42 C.F.R. Subpart E—Payment for Facility Services
Title 42 - Public Health
The basis for payment depends on where the services are furnished. (a) Hospital outpatient department. Payment is in accordance with part 413 of this chapter. (b) [Reserved] (c) ASC—(1) General rule. Payment is based on a prospectively determined rate. This rate covers the cost of services such as supplies, nursing services, equipment, etc., as specified in §416.61. The rate does not cover physician services or other medical services covered under part 410 of this chapter (for example, X-ray services or laboratory services) which are not directly related to the performance of the surgical procedures. Those services may be billed separately and paid on a reasonable charge basis. (2) Single and multiple surgical procedures. (i) If one covered surgical procedure is furnished to a beneficiary in an operative session, payment is based on the prospectively determined rate for that procedure. (ii) If more than one surgical procedure is furnished in a single operative session, payment is based on— (A) The full rate for the procedure with the highest prospectively determined rate; and (B) One half of the prospectively determined rate for each of the other procedures. (3) Deductibles and coinsurance. Part B deductible and coinsurance amounts apply as specified in §410.152 (a) and (i) of this chapter. [56 FR 8844, Mar. 1, 1991; 56 FR 23022, May 20, 1991] (a) The payment rate is based on a prospectively determined standard overhead amount per procedure derived from an estimate of the costs incurred by ambulatory surgical centers generally in providing services furnished in connection with the performance of that procedure. (b) The payment must be substantially less than would have been paid under the program if the procedure had been performed on an inpatient basis in a hospital. [56 FR 8844, Mar. 1, 1991] Whenever CMS proposes to revise the payment rate for ASCs, CMS publishes a notice in the [47 FR 34094, Aug. 5, 1982, as amended at 56 FR 8844, Mar. 1, 1991] (a) Timing, purpose, and procedures. (1) No more often than once a year, CMS conducts a survey of a randomly selected sample of participating ASCs to collect data for analysis or reevaluation of payment rates. (2) CMS notifies the selected ASCs by mail of their selection and of the form and content of the report the ASCs are required to submit within 60 days of the notice. (3) If the facility does not submit an adequate report in response to CMS's survey request, CMS may terminate the agreement to participate in the Medicare program as an ASC. (4) CMS may grant a 30-day postponement of the due date for the survey report if it determines that the facility has demonstrated good cause for the delay. (b) Requirements for ASCs. ASCs must— (1) Maintain adequate financial records, in the form and containing the data required by CMS, to allow determination of the payment rates for covered surgical procedures furnished to Medicare beneficiaries under this subpart. (2) Within 60 days of a request from CMS submit, in the form and detail as may be required by CMS, a report of— (i) Their operations, including the allowable costs actually incurred for the period and the actual number and kinds of surgical procedures furnished during the period; and (ii) Their customary charges for each surgical procedure furnished for the period. [47 FR 34094, Aug. 5, 1982, as amended at 56 FR 8845, Mar. 1, 1991] A beneficiary (or ASC as his or her assignee) may request a hearing by a carrier (subject to the limitations and conditions set forth in part 405, subpart H of this chapter) if the beneficiary or the ASC— (a) Is dissatisfied with a carrier's denial of a request for payment made on his or her behalf by an ASC; (b) Is dissatisfied with the amount of payment; or (c) Believes the request for payment is not being acted upon with reasonable promptness.
Title 42: Public Health
PART 416—AMBULATORY SURGICAL SERVICES
Subpart E—Payment for Facility Services
§ 416.120 Basis for payment.
§ 416.125 ASC facility services payment rate.
§ 416.130 Publication of revised payment methodologies.
§ 416.140 Surveys.
§ 416.150 Beneficiary appeals.
