CurrentAlaska MedicaidPolicy N/A

Ambulatory Surgical Center (ASC) Services — ASC fee schedule, authorization indicators, and maximum allowable payments

This document lists CPT procedure codes, short descriptions, authorization requirements, and maximum allowable ASC payment amounts applicable to Alaska Medicaid for the period effective 7/1/2025–6/30/2026. It affects providers billing ASCs to Alaska Medicaid.

Policy Summary

PayerAlaska Medicaid

PolicyAmbulatory Surgical Center (ASC) Services — ASC fee schedule and reimbursement guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionWhen billing ASC services, include required medical justification or obtain Comagine/HMS authorization for CPT codes marked with an 'x' before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+procedure codes enumerated

7/1/2025-6/30/2026coverage period

$1,197.48common max allowable

$758.37lower-tier max

$2,338.28highest example shown

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Per-code Coverage & Payment Entries (ASC Fee Schedule)

Per-code coverage entries (sample node)

Per-code entries include description, indicators for medical justification and authorization, and a maximum allowable payment amount.

Each ASC line lists: CPT code and short description; flags for 'Requires Medical Justification', 'Requires Comagine Authorization', and 'Requires HMS Authorization' (fields may be blank or marked 'x').

Example: CPT 10121 — INC & RMVL FB SUBQ TISS COMP; Requires Medical Justification = .; Requires Comagine Authorization = .; Requires HMS Authorization = .; Maximum Allowable = $1,047.18.

Per-code coverage entries (sample)

Billing/coverage stance by CPT code as listed in the ASC fee schedule excerpt:

Each listed CPT code is payable in the ASC setting subject to the 'Maximum Allowable' shown on the line.

SAMPLE CODES

15121 — Dermal autograft; Maximum Allowable = $1,197.48; authorization fields present but not populated in excerpt.
15650 — Transfer skin pedicle flap; Maximum Allowable = $1,682.88; authorization fields present but not populated in excerpt.
19302 — P-mastectomy w/lymph node removal; Maximum Allowable = $2,338.28; authorization fields may indicate special review in other sections.

Authorization markers: lines include 'Requires Medical Justification', 'Requires Comagine Authorization', and 'Requires HMS Authorization' (may be blank or marked 'x' for specific codes).

ASC coverage entries (fee schedule)

Coverage is represented by listed CPT codes with associated Maximum Allowable amounts. Some procedures indicate an authorization requirement.

For each CPT the fee schedule provides: code, short description, 'Requires Medical Justification', 'Requires Comagine Authorization', 'Requires HMS Authorization', Maximum Allowable (dollar amount), and Billing Notes (often blank).

Examples

20206 — BONE BIOPSY; Maximum Allowable = $758.37.
20670 — REMOVAL IMPLANT SUPERFICIAL; Maximum Allowable = $758.37.
20902 — REMOVAL OF BONE FOR GRAFT; Maximum Allowable = $1,478.37.
21120–21123 — RECONSTRUCTION OF CHIN; Maximum Allowable = $2,338.28; HMS Authorization = x (HMS prior authorization flag present).

ASC procedure coverage entries (chunks 54-73)

Coverage and payment entries for listed ASC CPT codes

Lines in this excerpt list CPT code, brief description, authorization flag placeholders, and the Maximum Allowable payment amount for the ASC setting.

Sample entries (chunks 54–73)

21465 — TREAT LOWER JAW FRACTURE; Maximum Allowable = $1,478.37.
21480 — Reset dislocated jaw; Maximum Allowable = $758.37.
21501 — DRAIN NECK/CHEST LESION; Maximum Allowable = $1,047.18.

Some lines explicitly mark Comagine authorization = x (see other chunks); many authorization fields are present but not populated in these pages.

ASC payment lines (no clinical criteria in excerpt)

Payment and administrative fields for ASC procedure codes in this excerpt

Each procedure line includes a 'Maximum Allowable' dollar amount which is the ASC payment limit for that CPT code, and a 'Billing Notes' field which is blank in most lines in the excerpt.

ANY of the following

23515 — Optx clavicular fx w/int fix; Maximum Allowable = $1,197.48.
23532 — Optx strclv dslc aq/chrn grf; Maximum Allowable = $1,478.37.

Authorization columns (Medical Justification / Comagine / HMS) appear per line but are frequently unfilled ('.') in the extract; when populated they indicate additional provider actions are required before payment.

ASC fee schedule entries (partial)

Coverage entries for listed CPT codes

The fee schedule enumerates many sequential CPT codes (upper-extremity group shown) with their Maximum Allowable amounts and authorization flag placeholders.

