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Updates to how we handle certain Ambulatory Surgical Center (ASC) and Ambulatory Payment Classification (APC) code edits under the ASC and APC payment methodologies


Specific CPT®/HCPCS codes that generate certain ASC and/or APC error codes that indicate a Medicare noncovered service or one that is not part of the Medicare ASC fee schedule or APC payment methodology will no longer be eligible for default payment. Changes to an individual provider's compensation will depend on the presence of the Medicare ASC and/or APC payment method within the provider contract. The changes are outlined below. 

All updates will start on November 1, 2019, unless otherwise noted. 

 

Description of ASC edit Provider types affected What’s changing
Not part of the ASC fee schedule (HCPCS codes not in Addendum AA, BB or EE)  Ambulatory surgery centers   Services will no longer be eligible for payment consistent with Medicare claims processing/payment rules.

HCPCS codes listed on Addendum EE

The list includes services that are on the Outpatient Prospective Payment System (OPPS) inpatient list, unlisted CPT codes and surgical procedures that are not recognized for payment under Medicare.

Ambulatory surgery centers 

 

 

Claims for covered services for members paid under the Medicare ASC payment method will be reimbursed at the outpatient contracted rate.

 

9 Noncovered under any Medicare outpatient benefit, for reasons other than statutory exclusion Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
10 Service submitted for denial (condition code 21)  Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
13 Separate payment for services is not provided by Medicare  Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
18 Inpatient procedure Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
24

Date out of OCE range 

 

Service will no longer be eligible for payment consistent with Medicare processing rules.
28 Code not recognized by Medicare for outpatient claims; alternate code for same service may be available  Service will no longer be eligible for payment consistent with Medicare processing rules.
50 Noncovered under any Medicare outpatient benefit, based on statutory exclusion  Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
59 Clinical trial requires diagnosis code V707 as other than primary diagnosis (deleted, retroactive to the earliest included version)  Inactive code; no longer eligible for payment.
61 Service can only be billed to the DMERC  Claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
67 Service provided prior to FDA approval  Service will no longer be eligible for payment consistent with Medicare processing rules.
68 Service provided prior to date of National Coverage Determination (NCD) approval  Based on coverage policy at the time of service; claims for covered services for members paid under the Medicare APC payment method will be reimbursed at the outpatient contracted rate.
69 Service provided outside approval period  Service will no longer be eligible for payment consistent with Medicare processing rules.
80 Mental health code not approved for partial hospitalization  Service will no longer be eligible for payment consistent with Medicare processing rules.
81 Mental health service not payable outside the partial hospitalization program  Service will no longer be eligible for payment consistent with Medicare processing rules.