Ambulatory Surgery Center (ASC) - Site of Care Policy
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Defines Kaiser Permanente Washington requirements for prior authorization and medical necessity review of outpatient surgical site-of-care (ASC vs hospital outpatient/inpatient) for specified counties and procedure groups; affects providers performing GI, general surgery, plastic, orthopedic/podiatry procedures and Kaiser members in the listed counties.
Added additional codes for Deep Brain Stimulation, Rhinoplasty, Sinus Surgery, Knee Surgery, Treatment for Snoring, and Spinal Procedures to the ASC Site of Care policy.
Consolidated ASC list of codes to a criteria page.
Coverage criteria and medical-necessity rules
Planned surgical procedures considered medically necessary in hospital outpatient department
Certain planned surgical procedures performed in a hospital outpatient department are considered medically necessary for an individual who meets ANY of the following criteria:
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Inability to access an ambulatory surgical center
A planned surgical procedure performed in a hospital outpatient department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to ANY one of the following:
Any single barrier permits hospital outpatient site
Any single barrier permits hospital outpatient site
Any single barrier permits hospital outpatient site
ASC Site of Care Code Applicability
ASC Site of Care applies to the listed CPT/HCPCS codes and requires plan-specific prior authorization and code currency verification.
Verify each listed code and plan-specific authorization using the Pre-authorization Code Check; deleted or out-of-effect codes may not be covered.
The lists of procedure and diagnosis codes in this policy are provided for reference only. Listing a code does not by itself indicate that the service described by the code is a covered or non‑covered benefit; coverage and payment depend on the member-specific contract, applicable laws, and other applicable policies. Use plan-specific resources (for example, the Pre-authorization Code Check) to verify coverage and prior authorization requirements for a given code.
Within the extracted sections shown, there are no explicit exclusions stated beyond the regional code listings. The content in these chunks enumerates Orthopedics/Podiatry procedure codes for the named counties but does not set out policy-level exclusions for services associated with those codes.
These chunks present code lists (for example, orthopedics/knee procedure codes) and do not include separate coverage rules or exclusions. The code listings are provided for reference and do not themselves define medical necessity or guarantee coverage.
Some entries in the code tables may be deleted or otherwise not in effect at the time of service; such codes may not be covered. Verify code currency and plan-specific authorization requirements (for example, via the Pre-authorization Code Check) before submission.
The provided extract does not contain any statements labeling services or codes as not medically necessary. No explicit 'not medically necessary' determinations are present in these chunks.
CPT / HCPCS code lists by specialty and applicability
| 24000 | Arthrotomy, elbow, including exploration, drainage, or removal of foreign body. |
| 24006 | Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure). |
| 24100 | Arthrotomy, elbow; with synovial biopsy only. |
| 24101 | Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body. |
| 24102 | Arthrotomy, elbow; with synovectomy. |
| 24105 | Excision, olecranon bursa. |
| 24110 | Excision or curettage of bone cyst or benign tumor, humerus. |
| 24115 | Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft). |
| 24116 | Excision or curettage of bone cyst or benign tumor, humerus; with allograft. |
| 24120 | Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process. |
Provider responsibilities: authorization, verification, and documentation
Prior authorization required for site-of-care determination
Prior authorization is required to determine the medically appropriate site of care for certain elective outpatient surgical procedures. To verify whether a specific CPT/HCPCS code requires prior authorization for a given plan, use the Pre-authorization Code Check.
- Prior authorization required to ensure appropriate site of care for listed procedures.
- Use the Pre-authorization Code Check to verify code-level authorization requirements by plan type.
Codes listed for ASC/site-of-care review (regional)
This excerpt lists CPT codes associated with procedures that are included in the ASC/site-of-care review for the named counties (Benton, Kitsap, Spokane, and Whatcom). The presence of a code in these lists does not by itself state the specific prior authorization submission requirements or documentation triggers — verify authorization and submission instructions by plan using the Pre-authorization Code Check.
- General Surgery: multiple CPT codes (e.g., 47562, 47563, 47564, 49505, 49507, 49520, 49521, 49525, 49550, 49553, 49555, 49557, 49591, 49593).
- Orthopedics/Podiatry: multiple CPT codes (e.g., 25272, 25275, 25280, 25295, 27409, 27416, 27418, 27422, 27424, 27427, 27428, 27429).
- Treatment for Snoring/Palatopharyngoplasty: CPT/HCPCS codes referenced in policy.
ASC CPT code listing (regional)
The ASC-specific CPT lists in this policy apply regionally (Benton, Kitsap, Spokane, and Whatcom counties initially) and were expanded over time per policy history. Codes shown in this policy were consolidated for the ASC criteria page; deleted or out-of-effect codes may not be covered. Always confirm current code status and ASC authorization applicability via the Pre-authorization Code Check.
- Phased implementation for Non‑Medicare members beginning in Benton, Kitsap, Spokane, and Whatcom counties.
- ASC code lists were consolidated to the criteria page and updated periodically (see policy history).
- Deleted/out‑of‑effect codes may not be covered; code currency affects coverage.
Authorization and denial triggers, documentation — not specified in this extract
This excerpt does not enumerate explicit authorization approval or denial triggers, nor does it provide step-by-step documentation or submission requirements. Where criteria are specified for hospital outpatient medical necessity (e.g., advanced liver disease, anticipated overnight recovery, need for transfusion, bleeding disorders, brittle diabetes, significant cardiac or pulmonary disease, developmental/cognitive considerations), those are considerations for determining appropriate site of care but are not presented here as formal authorization/denial rules. Use plan-specific authorization guidance for actionable triggers and required documentation.
- Authorization/denial triggers are not specified in this extract; clinical criteria examples for hospital outpatient setting are listed (see policy for details).
- Documentation requirements and submission instructions are not provided in these chunks — verify with plan-specific authorization resources.
Step therapy
Step therapy does not apply to the site-of-care/ASC prior authorization rules in this excerpt.
- No step therapy rules are included in these policy excerpts.
Code verification and documentation reminder
Provider action reminder: verify code-level prior authorization and site-of-care applicability using the Pre-authorization Code Check before scheduling or billing. Inclusion of a code in the policy lists is for reference and does not guarantee coverage or reimbursement.
- Verify authorization requirements by plan via Pre-authorization Code Check.
- Listing of codes is reference only; check member contract and plan rules for coverage and reimbursement.
Background and rationale
Surgical procedures may be performed in multiple settings—including an inpatient hospital, an on‑ or off‑campus outpatient hospital/medical center, an ambulatory surgical center (ASC), or a physician office. Selection of the appropriate site of care affects patient safety and cost; for selected elective outpatient procedures the plan will review medical necessity to determine whether the hospital outpatient department or an ASC is the medically appropriate site.
Definitions and key terms
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