New reimbursement policy: Surgical site of care - facility

Effective December 1, 2026, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is implementing a new Surgical Site of Care reimbursement policy for Medicare Advantage.

Reimbursement Based on Site of Care

Facility outpatient surgical services performed in an ambulatory surgery center (ASC) will continue to be reimbursed at 100% of the Blue Cross NC allowance.

Facility outpatient surgical services performed in a hospital outpatient department (HOPD) will be reimbursed at 100% of the Blue Cross NC allowance when submitted with Modifier KX, indicating that the site-of-care criteria have been met.

When surgical services are performed in an HOPD and the site-of-care criteria are not met, Modifier KX should not be reported. Reimbursement for facility claims will be based on 60% of the Blue Cross NC allowance.

Providers must report all services and conditions related to the encounter using appropriate HIPAA-compliant coding.

The policy supports the use of the most appropriate and cost-effective site of care while maintaining access to outpatient surgical services.

For additional details, review the related Medicare reimbursement policy notification and reimbursement policy.

Applicability

This policy applies to Medicare Advantage. It does not apply to Commercial, Inter-Plan Program (IPP) Host, IPP Home or Federal Employee Program (FEP).