10 Colo. Code Regs. § 2505-10-8.570
Current through Register Vol. 47, No. 16, August 25, 2024
Section 10 CCR 2505-10-8.570 - AMBULATORY SURGERY CENTERS8.570.1DEFINITIONSAmbulatory Surgery Center (ASC) means an entity that operates exclusively for the purpose of furnishing surgical services for its clients that do not require hospitalization. An ASC may be independent or part of a hospital, but only if the building space utilized by the ASC is physically, administratively, and financially independent and distinct from other operations of the hospital.
CMS means the Centers for Medicare and Medicaid Services.
The Department refers to the Colorado Department of Health Care Policy and Financing.
Inpatient Basis in Hospitals means preventive, therapeutic, surgical, diagnostic, medical and rehabilitative services that are furnished by the Hospital for the care and treatment of inpatients and are provided in the Hospital by or under the direction of the physician.
8.570.2REQUIREMENTS FOR PARTICIPATION8.570.2.A. An ASC shall be certified by CMS to participate in the Medicare program as an ASC and be licensed by the Colorado Department of Public Health and Environment as an ASC.8.570.3COVERED SERVICES AND LIMITATIONS8.570.3.A. Covered services are those surgical and other medical procedures that: 1. Are ASC procedures that are grouped into categories corresponding to the CMS defined groups.2. Are commonly performed on an inpatient basis in hospitals, but may be safely performed in an ASC.3. Are limited to those requiring a dedicated operating room (or suite), and generally requiring a post-operative recovery room or short-term (not overnight) convalescent room.8.570.3.B. Covered surgical procedures are limited to those that do not generally exceed: 1. A total of 4 hours recovery or convalescent time.8.570.3.C. If the covered surgical procedures require anesthesia, the anesthesia must be:1. Local or regional anesthesia; or8.570.4.DENTAL PROCEDURES1. Qualifying clients may receive covered and medically necessary dental services in an ASC when those services cannot be delivered safely and effectively in a private office.
8.570.5NON-COVERED SERVICES8.570.5.A Non-covered services are those services that: 1. Are not commonly performed in an ASC;2. May safely be performed in a physician's office;3. Generally result in extensive blood loss;4. Require major or prolonged invasion of body cavities;5. Directly involve major blood vessels;6. Are generally emergency or life-threatening in nature;7. Pose a significant safety risk to clients or are expected to require active medical monitoring at midnight of the day on which the surgical procedure is performed (overnight stay) when furnished in an ASC; or,8. Are not listed in the annual ASC billing manual.8.570.6.CLIENT ELIGIBILITYEligible Clients include any Client enrolled in Colorado Medicaid for whom a covered ASC service is a medical necessity as defined at 10 CCR 2505-10 Section 8.076.1.8.
8.570.7.PRIOR AUTHORIZATIONThe physician performing the surgery shall be responsible for obtaining all necessary Prior Authorizations for those procedures requiring pre-procedure approval by the Department.
8.570.8REIMBURSEMENT8.570.8.A For payment purposes, ASC surgical procedures are placed into groupers. The Health Care Procedural Coding System (HCPCS) is used to identify surgical services.8.570.8.B Reimbursement for approved surgical procedures shall be allowed only for the primary or most complex procedure. No reimbursement is allowed for multiple or subsequent procedures. No reimbursement shall be allowed for services not included on the Department approved list for covered services. Approved surgical procedures identified in the ASC groupers shall be reimbursed a facility fee at the lower of the following: 2. Department approved list for covered services.8.570.9ALLOWABLE COSTS8.570.9.A The services payable under this rule are facility services furnished to clients in connection with covered surgical procedures specified in Section 8.570.3. 1. Services and items reimbursed as part of the facility fee include, at a minimum, the following: a. Use of the facilities where the surgical procedures are performed.b. Nursing, technician, and related services.c. Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances and equipment directly related to the provision of surgical procedures.d. Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure.e. Administrative, record keeping and housekeeping items and services.f. Materials for anesthesia.g. Intra-ocular lenses (IOLs).h. Supervision of the services of an anesthetist by the operating surgeon.2. Services and items that are not reimbursed as part of the facility fee, but that may be reimbursed separately include the following: c. Laboratory, X-ray or diagnostic procedures (other than those directly related to performance of the surgical procedure.)d. Prosthetic devices (except IOLs).f. Leg, arm, back and neck braces.h. Durable medical equipment for use in the client's home.