Subsection 144-101-II-4.04 - COVERED SERVICESCovered services are those items and services, stated below, which are furnished by an ASC in connection with a covered surgical procedure. Unless otherwise stated below, only covered surgical procedures currently on the Medicare-approved list of ASC covered procedures are allowed. See the Federal Registrar for the annual ASC final rule or http://www.cms.hhs.gov/ASCPayment/ for the current listing. Covered surgical procedures are those that would not be expected to pose a significant safety risk to a member when performed in an ASC, and for which standard medical practice dictates that the member would not typically be expected to require active medical monitoring and care at midnight following the procedure.
Coding for covered services is based on the latest version of the American Medical Association's standard Current Procedural Terminology (CPT) codes and can be accessed through the Department's website at: https://mainecare.maine.gov/.
A. The following items and services are covered services and are included in the all-inclusive rates for reimbursement in this Section of the MaineCare Benefits Manual: (1) Nursing, technical personnel and other related services; These include all services in connection with covered procedures furnished by nurses, technical personnel and other support staff involved in patient care who are employees of the ASC.
(2) Use of surgical center facilities;(3). Drugs and biologicals for which separate payments are not allowed under the hospital outpatient prospective payment system (OPPS);(4) Any laboratory testing performed under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver.(5) Medical and surgical supplies not on pass-through status under 42 CFR 419.66 Subpart G;(8) Implanted prosthetic devices, including intraocular lenses (lOLs), (payment for presbyopia-correcting intraocular lens and astigmatism-correcting intraocular lens will be a the rate of a conventional intraocular lens) and related accessories and supplies not on pass-through status under 42 CFR 419.66 Subpart G;(9) Implanted DME and related accessories and supplies not on pass-through status under 42 CFR 419.66 Subpart G;(10) Splints and casts and related devices;(11) Radiology services for which separate payment is not allowed under the OPPS, and other diagnostic tests or interpretive services that are integral to a surgical procedure;(12) Administrative, recordkeeping and housekeeping items and services;(13) Materials, including supplies and equipment for the administration and monitoring of anesthesia; and(14) Supervision of the services of an anesthetist by the operating surgeon.B.Ancillary ServicesAncillary items and services that are integral to a covered surgical procedure (defined above) and for which separate payment is allowed, include the following:
(1) Brachytherapy sources;(2) Certain implantable items that have pass-through status under the OPPS;(3) Certain items and services that CMS designates as contractor-priced, including but not limited to, the procurement of corneal tissue;(4) Certain drugs and biologicals for which separate payment is allowed under the OPPS.(5) Certain radiology services for which separate payment is allowed under the OPPS. When an ASC bills for services covered under this Section of the MaineCare Benefits Manual for a given operative procedure, the physician(s) involved in performing the operative procedure is to bill for his or her professional services only under Chapter II, Section 90, and not for related ancillary services such as anesthesia supplies, which are covered services under this Section.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-4, subsec. 144-101-II-4.04