Ambulatory Surgery Center (ASC) Groupers Updated

Although TRICARE implemented the TRICARE Outpatient Prospective Payment System (OPPS) on May 1, 2009, there are still several OPPS-exempt type facilities that will be reimbursed under the ASC grouper payment system.

Per the TRICARE Reimbursement Manual, Chapter 9 (Ambulatory Surgical Center (ASC) Reimbursement), only those procedures that have an ambulatory surgery rate listed on TRICARE Management Activity’s (TMA’s) Web site at http://www.tricare.mil/ambulatory are to be reimbursed under the groupers. All TriWest grouped procedures have been end dated as of April 30, 2009. Facility claims with dates of service on or after May 1, 2009 for procedures that are not listed on TMA’s Web site will be reimbursed at the lesser of billed charges or the contractual rate.

The ASC grouper listing in the Reimbursement Rates section of www.triwest.com/provider has been updated to reflect the end date of all TriWest groupers.

In addition, with OPPS, TRICARE implemented the Inpatient Only list. This list of procedures must be done in an inpatient setting and cannot be done in any outpatient setting. A complete list can be found at http://www.tricare.mil/inpatientprocedures. If a request for authorization for one of these procedures is requested in an outpatient setting, the request will be denied. If a claim is submitted from an outpatient setting, the claim will be denied. This list applies to all TRICARE beneficiaries, including active duty service members (ADSMs).

Published Date: 07/23/2009