Example codes

24530 — Treat humerus fracture; Maximum Allowable = $758.37.
24546 — Treat humerus fracture; Maximum Allowable = $1,682.88.
24586 — Treat elbow fracture; Maximum Allowable = $1,478.37.

Authorization fields are present but often blank in this partial section; a few codes in other sections are marked 'x' for medical justification or Comagine authorization.

Per-CPT payment entry (example node)

Per-line entries include description, authorization fields, and maximum allowable payment.

Example payment entry: CPT 25355 — Maximum Allowable = $1,197.48; authorization fields (Medical Justification / Comagine / HMS) appear but are not populated in this excerpt.

ASC fee schedule entries (hand/upper extremity)

Listed ASC-covered CPTs for hand and upper extremity procedures with payment amounts; authorization fields are present but not populated in this excerpt.

Hand and upper-extremity CPT lines include code, description and a Maximum Allowable payment (examples shown below); authorization flags appear but are blank in this extract.

ANY of the following

26170 — Removal of palm tendon each; Maximum Allowable = $1,197.48.
26185 — Remove finger bone; Maximum Allowable = $1,478.37.
26531 — Revise knuckle with implant; Maximum Allowable = $2,338.28.

Billing Notes fields are present after each line but are mostly empty in the provided pages.

Per-code reimbursement and authorization indicators (partial)

Payment and authorization indicators for listed ASC CPT codes (partial).

Some CPT codes explicitly require medical justification (marked 'x'); other authorization columns may be blank or contain an 'x' indicating Comagine or HMS review is required for specific codes.

ANY of the following

26650 — TREAT THUMB FRACTURE; Maximum Allowable = $1,047.18; authorization fields blank in excerpt.
27332 — Removal of knee cartilage; Requires Medical Justification = x; Maximum Allowable = $1,478.37.
27372 — REMOVAL OF FOREIGN BODY; Maximum Allowable = $2,338.28.

Providers should note the 'x' marks where present indicate that additional documentation or prior authorization may be required for payment consideration.

Examples of CPT payment/authorization entries

Payment and authorization notes per CPT code (partial listing):

ANY of the following

27339 — payable; Maximum Allowable = $1,197.48.
27422 — payable; Maximum Allowable = $2,338.28.
27440/27441 — listed with 'requires medical justification' for some revision knee procedures (see lines marked 'x'); Maximum Allowable examples shown.

These entries illustrate that action (payable) and any authorization requirement are shown per code alongside the Maximum Allowable amount.

ASC covered procedure entries (partial)

Each listed CPT code is covered by Alaska Medicaid in ASC setting subject to the listed maximum allowable and any authorization/documentation requirements.

Procedure lines indicate coverage stance = payable in ASC with the Maximum Allowable amount specified; authorization flags indicate when medical justification or prior authorization is required.

ANY of the following

27647 — REPAIR ACHILLES TENDON; Maximum Allowable = $1,197.48; authorization fields blank.
27700 — REVISION OF ANKLE JOINT; Requires Medical Justification = x; Maximum Allowable = $1,682.88.
28118 — REMOVAL OF HEEL BONE; Maximum Allowable = $1,478.37.

When 'Requires Medical Justification' is marked 'x' the provider should submit supporting clinical documentation per payer instructions prior to payment review or as part of prior authorization workflows where applicable.

Per-code reimbursement entries

Per-procedure reimbursement parameters for ASC services of the foot and ankle

Foot and ankle procedure lines list: CPT code, description, authorization placeholders (Medical Justification / Comagine / HMS), Maximum Allowable payment, and Billing Notes (often blank).

ANY of the following

28525 — Treat toe fracture; Maximum Allowable = $1,197.48; auth fields blank in excerpt.
28545 — Treat foot dislocation; Maximum Allowable = $758.37.
28118 — Removal of heel bone; Maximum Allowable = $1,478.37.

Most foot/ankle lines show the Maximum Allowable in the range observed elsewhere in the schedule ($758.37 – $2,338.28) and include authorization flags that may be used to require additional review for specific codes.

Coverage and payment entries (per-CPT)

Lines list CPT code, short description, authorization flags, and maximum allowable payment.

Each fee-schedule line identifies the CPT, a brief description, the Maximum Allowable payment, and columns for authorization/medical justification; values are shown per code in the excerpt.

ANY of the following

28525 — Treat toe fracture; Maximum Allowable = $1,197.48; authorization placeholders present.
29848 — Knee arthroscopy/surgery; Maximum Allowable = $2,081.73.
29880 — Knee arthroscopy/surgery; marked 'Requires Medical Justification' = x; Maximum Allowable = $1,478.37.

