Chapter 42. Free-Standing Medicare-Certified Ambulatory Surgical Centers

“Covered surgical procedures” means those surgical and other medical procedures which meet the criteria specified in 42 CFR Part 416, Subpart F, §416.166(a) and (b), and which are published by the Centers for Medicare and Medicaid Services (CMS) in the Federal Register.

“Dental Benefits Administrator (DBA)” means an entity that administers the dental program for the Maryland Department of Health.

“Dental services” means emergency, preventive, or therapeutic services for oral diseases which are administered by or under the general supervision of a dentist in the practice of the profession.

“Department” means the Maryland Department of Health as defined in COMAR 10.09.36.01.

“Free-standing Ambulatory Surgery Center (ASC)” means an entity capable of providing ambulatory surgical services, which is not located in a hospital setting, and which is Medicare-certified to furnish ambulatory surgical services.

“Hospital” means any institution which falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.01.

“Medical Assistance Program” means the Medical Assistance Program as defined in COMAR 10.09.36.01.

“Medicare” means Medicare as defined in COMAR 10.09.36.01.

“Medicare-certified facility” means a facility which:

“Patient” means a recipient awaiting or undergoing health care or treatment.

“Physician” means an individual legally licensed to practice medicine in the state in which the physician's practice is located.

“Podiatrist” means a Doctor of Podiatry (D.P.M.) who is licensed to practice podiatry by the Board or by the state in which the service is rendered.

“Program” means Program as defined in COMAR 10.09.36.

“Provider” means a free-standing ambulatory surgical center which, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of a provider account number.

“Recipient” means recipient as defined in COMAR 10.09.36.01.

If located in Maryland, comply with requirements of Health-General Article, Title 17, Subtitles 2 and 3, Annotated Code of Maryland, and either COMAR 10.10.01 or 10.10.06, as applicable; or

If located out-of-State, comply with other applicable standards established by the state or locality in which the service is provided.

Be approved by Medicare to furnish ambulatory surgical services to patients and maintain documentation of certification by the Department of Health and Human Services and the Centers for Medicare and Medicaid Services;

Have clearly defined, written, patient care policies;

Maintain adequate documentation of each recipient visit as part of the plan of care, which at a minimum, shall include:

Have written, effective procedures for infection control which are known to all levels of staff as specified in COMAR 10.06.01;

Be approved by the state in which the service is provided, except where a Certificate of Need is not required;

Provide for in-house Program evaluation and clinical record review which assess use of services for appropriateness in meeting a recipient's needs;

Refer laboratory testing only to independent medical laboratory providers.

Generally result in extensive blood loss;

Require major or prolonged invasion of body cavities;

Directly involve major blood vessels;

Are generally emergency or life-threatening in nature;

Commonly require systemic thrombolytic therapy;

Are designated as requiring inpatient care (overnight);

Can only be reported using a CPT unlisted surgical procedure code; or

Are otherwise excluded under 42 CFR §411.15(a)—(h) and (j)—(s);

Nursing, technician, and related services;

Use of the facility;

Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances, and any equipment directly related to the provision of surgical procedures;

Administrative costs;

Materials including supplies and equipment for the administration and monitoring of anesthesia;

Radiology services for which separate payment is not allowed and other diagnostic tests or interpretive services that are integral to a surgical procedure;

Supervision of the services of a nurse anesthetist by the operating surgeon;

Ancillary items and services that are integral to a covered surgical procedure as defined in 42 CFR §416.166; and

Any laboratory testing performed under a Clinical Laboratory Improvement Amendment of 1988 (CLIA) certificate of waiver.

Reimbursement fees equal 80 percent of the current Medicare-approved ASC facility fee for services furnished to Medicaid recipients in connection with covered surgical procedures.

If one covered surgical procedure is furnished to a recipient, payment is at the Maryland Medicaid Program payment amount which is 80 percent of the current Medicare approved facility fee for that procedure.

If more than one covered surgical procedure is provided to a recipient in a single operative session, payment is made at 100 percent of the Maryland Medicaid Program payment amount for the procedure with the highest reimbursement rate. Other covered surgical procedures furnished during the same session are reimbursed at 50 percent of the Maryland Medicaid Program payment amount for each procedure.

When a covered surgical procedure is terminated before the completion due to extenuating circumstances or circumstances that threaten the well-being of the patient, the Medicaid Program payment amount is based on one of the following:

For covered dental services that have a reimbursement amount of $1,000 through $2,999.99, the ASC facility fee will be $600;

For covered dental services that have a reimbursement amount of $3,000 through $4,999.99, the ASC facility fee will be $1,250;

For covered dental services that have a reimbursement amount of $5,000 through $7,999.99, the ASC facility fee will be $2,500; and

For covered dental services that have a reimbursement amount of $8,000 and over, the ASC facility fee will be $3,000.

The provider accepts Medicare assignment;

Medicare makes direct payment to the provider; and

Medicare has determined that the services are medically justified, excludes dental services.

Deductible is paid in full;

Coinsurance shall be paid lesser of:

Services not covered by Medicare, but considered medically necessary by the Program, according to the limitations of Regulation .04C of this chapter.

Completion of forms and reports;

Broken or missed appointments;

Professional services rendered by mail or telephone; or

Providing a copy of a recipient’s medical record when requested by another licensed provider on behalf of the recipient.