization must not be obtained during: Labor, childbirth, or an abortion. During a period of time when the recipient is under the influence of alcohol or other agents affecting awareness. Failure to meet the above criteria or to properly complete the Sterilization Consent Form results in the denial of Medicaid reimbursement. 19

20 Sterilization Consent Form Federal regulations require both male and female recipients to give written consent prior to sterilization procedures being performed. To meet this requirement, the provider must submit with the claim a Consent for Sterilization Form, HHS-687 (11/06) that the recipient has signed. A copy (both in English and Spanish) of the Consent For Sterilization Form and instructions on how to complete it are on the Florida Medicaid Provider Reimbursement Handbook, CMS

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22 Medicaid Reimbursement 22

23 Chapter 3 Chapter 3 of the Ambulatory Surgical Center Services Coverage and Limitations Handbook contains information about: Reimbursement for Ambulatory Surgery Payment Groups Medicaid Payment on Medicare Crossover Claims Valid Modifiers for ASCs Billing Medicaid Single and Multiple Procedure Billing Appendix A: Covered Ambulatory Surgical Center Procedure Codes 23

24 Payment for Ambulatory Surgery To encourage recipients and physicians to use less costly alternatives for outpatient hospital facilities for surgical procedures that may be safely and effectively performed on an ambulatory basis, Medicaid provides payment of a facility fee for services furnished by Medicare-certified ASCs in connection with designated covered surgical procedures. 24

25 Payment Groups Each covered ASC surgical procedure is assigned a payment group. Medicaid reimburses ASC services using the payment group rates described in the next slide. The payment rates remain in effect until revised by Florida Medicaid. 25

26 Payment Groups Group Number Medicaid Reimbursement 1 $333 2 $446 3 $510 4 $630 5 $717 6 $826 7 $995 8 $973 9 $1,339 26

27 Payment Groups Group Number Medicaid Reimbursement 10 $ $1, $2, $3, $275 Payments for cataract removal incudes an allowance of $150 for a standard intraocular lens (IOL) blended into the rate. This does not preclude a recipient from selecting a Premium IOL and assuming financial responsibility for the difference between the Premium IOL cost and the $150 intraocular lens (IOL) allowance. 27

28 What Does the Group Rate Cover? The payment group rate assigned to each surgical procedure performed in an ASC is complete reimbursement for that procedure and includes all the items, supplies, and services listed on the next slide. These services and items are not payable separately. 28

29 What Does the Group Rate Cover? Nursing services, services of technical personnel, and other related services. The use by the patient of the ASC s facilities. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances and equipment. Diagnostic or therapeutic services performed by the ASC on the day of the surgical service. Administrative, record keeping, and housekeeping items and services. Blood, blood plasma, platelets, and its components. Materials for anesthesia. Standard Intraocular lenses (IOLs) less than $150 or items directly related to the provision of a surgical procedure. 29

30 What Does the Group Rate Not Cover? The items and services noted in the next slide are not ASC facility services and are not included in the single group rate payment made to facilities for surgical services. These non-asc services are covered and paid for under the applicable Medicaid program, e.g., physicians services rendered in an ASC are covered under the Medicaid Physician Services program. 30

31 What Does the Group Rate Not Cover? Physicians services The sale, lease, or rental of durable medical equipment to ASC patients for use in their home Prosthetic devices, except IOLs Ambulance services Leg, arm, back, and neck braces Artificial legs, arms, and eyes Services furnished by an independent laboratory X-rays or diagnostic procedures not directly related to the performance of the surgical procedure 31

32 Modifiers Modifiers other than 50, 73, and 74 are not required for Medicaid billing. Any claim line with a modifier(s) other than those listed above may contribute to the denial of claim lines. 32

33 See Appendix A in the Ambulatory Surgical Center Services Coverage and Limitations Handbook for a list of covered procedures, effective dates(s), and their group designation. 33

34 Online Information All Medicaid handbooks, fee schedules, forms, provider notices, and other important Medicaid information are available on the Medicaid fiscal agent s Web Portal at: Click on Public Information for Providers, then on Provider Support, and then click on Handbooks Fee Schedules Forms 34

35 The Agency has thirteen Medicaid area offices in eleven areas throughout the state that serve as the local liaisons to providers and recipients. For questions regarding Ambulatory Surgical Center Services, contact your local Medicaid area office at: 35