Examples of covered ASC facility services include:
Nursing Services, Services of Technical Personnel, and Other Related Services
These include all services in connection with covered procedures furnished by nurses and technical personnel who are employees of the ASC. In addition to the nursing staff, this category includes orderlies, technical personnel, and others involved in patient care;
Use by the Patient of the ASC’s Facilities
This category includes operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use by the patient’s relatives in connection with surgical services; and
Drugs, Biologicals, Surgical Dressings, Supplies, Splints, Casts, Appliances, and Equipment
This category includes all supplies and equipment commonly furnished by the ASC in connection with surgical procedures. See below for certain exceptions. Drugs and biologicals are limited to those that cannot be self-administered.
Coverage policy for surgical dressings is similar to that followed under Part B. Under Part B, coverage for surgical dressings is limited to primary dressings; i.e., therapeutic and protective coverings applied directly to lesions on the skin or on openings to the skin required as the result of surgical procedures. (Items such as Ace bandages, elastic stockings and support hose, Spence boots and other foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are generally used as secondary coverings and therefore are not covered as surgical dressings.) Surgical dressings usually are applied first by a physician and are covered as “incident to” a physician’s service in a physician’s office setting. In the ASC setting, such dressings are included in the facility’s services.
However, others may reapply surgical dressings later, including the patient or a member of the patient’s family. When the patient on a physician’s order obtains surgical dressings from a supplier, e.g., a drugstore, the surgical dressing is covered under Part B. The same policy applies in the case of dressings obtained by the patient on a physician’s order following surgery in an ASC; the dressings are covered and paid as a Part B service by the local Part B contractor, included in the definition of facility services.
Similarly, “other supplies, splints, and casts” include only those furnished by the ASC at the time of the surgery. Additional covered supplies and materials furnished later are generally furnished as “incident to” a physician’s service, not as an ASC facility service. The term “supplies” includes those required for both the patient and ASC personnel, e.g., gowns, masks, drapes, hoses, and scalpels, whether disposable or reusable.
Diagnostic or Therapeutic Items and Services
These are items and services furnished by ASC staff in connection with covered surgical procedures. With respect to diagnostic tests, many ASCs perform simple tests just before surgery, primarily urinalysis and blood hemoglobin or hematocrit, which are generally included in their facility charges. To the extent that such simple tests are included in the ASC’s facility charges, they are considered facility services. However, under the Medicare program, diagnostic tests are not covered in laboratories independent of a physician’s office, rural health clinic, or hospital unless the laboratories meet the regulatory requirements for the conditions for coverage of services of independent laboratories. (See 42CFR416.49.) Therefore, diagnostic tests performed by the ASC other than those generally included in the facility’s charge are not covered under Part B as such and are not billed to the carrier as diagnostic tests. If the ASC has its laboratory certified as meeting the regulatory conditions, then the laboratory itself bills the contractor (or the beneficiary) for the tests performed.
The ASC may make arrangements with an independent laboratory or other laboratory, such as a hospital laboratory, to perform diagnostic tests it requires prior to surgery. In general, however, the necessary laboratory tests are done outside the ASC prior to scheduling of surgery, since the test results often determine whether the beneficiary should even have the surgery done on an outpatient basis in the first place.
Administrative, Recordkeeping, and Housekeeping Items and Services
These include the general administrative functions necessary to run the facility e.g., scheduling, cleaning, utilities, and rent.
Blood, Blood Plasma, Platelets, etc., Except Those to Which Blood Deductible Applies
While covered procedures are limited to those not expected to result in extensive loss of blood, in some cases, blood or blood products are required. Usually the blood deductible results in no expenses for blood or blood products being included under this provision. However, where there is a need for blood or blood products beyond the deductible, they are considered ASC facility services and no separate charge is permitted to the beneficiary or the program.