Clinical UM Guideline


Subject:  Ambulatory or Outpatient Surgery Center Procedures
Guideline #:  CG-SURG-10Current Effective Date:  01/05/2016
Status:RevisedLast Review Date:  11/05/2015

Description

This document addresses procedures performed in the ambulatory or outpatient surgery centers.

Ambulatory surgery refers to surgical or invasive diagnostic procedures performed by qualified providers in ambulatory or dedicated surgical suites with pre-procedural and immediate post-procedural care on the same day or observation admissions without hospitalization (Patient Selection Criteria for Ambulatory [Same Day] Surgery VHA Handbook).

Note: Please see the following related documents for additional information:

Clinical Indications

Note:  The medical necessity of the procedure may be separately reviewed against the appropriate criteria.  

Medically Necessary: 

The use of an outpatient or ambulatory surgery center (ASC) facility, rather than an office-based setting, is considered medically necessary when any of the following criteria are met: 

  1. The procedure must be of a level of complexity that it may not be performed in a less intensive setting such as an office-based setting, but also not so complex as to require immediate access to specific services of a medical center/hospital setting or post-operative recovery in an inpatient facility.  For example the procedure's complexity requires one the following, including but not limited to:
    1. need for anesthesia or sedation beyond topical anesthesia, digital block, or local anesthesia with concomitant need for monitoring of physiologic parameters beyond intermittent checks of vital signs; or
    2. need for recovery period of significant duration beyond the capacity of a physician's office;
      OR
  2. The individual has clinical conditions which may compromise the safety of an office-based procedure, including but not limited to:
    1. medical conditions which require enhanced monitoring, medications or a prolonged recovery period; or
    2. increased risk for complication due to severe comorbidity, such as that evidenced by an American Society of Anesthesiologist's (ASA) class I-II physical status.

Not Medically Necessary:

All other uses of outpatient or ASC facility, rather than an office-based setting, are considered not medically necessary.

Coding

Coding edits for medical necessity review are not implemented for this guideline. Where a more specific policy or guideline exists, that document will take precedence and may include specific coding edits and/or instructions. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Discussion/General Information

While hospitals continue to provide essential services for serious illness, much health care activity takes place in the ambulatory setting.  Surgical practices have been transformed so that more than half of all surgery in the United States is performed on an ambulatory basis (Patient Selection Criteria for Ambulatory [Same Day] Surgery VHA Handbook).  Ambulatory (or outpatient) surgery provides an efficient and flexible means to provide many surgical and therapeutic procedures without requiring an inpatient hospital admission.

References

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. Medicare Claims Processing Manual. Chapter 14 - Ambulatory Surgical Centers. (Rev. 2020, 08-22-14). Available at: https://www.cms.gov/manuals/downloads/clm104c14.pdf.  Accessed on October 30, 2015.
  2. American Medical Association Amended Core Principles (Office-based Surgery Principles) presented to AMA House of Delegates 1/03. Available at: https://www.ama-assn.org/ssl3/ecomm/PolicyFinderForm.pl?site=www.ama-assn.org&uri=/resources/html/PolicyFinder/policyfiles/HnE/H-475.984.HTM. Accessed on October 30, 2015.
  3. Guidelines for Office-Based Anesthesia, American Society of Anesthesiologists (Approved by the ASA House of Delegates on October 13, 1999, and re-affirmed on October 15, 2014). Available at: http://www.asahq.org/search?q=office-based%20surgery. Accessed on October 30, 2015.
  4. Criteria and Standards for Performance of Ambulatory (Same Day) Surgery Performed in Ambulatory or Dedicated Surgical Suites. VHA Handbook 1102.5 Appendix A dated May 20, 2003.
Index

Ambulatory or Outpatient Surgery Center Procedures
Ambulatory Surgery Center Procedures
Outpatient Surgery Center Procedures

History
StatusDateAction
Revised11/05/2015Medical Policy & Technology Assessment Committee (MPTAC) review. Revised medically necessary clinical indications. Added not medically necessary statement. Updated review date, References and History sections of document.
Reviewed11/13/2014MPTAC review. Updated review date, References and History sections of document.
Reviewed11/14/2013MPTAC review. Updated review date, References and History sections of document.
Reviewed11/08/2012MPTAC review. Updated review date, References and History sections of document.
Reviewed11/17/2011MPTAC review. Updated review date, References and History sections of document.
Reviewed11/18/2010MPTAC review. Updated review date, References and History sections of document.
Reviewed11/19/2009MPTAC review. Updated review date, References and History sections of document.
Reviewed11/20/2008MPTAC review. Updated review date, References and History sections of document.
Reviewed11/29/2007MPTAC review. Updated review date, References and History sections of document.
Reviewed12/07/2006MPTAC review. A review of the literature from September 2005 – September 2006 did not result in a change in the clinical criteria. Revised coding language, updated References and History sections of document.
Revised12/01/2005MPTAC review. Review based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger OrganizationsLast Review DateDocument  NumberTitle
Anthem, Inc.  None
WellPoint Health Networks, Inc.12/02/2004NoneAmbulatory or Outpatient Surgery Center Procedures