Providers should reference the specific CPT line for the applicable Maximum Allowable and any indicated authorization requirement when preparing claims or authorization requests.

Sample coverage/payment nodes (JSON-encoded)

Authorization and payment attributes for listed ASC CPT codes (examples):

ANY of the following

30410 — RECONSTRUCTION OF NOSE; Comagine Authorization = x; Maximum Allowable = $1,682.88.
30801 — Ablate inferior turbinate superficial; some codes show 'Requires Medical Justification' and lower Maximum Allowable (e.g., $758.37).
31253 — Nasal/sinus endoscopy total; Maximum Allowable = $1,682.88; authorization fields present.

These example nodes show that authorization flags (Comagine/HMS/Medical Justification) are used selectively and that Maximum Allowable values vary by procedure complexity and code.

Per-code coverage/fee list

Coverage stance and criteria as presented in these pages:

The fee schedule lists covered CPT codes for ASC services with the payer's Maximum Allowable payment; authorization or medical justification requirements are indicated per-line when applicable and otherwise left blank in this excerpt.

Actionable guidance: bill using the listed CPT and expect reimbursement up to the Maximum Allowable shown on the corresponding line; if a code's authorization column is marked 'x' obtain the required prior authorization or include medical justification with the claim as directed by the payer's procedures.

CPT Codes, Descriptions & Maximum Allowable Rates

Covered CPT CodesCPTCovered

21930	EXC BACK LES SC < 3 CM
21931	EXC BACK LES SC 3 CM/>
21932	EXC BACK TUM DEEP < 5 CM
21933	EXC BACK TUM DEEP 5 CM/>
21935	RESECT BACK TUM < 5 CM
21936	RESECT BACK TUM 5 CM/>
22310	CLOSED TX VERT FX W/O MANJ
22315	CLOSED TX VERT FX W/MANJ
22505	MANIPULATION OF SPINE
22511	PERQ LUMBOSACRAL INJECTION

1–10 of 78

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Authorization, Documentation & Billing Requirements

Documentation Required

Authorization indicators per code

Per-code ASC fee lines include explicit columns for Requires Medical Justification, Requires Comagine Authorization, and Requires HMS Authorization; some codes in the excerpt show an 'x' in one of those columns indicating an affirmative requirement while many lines are blank (no marker).

Documentation Required

Authorization and documentation markers

The fee schedule lists, per CPT, whether 'Requires Medical Justification', 'Requires Comagine Authorization', and 'Requires HMS Authorization' are present; multiple example codes are shown in the excerpt with those markers (some populated with 'x', most left blank).

Examples of codes shown with these fields: 15570, 15572, 15574, 15576, 15823 (see excerpt fields).

Terms & Field Definitions

Definition: Maximum Allowable

Maximum Allowable (definition)The dollar amount listed next to each CPT code representing the payer's maximum reimbursable amount for that procedure in the ASC fee schedule excerpt.

Definition: CPT codes

CPT (definition)Current Procedural Terminology (CPT) codes and descriptions (AMA copyright) used to identify procedures in the fee schedule.

Maximum Allowable — reference

Maximum Allowable (reference)In this ASC fee schedule 'Maximum Allowable' is the payment amount listed next to each procedure code for ASC services.

Authorization markers (definitions)

Policy Summary

PayerAlaska Medicaid

PolicyAmbulatory Surgical Center (ASC) Services — ASC fee schedule and reimbursement guidance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionWhen billing ASC services, include required medical justification or obtain Comagine/HMS authorization for CPT codes marked with an 'x' before submitting claims.

SourceLink

On This Page

Where an 'x' appears in an authorization column it indicates that additional authorization or medical justification is required for that code (examples appear throughout the fee schedule).

HMS authorization required for select CPT codes

Certain CPT lines explicitly show an HMS Authorization flag marked 'x', indicating HMS-level prior authorization is required for those procedures.

Examples with HMS Authorization = x include CPT 21120 and 21121 (reconstruction of chin) as shown in the excerpt.

Prior Authorization

Prior authorization flags in ASC fee entries

Some ASC fee schedule entries include a Comagine authorization marker ('x') for specific CPT codes, indicating those services may require prior authorization through Comagine.

Examples: CPT 22102 and 22103 are marked 'Requires Comagine Authorization = x' in the excerpt.

Documentation Required

Authorization and justification flags for ASC procedures

Each ASC procedure line displays fields for 'Requires Medical Justification', 'Requires Comagine Authorization', and 'Requires HMS Authorization'; in this excerpt those columns are present for each code though many are not populated.

