Title 42

SECTION 416.166

416.166 Covered surgical procedures.

§ 416.166 Covered surgical procedures.

(a) Covered surgical procedures. (1) Effective for services furnished on or after January 1, 2008 through December 31, 2020, covered surgical procedures are those procedures that meet the general standards described in paragraph (b)(1) of this section (whether commonly furnished in an ASC or a physician's office) and are not excluded under paragraph (c) of this section; and

(2) Effective for services furnished on or after January 1, 2021, covered surgical procedures are those procedures that meet the requirements described in paragraph (b)(2) of this section (whether commonly furnished in an ASC or a physician's office).

(b) Requirements for covered surgical procedures - (1) General standards. Effective for services furnished on or after January 1, 2008 through December 31, 2020, subject to the exclusions in paragraph (c) of this section, covered surgical procedures are surgical procedures specified by the Secretary and published in the Federal Register and/or via the internet on the CMS website that are separately paid under the OPPS, that would not be expected to pose a significant safety risk to a Medicare beneficiary when performed in an ASC, and for which standard medical practice dictates that the beneficiary would not typically be expected to require active medical monitoring and care at midnight following the procedure.

(2) Effective for services furnished on or after January 1, 2021, covered surgical procedures are surgical procedures specified by the Secretary and published in the Federal Register and/or via the internet on the CMS website that:

(i) Are separately paid under the OPPS; and

(ii) Are not:

(A) Designated as requiring inpatient care under § 419.22(n) of this subchapter as of December 31, 2020;

(B) Only able to be reported using a CPT unlisted surgical procedure code; or

(c) General exclusions effective January 1, 2008 through December 31, 2020. Notwithstanding paragraph (b)(1) of this section, covered surgical procedures do not include those surgical procedures that -

(1) Generally result in extensive blood loss;

(2) Require major or prolonged invasion of body cavities;

(3) Directly involve major blood vessels;

(4) Are generally emergent or life-threatening in nature;

(5) Commonly require systemic thrombolytic therapy;

(6) Are designated as requiring inpatient care under § 419.22(n) of this subchapter;

(7) Can only be reported using a CPT unlisted surgical procedure code; or

(8) Are otherwise excluded under § 411.15 of this chapter.

(d) Physician considerations beginning January 1, 2021. Physicians consider the following safety factors as to a specific beneficiary when determining whether to perform a covered surgical procedure. The covered procedure -

(1) Is not expected to pose a significant safety risk when performed in an ASC;

(2) Is one for which standard medical practice dictates the beneficiary would not typically be expected to require active medical monitoring and care at midnight following the procedure;

(3) Generally results in extensive blood loss;

(4) Requires major or prolonged invasion of body cavities;

(5) Directly involves major blood vessels;

(6) Is generally emergent or life-threatening in nature; and

(7) Commonly requires systemic thrombolytic therapy.

(e) Additions to the list of ASC covered surgical procedures beginning January 1, 2021. On or after January 1, 2021, CMS adds surgical procedures to the list of ASC covered surgical procedures as follows.

(1) CMS identifies a surgical procedure that meets the requirements at paragraph (b)(2) of this section.

(2) CMS is notified of a surgical procedure that could meet the requirements at paragraph (b)(2) of this section and CMS confirms that such surgical procedure meets those requirements.

[85 FR 86301, Dec. 29, 2020]