Find policies, billing codes, payers, states, and providers
Ambulatory Surgery Center (ASC) - Site of Care Policy
Customize your policy alerts
Sign up for all Kaiser Permanente policy alerts
Know when Kaiser Permanente releases new policies or updates existing guidance.
Monitor payer policy activity
Defines site-of-care review and medical necessity criteria for elective outpatient surgical procedures to determine when procedures should occur in an ASC versus a hospital outpatient department; applies to Kaiser Foundation Health Plan of Washington members and their providers in specified Washington counties.
MPC approved the additional codes (Deep Brain Stim, Rhinoplasty, Sinus Surgery, Knee Surgery, Treatment for Snoring, Spinal Procedures) to the ASC SOC policy.
Expansion of the ASC Site of Care policy to Medicare line of business.
Updated applicable codes to include new CPT codes effective 1/1/2023: 49591, 49593, 49595, 49613, 49615, 49617, 49621, 49623.
Coverage criteria — when hospital outpatient department is required
Clinical risk-based criteria (Non-Medicare)
Covered when ANY of the following clinical risk criteria are present (Non‑Medicare):
Each listed item individually qualifies the hospital outpatient department as medically necessary for the planned procedure.
Access-based criteria (Non-Medicare)
A planned elective surgical procedure is considered medically necessary in a hospital outpatient department (Non‑Medicare) when ANY one of the following access-based conditions prevents use of an ambulatory surgical center (ASC):
Any one condition makes hospital outpatient department medically necessary when ASC access is unavailable.
Listing of a code in this policy does not by itself indicate that the service described by the code is covered. Benefit coverage is determined by the member's contract and applicable law, and the inclusion of a code in this document does not guarantee reimbursement or payment. Other policy provisions and plan limitations may apply; consult the member Evidence of Coverage and use the Pre-authorization Code Check to confirm authorization requirements for a specific code and plan.
This segment of the policy does not include explicit exclusion statements for the listed procedures. Code listings are provided for reference by specialty and county and do not substitute for benefit-specific exclusion language that may exist elsewhere in plan documents.
CPT code listings for Orthopedics/Podiatry and Plastic Surgery are presented by county groupings (Benton, Kitsap, Spokane, and Whatcom). These lists enumerate procedure codes but do not contain explicit coverage exclusions in this section; applicability remains subject to member contract terms and any separate policy exclusions.
Codes that have been deleted or that are not in effect on the date of service may not be covered. When using these code lists, verify that the CPT/HCPCS codes are current for the service date and confirm coverage via the Pre-authorization Code Check as needed.
For Medicare members, an ASC site-of-care review is not required through August 1, 2026. Non-Medicare criteria described in this policy apply as implemented through the phased rollout; providers should follow the Non-Medicare clinical and access-based criteria for site-of-care decisions unless otherwise directed for Medicare lines of business. Use plan-specific authorization tools to confirm requirements.
Within the chunks comprising these code lists there are no explicit statements labeling any listed procedures as 'not medically necessary.' Medical necessity determinations remain governed by the policy's clinical criteria, member contract provisions, and any separate medical necessity guidance.
Procedure and CPT/HCPCS code lists
| 24164 | Removal of prosthesis, includes debridement and synovectomy when performed; radial head |
| 24200 | Removal of foreign body, upper arm or elbow area; subcutaneous |
| 24220 | Injection procedure for elbow arthrography |
| 24300 | Manipulation, elbow, under anesthesia |
| 24301 | Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) |
| 24305 | Tendon lengthening, upper arm or elbow, each tendon |
| 24310 | Tenotomy, open, elbow to shoulder, each tendon |
| 24330 | Flexor-plasty, elbow (eg, Steindler type advancement) |
| 24331 | Flexor-plasty, elbow; with extensor advancement |
| 24332 | Tenolysis, triceps |
Provider requirements and prior authorization actions
Prior Authorization Required for Site-of-Care
Prior authorization is required to determine the appropriate site of care for certain elective outpatient surgical procedures and to encourage safe, cost-effective settings (e.g., ambulatory surgical center vs outpatient hospital vs inpatient). This applies to applicable members/plans as determined by the member contract and plan type.