Providers should check the corresponding marker column for each CPT when preparing claims, as shown on each procedure line.

Documentation Required

Authorization and justification fields present but not populated

Many CPT entries include the authorization/justification columns but in the excerpt those fields are not populated (left blank) for numerous codes.

Blank values in these columns do not indicate affirmative authorization is required; they reflect no marker on the provided pages.

Documentation Required

Authorization fields present but blank

The schedule repeatedly shows authorization fields (medical justification, Comagine, HMS) on CPT lines that are left blank across many codes in this excerpt, indicating placeholders exist even when no requirement is marked.

Billing Notes fields are also present but mostly empty on the shown lines.

Documentation Required

Authorization / medical justification flags present

Every CPT entry includes columns for Requires Medical Justification, Requires Comagine Authorization, and Requires HMS Authorization; the excerpt shows these fields consistently even when not explicitly marked.

Presence of these columns indicates authorization tracking is performed per code elsewhere in the policy or via payer workflows.

Documentation Required

Authorization and medical justification indicators (partial)

Most CPT lines show the Comagine/HMS authorization columns blank in this excerpt, but selected codes do have an 'x' for medical justification—indicating only a subset require additional clinical justification.

The excerpt notes that a few lines have 'Requires Medical Justification = x' while Comagine/HMS columns remain blank for those entries.

Prior Authorization

Medical justification required for specific knee procedures

CPT 27332 and 27333 are shown with 'Requires Medical Justification = x', indicating medical justification is required for removal of knee cartilage procedures.

Both codes list Maximum Allowable = 1,478.37 and include the medical justification marker 'x'.

Documentation Required

Authorization indicators on CPT lines

Each CPT line in the fee schedule includes the three authorization flags (Medical Justification, Comagine, HMS); in this excerpt most are blank indicating no marker, but the fields exist per code.

Providers must inspect the specific CPT row to confirm whether any of these flags is marked before billing.

Prior Authorization

Example explicit authorization requirement

The excerpt includes specific examples where 'Requires Medical Justification' is explicitly marked with an 'x', demonstrating that some CPTs require additional justification prior to payment.

Example: CPT 27700 'REVISION OF ANKLE JOINT' is marked 'Requires Medical Justification = x' in the schedule.

Documentation Required

Authorization and justification fields for ASC procedures

Many ASC procedure entries present the Comagine and HMS authorization fields along with medical justification, but in the provided excerpt those fields are commonly blank (no 'x') for the listed codes.

Providers should verify authorization requirements for each code rather than assume absence of a marker in this excerpt applies universally.

Documentation Required

Authorization flags per CPT

Most CPT rows include the three authorization flags; the excerpt shows these columns repeatedly and only a minority of codes are marked—providers must check each CPT's flags before submission.

Sample lines (28525, 28531, 28545) show the authorization columns present but not marked in the excerpt.

Prior Authorization

Codes requiring medical justification

A number of specific CPT codes are shown with 'x' under 'Requires Medical Justification' indicating they require supporting clinical documentation; check the code line for the 'x' marker.

Examples: CPT 29880 and 29881 (knee arthroscopy/surgery) are marked 'Requires Medical Justification = x' in the excerpt.

Prior Authorization

Comagine prior authorization requirement (examples)

Selected reconstruction and revision CPT codes are marked with 'Requires Comagine Authorization = x' in the excerpt, indicating prior authorization via Comagine may be required for those services.

Examples in the excerpt include CPT 30400, 30410, 30420, 30430, 30435, and 30450 with Comagine Authorization = x.

Documentation Required

Authorization requirements (placeholders)

The ASC fee lines consistently include placeholders for 'Requires Medical Justification', 'Requires Comagine Authorization', and 'Requires HMS Authorization' even where those fields are not populated on the shown pages.

Absence of an 'x' in this excerpt does not eliminate the need to confirm authorization requirements via payer or authorization vendor when applicable.

Authorization markers — 'Requires Medical Justification'Marks when additional clinical justification is indicated; some codes in the excerpt show 'x'.

Authorization markers — 'Requires Comagine Authorization'Indicates review by Comagine may be required; shown as a field per code (sometimes marked 'x').

Authorization markers — 'Requires HMS Authorization'Indicates review by HMS may be required; shown as a field per code (sometimes marked 'x').

HMS Authorization

HMS Authorization — meaningAn 'x' in the HMS Authorization field indicates the listed code requires HMS prior authorization for that procedure in this excerpt.

