Surgical Site of Care, Facility Notification

Description

Hospital Outpatient Department is a portion of hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization. This can be on the hospital’s main campus or an off-campus site.

Ambulatory Surgical Centers (ASC) are healthcare facilities that provide same-day outpatient surgical care, not requiring hospitalization. ASCs do not share space with other entities during their operating hours.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse facility outpatient surgical procedures based on site of care, according to the criteria outlined in this policy.

Reimbursement Guidelines

For facility outpatient surgical procedures performed in an ambulatory surgical center, reimbursement will be based on 100% of Blue Cross NC allowance.

Surgical procedures performed in a hospital outpatient department must be submitted with Modifier KX, indicating that criteria have been met for this site of service. With appropriate appendage of Modifier KX, reimbursement will be based on 100% of the Blue Cross NC allowance. Review the complete site of care criteria (PDF).

When surgical procedures performed in a hospital outpatient department do not meet the criteria for HOPD use, Modifier KX is not allowed; reimbursement will be based on 60% of the Blue Cross NC allowance.

Providers must submit on their claim all services and conditions related to the encounter via comprehensive Health Insurance Portability and Accountability Act (“HIPAA”) compliant coding.

Billing and Coding

Applicable codes noted throughout policy are for reference only and may not be all inclusive.  For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related policy

Ambulatory Surgical Center (ASC) Reimbursement

Facility Billing Guidelines

Services Bundled into Inpatient/Outpatient Stays

References

American Medical Association, Current Procedural Terminology (CPT^®)

Healthcare Common Procedure Coding System

History

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, Healthy Blue + Medicare (HMO-POS D-SNP), and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.

This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.