compared to the HOPD setting and, therefore, would result in a finan-
cial incentive to perform certain device-intensive procedures in the
ASC setting rather than the HOPD setting."
Why aren't there any unlisted codes on the ASC-payable list?
This is a great question. Unlisted codes can be reimbursed in the
HOPD as well as the physician's office setting. Those facilities submit
supporting evidence to their Medicare Administrative Contractors
(MACs) as to why they must use the unlisted code, and then the MAC
decides whether to provide reimbursement for the code. ASCs don't
have that option. ASCs won't be reimbursed if the procedure "can
only be reported using a CPT unlisted surgical procedure code," says
Part 416 of the Code of Federal Regulations, which governs ASCs. In
the 2017 final payment rule, CMS states that "all unlisted codes are
noncovered in the ASC because we are unable to determine (due to
the nondescript nature of unlisted procedure codes) if a procedure
that would be reported with an unlisted code would not be expected
to pose a significant risk to beneficiary safety when performed in an
ASC, and would not be expected to require active medical monitoring
and care of the beneficiary at midnight following the procedure." This
does not explain why unlisted codes can still be reimbursed in the
physician's office, however.
Why are there so many other codes
for which ASCs cannot be reimbursed?
CMS limits its ASC-covered procedures to those "that would not be
expected to pose a significant safety risk to a Medicare beneficiary
when performed in an ASC, and for which standard medical practice
dictates that the beneficiary would not typically be expected to require
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