ASC Multiple Procedure Methodology

Reimbursement Policy:
Ambulatory Surgery Center Grouper Methodology/Multiple Procedure Reduction

Effective Date:
September 25, 2015
(see the Procedure section below for transition dates of various plans/products)

Last revised date:
June 1, 2017

Purpose:
Provide guidelines for the reimbursement of multiple procedures performed in an Ambulatory Surgery Center. This policy applies to ambulatory surgery centers using group methodology reimbursement only.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g.
  • COB

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
When applicable multiple procedures are performed in an ambulatory surgery center on the same patient during the same surgical session, multiple procedure reductions shall be applied.

Procedure:
Beginning September 25, 2015 and continuing as a phased in approach, Horizon BCBSNJ shall align with CMS and consider the grouper containing the procedure code with the highest allowable to be the primary procedure, regardless of the order in which they appear on the claim or the highest billed charges. All subsequent reimbursable procedures will be reduced.

Transition to the CMS grouper reimbursement methodology will occur as a phased-in approach as noted below:

Horizon BCBSNJ plan/product CMS grouper methodology implementation1
Medicare Advantage September 25, 2015
Managed care network plans/products November 9, 2015
Non-managed care plans/products February 20, 2016
State Health Benefit Plans April 4, 2016
Federal Employee Plan (FEP) May 2, 2016
ITS/Par Other/MPL September 5, 2016
OMNIA plans May 15, 2017

1Until the change in reimbursement methodology as reflected in this Policy is fully implemented systemically, ASC’s may observe some variability in reimbursement received depending on plan in which the patient is enrolled.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
08/15/2016: Policy approved
10/4/2016: Policy revised to include effective date for ITS/Par Other/MPL on CMS Grouper Methodology
06/01/2017: Policy revised to include effective date for OMNIA on CMS Group Methodology

Policy099_v2.0_06012017