Outpatient Surgical Site of Service
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Policy requires prior authorization for hospital outpatient (POS 22) site of service for select outpatient surgical procedures for Commercial Fully Insured members and directs that services not meeting criteria must be performed at an ambulatory surgery center (ASC) unless an attestation of no accessible ASC is on file.
Prior authorization required to review medical necessity of a hospital outpatient site of service (place of service 22) for Hernia Repair and Laparoscopic Cholecystectomy for Commercial Fully Insured members.
Criterion I.E.4 (prolonged surgery greater than 3 hours) will be removed as a medically necessary reason for use of hospital outpatient department instead of ambulatory surgery center.
Coverage Criteria — Hospital Outpatient vs ASC
Hospital outpatient site coverage with PA
Covered at hospital outpatient site (place of service 22) only when prior authorization for medical necessity is obtained for the listed procedures; if criteria are not met the service must be performed at an ASC or an ASC attestation provided.
See appendix CPT list for specific codes
If no ASC is available, indicate this on the PA request or have a signed attestation on file to prevent delays.
ASC availability and attestation
- ONE of: Have a signed attestation on file with The Plan indicating no accessible ASC or privileges at an accessible ASC.
Signed attestation form available from The Plan.
- ONE of: If no attestation is on file, indicate on the PA submission that no ASC is available to prevent delay of prior authorization review.
Providers anticipating future site-of-service auth requests are encouraged to submit a prospective attestation.
Performing the service in a hospital outpatient setting without meeting criteria risks denial.
Criterion I.E.4 (prolonged surgery >3 hours) removed as justification.
This policy does not apply to Providence Medicare and Providence OHP members. These provisions are specific to Commercial Fully Insured members and do not supersede existing benefit determinations of coverage.
If the medical policy criteria for hospital outpatient site of service (place of service 22) are not met, the hospital outpatient setting is not covered and the procedure must be performed at an ambulatory surgery center (ASC) for coverage. Providers who do not have a geographically accessible ASC or do not have privileges at an accessible ASC must have a signed ASC attestation on file with The Plan or indicate on the prior authorization request that no ASC is available to avoid delays in review.
Applicable Codes
| 47562 | Laparoscopy; cholecystectomy |
| 47563 | Laparoscopy; cholecystectomy with cholangiography |
| 47564 | Laparoscopy; cholecystectomy with exploration of common duct |
| 43281 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh |
| 43282 | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh |
| 49505 | Repair initial inguinal hernia, age 5 years or older; reducible |
| 49520 | Repair recurrent inguinal hernia, any age; reducible |
| 49525 | Repair inguinal hernia, sliding, any age |
| 49550 | Repair initial femoral hernia, any age; reducible |
| 49555 | Repair recurrent femoral hernia; reducible |
Provider Requirements and Operational Steps
Prior authorization required for POS 22
Prior authorization is required for medical necessity review when the hospital outpatient site of service (place of service 22) is requested for Hernia Repair or Laparoscopic Cholecystectomy for Commercial Fully Insured members.
Site-of-service step: perform at ASC or attest
If the medical policy criteria are not met for hospital outpatient site, the service must be performed at an ambulatory surgery center (ASC); providers without access or privileges at a geographically accessible ASC must provide an attestation.
- Providers who do not have a geographically accessible ASC or lack privileges must have a signed attestation on file with The Plan.
PA submission must indicate POS and include ASC attestation when needed
Indicate on the prior authorization request if the procedure will be performed in a hospital outpatient setting (place of service 22). If no ASC is available, submit an attestation on the PA submission or have a signed attestation on file with The Plan to prevent review delays.
- Make clear on the PA request that the procedure will be performed in POS 22 when applicable.
- If necessary, attest on the PA submission that no ASC is available; providers are encouraged to file a prospective attestation to facilitate future reviews.
Denial risk when hospital outpatient criteria not met
Performing the procedure in a hospital outpatient setting (POS 22) without meeting the medical policy criteria risks denial; services not meeting criteria are covered only when performed at an ASC.
- If medical policy criteria are not met for the outpatient site of service, the hospital outpatient setting is not covered and performing at POS 22 may be denied.
Background
This policy governs site-of-service determinations—specifically whether selected common general surgery procedures should be performed in a hospital outpatient department (place of service 22) versus an ambulatory surgery center (ASC). The policy focuses on administrative requirements for prior authorization of hospital outpatient site requests for the listed procedures rather than the clinical indications for the procedures themselves.
Definitions
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