How should we pay procedures that are not listed in Hospital Outpatient Surgical and ASTC schedules?
The IWCC used the CMS list of Hospital Outpatient Surgical Facility (HOSF) procedure codes (not reimbursement levels) to develop the HOSF and ASTC fee schedules. This list is more extensive than that approved by CMS for ASTCs. CMS excludes codes from this list for two main reasons: 1. The procedure is relatively minor and the facility component is included in the physician’s charge for the procedure; 2. CMS believes the procedure should be done inpatient. For procedures that CMS classifies as inpatient, the IWCC recommends that if the procedure is performed in a hospital, payers and providers should use the POC76 default for the procedure. During the seminars, IWCC administrators said that there should be no payment for the procedure if performed in an ASTC setting. Conclusion: After more consideration and consultation, the Commission now recommends that codes excluded from the CMS template due to an “inpatient designation” should default to POC76 in both HOSF and ASTC settings.
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