Maximum Allowable — reference note

Maximum Allowable (reference note)The 'Maximum Allowable' dollar amount appears after each CPT code and represents the ASC maximum payable for that procedure in this policy excerpt.

Comagine Authorization

Comagine Authorization — definitionAn 'x' in the Comagine Authorization field indicates the code may require prior authorization review by Comagine, as shown for select codes in the excerpt.

Maximum Allowable — explicit

Maximum Allowable — explicit statement'Maximum Allowable' = the payment amount listed next to each procedure code for ASC services in this policy excerpt.

Authorization flags — definition

Authorization flags — what they representThe three per-code flags ('Requires Medical Justification', 'Requires Comagine Authorization', 'Requires HMS Authorization') indicate documentation or prior authorization requirements and appear for each CPT line in the excerpt.

Maximum Allowable — reference

Maximum Allowable — referenceThe dollar amount listed after each CPT code represents the ASC maximum payable (appears as 'Maximum Allowable = $' followed by the numeric value).

Authorization fields

Authorization fields — noteFields for 'Requires Medical Justification', 'Requires Comagine Authorization', and 'Requires HMS Authorization' appear for each CPT but are often not populated in the provided excerpt.

Maximum Allowable — description

Maximum Allowable — descriptionThe dollar amount listed after each CPT code is the payer's listed ASC maximum reimbursable amount for that procedure.

Billing Notes

Billing Notes (definition)A field following each CPT line intended for payer-specific billing instructions; in these chunks the billing notes are mostly blank.

Maximum Allowable — summary

Maximum Allowable — summary'Maximum Allowable' indicates the listed dollar payment amount applicable to the ASC procedure code in the fee schedule.

Authorization flags — per-code

Authorization flags — per-code indicatorsPer-line authorization flags appear for each CPT code; many entries are blank but some codes show 'x' to indicate a requirement (e.g., 'Requires Medical Justification = x').

Maximum Allowable — note

Maximum Allowable — noteThe 'Maximum Allowable' dollar amount is the numeric payment limit shown beside each CPT in the ASC fee schedule excerpt.

Requires Medical Justification

Requires Medical Justification — definitionFlag indicating additional clinical justification may be required prior to payment; some CPTs in the excerpt are explicitly marked with 'x'.

Maximum Allowable — reference repeat

Maximum Allowable — reference repeatIn this document 'Maximum Allowable' consistently denotes the ASC payment amount listed next to each CPT code.

Authorization indicators

Authorization indicators — referenceColumns for 'Requires Medical Justification', 'Requires Comagine Authorization' and 'Requires HMS Authorization' appear per-line to indicate potential documentation or prior authorization needs.

Requires Medical Justification — note

Requires Medical Justification — noteWhere present as 'x', this flag denotes that medical necessity documentation is required for that code (examples in the excerpt).

Requires Comagine Authorization — note

Requires Comagine Authorization — noteAn 'x' in the Comagine Authorization column indicates prior authorization by Comagine may be required for that CPT code (present on select codes).

Requires HMS Authorization — note

Requires HMS Authorization — noteAn 'x' in the HMS Authorization column indicates HMS prior authorization is required for the listed CPT (appears for specific codes in the excerpt).

Maximum Allowable — simple

Maximum Allowable — simple referenceThe numeric dollar amount listed after each CPT code in the fee schedule is the payer's maximum allowable payment for ASC claims.

Authorization/Justification flags

Authorization/Justification flags — explanationThe three per-code flags identify whether medical justification or specific authorizations (Comagine, HMS) may be required; fields are present for each CPT line in the excerpt.

Maximum Allowable = $ (payer meaning)

Maximum Allowable = $ — payer meaningIndicates the payer's maximum reimbursable amount for the procedure code as listed in the ASC fee schedule excerpt.

Requires Medical Justification (placeholder)

Requires Medical Justification — placeholder definitionA flag marking when supporting clinical documentation may be required; some codes in the excerpt show 'x', others are blank.

Comagine Authorization flag

Comagine Authorization flag — 'x' meaningAn 'x' in this field indicates the code may require prior authorization review by Comagine before payment.

Maximum Allowable = $

Maximum Allowable = $ (payer maximum)Specifies the payer's maximum reimbursable amount listed beside each CPT in the ASC fee schedule.

Maximum Allowable — cross-reference

Maximum Allowable — cross-referenceRepeated across the fee schedule to denote the payment cap for ASC-listed CPTs in this policy excerpt.

Authorization placeholders

Authorization placeholders — notePlaceholders for 'Requires Medical Justification', 'Requires Comagine Authorization', and 'Requires HMS Authorization' appear per-code but are often blank in the excerpt.