Only facilities that meet the criteria below may bill for ambulatory surgery center (ASC) services.

An ambulatory surgery center is an outpatient facility where surgical services are provided and that meets the following three requirements:

(1) Must be licensed by the state(s) in which it operates, unless that state does not require licensure.

(2) Must have at least one of the following credentials:

(a) Medicare certification as an ambulatory surgery center; or

(b) Accreditation as an ambulatory surgery center by a nationally recognized agency acknowledged by the Centers for Medicare and Medicaid Services (CMS).

(3) Must have an active ambulatory surgery center provider account with the department of labor and industries.

Ambulatory surgery centers must submit bills for services on a national standard form specified by the department of labor and industries. Bills also may be submitted electronically using department file format specifications. Providers must follow the instructions in the General Provider Billing Manual and Billing Instructions. Special billing policies for ambulatory surgery centers are in the Medical Aid Rules and Fee Schedules under Ambulatory Surgery Center Payment Policies.

The department will use the Centers for Medicare and Medicaid Services (CMS) list of procedures covered in an ambulatory surgery center plus additional procedures as determined by the department. All procedures covered in an ambulatory surgery center are listed in the Medical Aid Rules and Fee Schedules, Ambulatory Surgery Center Payment Policies section. Certain procedures are still subject to the utilization review program. Procedures that are not listed are not covered in an ambulatory surgery center.

Under certain conditions, the director, the director's designee, or self-insurer, in their sole discretion, may determine that a procedure not on the list may be authorized in an ambulatory surgery center. For example, if the procedure could be harmful to a particular patient unless performed in an ambulatory surgery center. Requests for coverage under these special circumstances require prior authorization. The process for requesting coverage is outlined in the Medical Aid Rules and Fee Schedules, Ambulatory Surgery Center Payment Policies section.

The department will allow some procedures to be covered in an outpatient setting that CMS covers only in an inpatient setting. The department will cover these procedures in an ambulatory surgery center if the following criteria are met:

(1) The surgeon deems that it is safe and appropriate to perform such a procedure in an outpatient setting; and

(2) The procedure meets the department's utilization review requirements.

The department pays the lesser of the billed charge (the ASC's usual and customary fee) or the fee schedule's maximum allowed rate. The fee schedule for ambulatory surgery centers is in the Medical Aid Rules and Fee Schedules.

The fee schedule, codes, and policies for ambulatory surgery centers will be reviewed periodically. The department will publish provider bulletins to clarify, update, and inform ambulatory surgery centers about changes in policies or fees. They also will be published each July in the Medical Aid Rules and Fee Schedules.