Section 418.101023. Reimbursement for ASC or FSOF.

(1) Reimbursement for surgical procedures performed in an ASC or FSOF shall be determined by using the ASC rate published by CMS. The formula for determining the maximum allowable paid (MAP) for a surgical procedure in an ASC or FSOF is determined by multiplying the (Medicare ASC rate) X (1.30). The MAP shall be published in the health care services fee schedule.

(2)   When 2 or more surgical procedures are performed in the same operative session, the facility shall be reimbursed at 100% of the maximum allowable payment or the facility's usual and customary charge, whichever is less, for the procedure classified in the highest payment group. Any other surgical procedures performed during the same session shall be reimbursed at 50% of the maximum allowable payment or 50% of the facility's usual and customary charge,

whichever is less. A facility shall not un-bundle surgical procedure codes when billing the services.

(3)   When an eligible procedure is performed bilaterally, each procedure shall be listed on a separate line of the claim form and shall be identified with LT for left and RT for right. At no time shall modifier 50 be used by the facility to describe bilateral procedures.

(4)   Implants are included in the maximum allowable paid unless the CMS list it as a pass through item. Pass through items will be provided on the agency’s website, www.michigan.gov/wca. If an item is implanted during the surgical procedure and the ASC or FSOF bills the implant and includes the copy of the invoice, then the implant shall be reimbursed at the cost of the implant plus a percent markup as follows:

(a)   Cost of implant: $1.00 to $500.00 shall receive cost plus 50%.

(b)   Cost of implant: $500.01 to $1000.00 shall receive cost plus 30%.

(c)   Cost of implant: $1000.01 and higher shall receive cost plus 25%.

(5)     Laboratory services shall be reimbursed by the maximum allowable payment as determined in R 418.101503.

(6)      When a radiology procedure is performed intra-operatively, only the technical component shall be billed by the facility and reimbursed by the carrier. The professional component shall be included with the surgical procedure. Pre-operative and post-operative radiology services may be globally billed.

(7)   When the freestanding surgical facility provides durable medical equipment, the items shall be reimbursed in accord with R 418.101003b.

History: 2005 AACS; 2006 AACS; 2008 AACS; 2010 AACS; 2014 AACS.