Exception.

Exception. The national ASC payment rates for the following items and services are not determined in accordance with paragraph (a) of this section but are paid an amount derived from the payment rate for the equivalent item or service set under the payment system established in part 419 of this subchapter as updated annually in the Federal Register and/or via the Internet on the CMS Web site. If a payment rate is not available, the following items and services are designated as contractor-priced:
(1) Covered ancillary services specified in § 416.164(b), with the exception of radiology services and certain diagnostic tests as provided in § 416.164(b)(5) and non-opioid pain management drugs that function as a supply when used in a surgical procedure as provided in § 416.164(b)(6).
(2) The device portion of device-intensive procedures, which are procedures that -
(i) Involve implantable devices assigned a CPT or HCPCS code;
(ii) Utilize devices (including single-use devices) that must be surgically inserted or implanted; and
(iii) Have a HCPCS code-level device offset of greater than 30 percent when calculated according to the standard OPPS ASC ratesetting methodology.
(3) Procedures using certain separately paid implantable devices that are approved for transitional pass-through payment in accordance with § 419.66 of this subchapter.
(4) Notwithstanding paragraph (b)(2) of this section, low volume device-intensive procedures where the otherwise applicable payment rate calculated based on the standard methodology for device intensive procedures described in this paragraph (b) would exceed the payment rate for the equivalent service set under the payment system established under part 419 of this chapter, for which the payment rate will be set at an amount equal to the amount under that payment system.

Source

42 CFR § 416.171


Scoping language

None
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