Medlearn
Matters…Information for Medicare
Providers
(Issued by the Centers for
Medicare & Medicaid
Services)
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Manual Revision
Regarding Waiver of Annual Deductible and Coinsurance for
Both Ambulatory Surgery Centers (ASCs) and ASC/Hospital
Outpatient Department Physician Services
Provider Types Affected
Hospitals outpatient departments billing for physician
services, ASCs, and physicians.
Impact to You
The Omnibus
Budget Reconciliation Act (OBRA) 1986 and OBRA 1987
rescinded the waiver of the Medicare Part B coinsurance
and deductible requirements for ASC facility services and
ASC/hospital outpatient department physician
services.
What You Need to Know
Medicare
is updating language in its manuals to ensure consistency
with these legislative changes and this change.
What You Need to Do
ASCs and hospital outpatient department billing staffs
are reminded to be familiar with these policies.
Background
Effective April 1,
1988, section 4054 of OBRA 1987 (Public Law 100-203)
imposed the Medicare Part B coinsurance and deductible
requirements for physician services in connection with an
ASC covered procedure that is performed in an ambulatory
setting.
For any physician services furnished on or after April
1, 1988, in connection with an ASC covered procedure,
performed in an ASC or in a hospital on an outpatient
basis, Medicare pays 80 percent of the physician fee
schedule amount. After the beneficiary deductible is met,
the beneficiary is responsible for 20 percent of the
physician fee schedule amount.
Section 9343(e) of OBRA 1986 (Public Law 99-509)
imposed that for any procedure on the ASC list furnished
in an ASC, Medicare pays 80 percent of the applicable ASC
fee schedule amount for such services furnished to
Medicare patients. After the beneficiary’s
deductible is met, the beneficiary is responsible for 20
percent of the applicable facility fee schedule amount
for that facility service. This provision was made for
services furnished on or after July 1, 1987.
Additional Information
If you
have additional questions, please contact your carrier at
their toll-free number, which may be found at:
http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf
.
Disclaimer
Medlearn Matters articles are
prepared as a service to the public and are not intended
to grant rights or impose obligations. Medlearn Matters
articles may contain references or links to statutes,
regulations, or other policy materials. The information
provided is only intended to be a general summary. It is
not intended to take the place of either the written law
or regulations. We encourage readers to review the
specific statutes, regulations, and other interpretive
materials for a full and accurate statement of their
contents.
For more information, visit the Medlearn Matters Web
page at: http://www.cms.hhs.gov/MedlearnMattersArticles/
Related Change Request (CR) #:
3471
Medlearn Matters Number: MM3471
Related CR Release Date: October 22,
2004
Related CR Transmittal #: 11
Effective Date: November 22,
2004
Implementation Date: November 22, 2004
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