Chapter 5160-22 Ambulatory Surgery Center Services

5160-22-01 Ambulatory surgery center eligible providers.

(A) The department will reimburse an ambulatory surgery center (ASC) for facility services furnished in connection with covered surgical procedures when the services are provided by an eligible ASC provider to an eligible medicaid recipient.

(B) An "ambulatory surgery center (ASC)" is any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization.

(C) All ASCs that meet the standards provided in the 42 C.F.R. 416.20 to 42 C.F.R. 416.49 (effective dates of these regulations are set forth below) and are certified for medicare participation by the Ohio department of health are eligible to become medicaid providers upon execution of the "Ohio Medicaid Provider Agreement."

42 C.F.R. 416.20 effective May 20, 1991

42 C.F.R. 416.25 and 42 C.F.R. 416.26 effective March 1, 1991

42 C.F.R. 416.30 and 42 C.F.R. 416.35 effective August 2, 1996

42 C.F.R. 416.40 and 42 C.F.R. 416.41 effective June 17, 1986

42 C.F.R. 416.42 effective November 13, 2001

42 C.F.R 416.43 and 42 C.F.R 416.44 effective September 22, 2006

42 C.F.R 416.45 to 42 C.F.R 416.49 effective February 28, 1992

Effective: 05/10/2007
R.C. 119.032 review dates: 02/07/2007 and 05/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02
Prior Effective Dates: 3/20/84, 1/4/88, 2/17/91

5160-22-02 Covered ambulatory surgery center (ASC) services.

(A) Covered ASC surgical procedures.

(1) "Covered ASC surgical procedures" are procedures designated in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(2) Covered ASC procedures shall be listed under the column headings "Current ASC Group" and "Previous ASC Group" in appendix DD to rule 5101:3-1-60 of the Administrative Code, identified by number one, two, three, four, five, six, seven, eight or nine as described in paragraph (A)(2) of rule 5101:3-22-03 of the Administrative Code.

(3) The inclusion of any procedure as a covered ASC surgical procedure determines that reimbursement for facility services may be paid to an ASC and does not preclude its coverage in an inpatient or outpatient hospital setting.

(B) Noncovered ASC surgical procedures.

A facility fee is not reimbursable to an ASC for the following procedures:

(1) Surgical procedures not designated as covered ASC surgical procedures in appendix DD to rule 5101:3-1-60 of the Administrative Code; and

(2) Surgical procedures, regardless of their designation in appendix DD to rule 5101:3-1-60 of the Administrative Code, if they are not reimbursable under paragraphs (A)(1) to (A)(2)(g) of rule 5101:3-2-03 and rule 5101:3-4-28 of the Administrative Code.

(C) Covered ASC facility services.

"ASC facility services" are items and services furnished by an ASC in connection with a covered ASC surgical procedure. Facility services include but are not limited to:

(1) Nursing, technician, and related services;

(2) Use of the ASC facilities;

(3) Drugs, biologicals (e.g., blood), surgical dressings, splints, casts and appliances, and equipment directly related to the provision of the surgical procedure;

(4) Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;

(5) Administrative, recordkeeping, and housekeeping items and services;

(6) Materials for anesthesia;

(7) Intraocular lenses; and

(8) Supervision of the services of an anesthetist by the operating surgeon.

Effective: 07/01/2009
R.C. 119.032 review dates: 02/11/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 3/20/84, 1/4/88, 2/17/91, 12/29/95 (Emer), 5/21/96, 1/1/04

5160-22-03 Reimbursement of facility services in an ambulatory surgery center (ASC).

(A) Payment for facility services.

(1) Payment for facility services is based on a reimbursement rate for each surgical group classification as determined by the department. The reimbursement rate will be called the surgical group rate.

(2) Covered ASC procedures will be classified into nine surgical groups numbered one, two, three, four, five, six, seven, eight or nine. The surgical group classification for each covered procedure is contained in appendix DD to rule 5101:3-1-60 to the Administrative Code.

(3) Maximum reimbursement for facility services furnished with a covered surgical procedure will be the provider's billed charges or one hundred per cent of the surgical group rate as specified in paragraph (J) of rule 5101:3-1-60 of the Administrative Code, whichever is less.

(4) When more than one covered procedure is performed in a single operative session, reimbursement for facility services will be one hundred per cent of the surgical group rate for the primary procedure and fifty per cent of the surgical group rate for the secondary procedure. Any subsequent procedures will be reimbursed zero per cent of the surgical group rate.

(B) Payment for laboratory services, radiological services, and diagnostic and therapeutic procedures.

An ASC may be reimbursed in addition to the facility fee for laboratory procedures, radiological procedures, and diagnostic and therapeutic procedures provided in connection with a covered ASC surgical procedure. To be reimbursed for these services, ASC providers must bill using the appropriate HCPCS codes.

(1) Payment for laboratory services.

(a) An ASC facility may be reimbursed in addition to the facility payment for covered laboratory services they actually performed as long as the services are provided in accordance with Chapter 5101:3-11 of the Administrative Code.

(b) An ASC may not bill separately for the professional component of an anatomical pathology procedure.

(2) Payment for radiological services.

(a) An ASC may be reimbursed in addition to the facility fee for radiological procedures they actually performed as long as the services are provided and billed in accordance with rule 5101:3-4-25 of the Administrative Code.

(b) An ASC may not bill the department for the professional component separately.

(3) Payment for diagnostic and therapeutic procedures.

(a) An ASC may be reimbursed in addition to the facility fee for the provision of diagnostic and therapeutic services when provided in accordance with rules 5101:3-4-11, 5101:3-4-16, 5101:3-4-17 and 5101:3-4-18 of the Administrative Code.

(b) An ASC may not bill separately for the professional component of a diagnostic and therapeutic procedure.

(c) An ASC may not bill for any service designated as a professional only service in the rules cited in paragraph (B)(3)(a) of this rule.

(C) An ASC may also be reimbursed for laboratory, radiology and diagnostic and therapeutic services actually performed in the ASC in conjunction with covered services not eligible for an ASC facility payment.

Effective: 07/01/2009
R.C. 119.032 review dates: 02/11/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 1/4/88, 2/17/91, 12/29/95 (Emer), 5/21/96, 1/1/04