Description
Covered ancillary items and services identified in Appendix D are not payable if there is no approved ASC surgical procedure on the same claim or in history for the same date of service and same provider.
Affected Code(s)
All ancillary services
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §260- Ambulatory Surgical Center Services
9. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §40- Payment for Ambulatory Surgery
10. CMS Ambulatory Surgery Center Approved HCPCS Code and Payment Rates available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
11. AMA CPT Codebook
12. HCPCS Level II Codebook