- Prior authorization is required to ensure appropriate site-of-care for listed outpatient surgical procedures.
- Use the Pre-authorization Code Check to verify authorization requirements for a specific code by plan type.
Listed Procedures (may be ASC-eligible)
Several listed procedures in the gastroenterology section include CPT codes for cholecystectomy (e.g., 47562, 47563, 47564), which may be eligible for performance at an ambulatory surgical center (ASC) where clinically appropriate. Inclusion in the code list does not guarantee ASC eligibility; site-of-care determinations and any prior authorization expectations must be verified.
Prior Authorization — not specified here
This policy source contains extensive code listings but in some sections does not specify the prior authorization workflow or explicit triggers for approval/denial. When the policy is silent on workflow, follow plan-specific prior authorization processes and consult member Evidence of Coverage (EOC) or plan documents.
- Several Orthopedics/Podiatry code list segments focus on codes only and do not state prior authorization triggers or criteria.
- When unspecified, providers must follow the plan’s standard prior authorization procedures and confirm requirements via the Pre-authorization Code Check.
Pre-authorization Verification
Before scheduling or performing a procedure, verify whether pre-authorization is required for the specific CPT/HCPCS code and member plan using the Pre-authorization Code Check tool. Documentation of authorization (if required) should be obtained and retained per plan rules.
- Use Pre-authorization Code Check to confirm authorization requirements by plan.
- Obtain and document any required prior authorization before the date of service.
No explicit authorization or denial triggers
Some code list segments do not include explicit authorization or denial triggers (e.g., certain provider instructions are absent in the gastroenterology and orthopedics code listings). Absence of stated triggers does not mean prior authorization is not required — verify per plan.
- No explicit authorization/denial triggers listed in segments covering gastroenterology and orthopedics/podiatry.
- Providers should not assume automatic approval; check plan-level criteria and authorization requirements.
Coverage risk for deleted/out-of-effect codes
Deleted codes or codes not in effect at the time of service may not be covered. Providers should confirm the current validity of codes and coverage status for the date of service to avoid claim denials.
- Deleted or out-of-effect CPT/HCPCS codes referenced in the lists may not be covered.
- Verify code effectiveness and coverage prior to billing; consult plan documents and Pre-authorization Code Check.
Background and rationale
Surgical procedures may be performed in multiple settings — inpatient hospital, on- or off-campus outpatient hospital, ambulatory surgical center (ASC), or a provider's office. Site of care selection impacts both safety and cost. Kaiser Permanente uses prior authorization and the policy's clinical and access-based criteria to promote safe, appropriate, and cost-effective placement of elective outpatient surgeries; verify site-of-care authorization and plan coverage prior to scheduling.
Definitions and clinical term clarifications
Policy changes and effective dates
MPC approved expansion of the ASC Site of Care policy to the Medicare line of business; requires 60-day notice; effective August 1, 2026.
MPC approved addition of multiple procedure groups (Deep Brain Stim, Rhinoplasty, Sinus Surgery, Knee Surgery, Treatment for Snoring, Spinal Procedures) to the ASC Site of Care policy; 60-day notice required; effective April 1, 2026.
MPC approved expansion of ASC criteria to include Gastroenterology procedures for King and Thurston counties; 60-day notice required; effective October 1, 2023.
Updated applicable codes to include new CPT codes effective 2023-01-01: 49591, 49593, 49595, 49613, 49615, 49617, 49621, 49623.
Policy effective date updated (phased approach) to September 1, 2021 following earlier adjustments to the implementation timeline.
MPC approved ASC Site of Care criteria and required a 60-day notice; initial effective date July 1, 2021 (later adjusted).
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.