Wis. Admin. Code DHS § DHS 107.30

Current through December 30, 2024

Section DHS 107.30 - Ambulatory surgical center services

(1) COVERED SERVICES. Covered ambulatory surgical center (ASC) services are those medically necessary services identified in this section which are provided by or under the supervision of a certified physician in a certified ambulatory surgical center. The physician shall demonstrate that the recipient requires general or local anesthesia, and a postanesthesia observation time, and that the services could not be performed safely in an office setting. These services shall be performed in conformance with generally-accepted medical practice. Covered ambulatory surgical center services shall be limited to the following procedures:

(a)Surgical procedures:

1. Adenoidectomy or tonsillectomy;

2. Arthroscopy;

3. Breast biopsy;

4. Bronchoscopy;

5. Carpal tunnel;

6. Cervix biopsy or conization;

7. Circumcision;

8. Dilation and curettage;

9. Esophago-gastroduodenoscopy;

10. Ganglion resection;

11. Hernia repair;

12. Hernia - umbilical;

13. Hydrocele resection;

14. Laparoscopy, peritoneoscopy or other sterilization methods;

15. Pilonidal cystectomy;

16. Procto-colonoscopy;

17. Tympanoplasty;

18. Vasectomy;

19. Vulvar cystectomy; and

20. Any other surgical procedure that the department determines shall be covered and that the department publishes notice of in the MA provider handbook; and

(b)Laboratory procedures. The following laboratory procedures are covered but only when performed in conjunction with a covered surgical procedure under par. (a) :

1. Complete blood count (CBC);

2. Hemoglobin;

3. Hematocrit;

4. Urinalysis;

5. Blood sugar;

6. Lee white coagulant; and

7. Bleeding time.

(2) SERVICES REQUIRING PRIOR AUTHORIZATION. Any surgical procedure under s. DHS 107.06(2) requires prior authorization.

Note: For more information on prior authorization, see s. DHS 107.02(3).

(3) OTHER LIMITATIONS.

(a) A sterilization is a covered service only if the procedures specified in s. DHS 107.06(3) are followed.

(c) Reimbursement for ambulatory surgical center services shall include but is not limited to:

1. Nursing, technician, and related services;

2. Use of ambulatory surgical center facilities;

3. Drugs, biologicals, surgical dressings, supplies, splints, casts and appliances, and equipment directly related to the provision of a 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; and

6. Materials for anesthesia.

(4) NON-COVERED SERVICES.

(a) Ambulatory surgical center services and items for which payment may be made under other provisions of this chapter are not covered services. These include:

1. Physician services;

2. Laboratory services;

3. X-ray and other diagnostic procedures, except those directly related to performance of the surgical procedure;

4. Prosthetic devices;

5. Ambulance services;

6. Leg, arm, back and neck braces;

7. Artificial limbs; and

8. Durable medical equipment for use in the recipient's home.

Wis. Admin. Code Department of Health Services DHS 107.30

Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (3) (b) made under s. 13.92(4) (b) 7, Stats., Register December 2008 No. 636.

Amended by, correction in (3) (b) (Note) made under s. 13.92(4) (b) 7, Stats., Register February 2019 No. 758, eff. 3/1/2019

Amended by, CR 20-039: r. (3) (b) Register October 2021 No. 790, eff. 11/1/2021

For more information on non-covered services, see s. DHS 107.03.