1. (1) Covered services. Covered ambulatory surgical center (ASC) services are those medically necessary services identified in this section which are provided by or under the supervision of a certified physician in a certified ambulatory surgical center. The physician shall demonstrate that the recipient requires general or local anesthesia, and a postanesthesia observation time, and that the services could not be performed safely in an office setting. These services shall be performed in conformance with generally-accepted medical practice. Covered ambulatory surgical center services shall be limited to the following procedures:

   1. (a) Surgical procedures:

      1. 1. Adenoidectomy or tonsillectomy;
      2. 2. Arthroscopy;
      3. 3. Breast biopsy;
      4. 4. Bronchoscopy;
      5. 5. Carpal tunnel;
      6. 6. Cervix biopsy or conization;
      7. 7. Circumcision;
      8. 8. Dilation and curettage;
      9. 9. Esophago-gastroduodenoscopy;
      10. 10. Ganglion resection;
      11. 11. Hernia repair;
      12. 12. Hernia — umbilical;
      13. 13. Hydrocele resection;
      14. 14. Laparoscopy, peritoneoscopy or other sterilization methods;
      15. 15. Pilonidal cystectomy;
      16. 16. Procto-colonoscopy;
      17. 17. Tympanoplasty;
      18. 18. Vasectomy;
      19. 19. Vulvar cystectomy; and
      20. 20. Any other surgical procedure that the department determines shall be covered and that the department publishes notice of in the MA provider handbook; and

   2. (b) Laboratory procedures. The following laboratory procedures are covered but only when performed in conjunction with a covered surgical procedure under par. (a):

      1. 1. Complete blood count (CBC);
      2. 2. Hemoglobin;
      3. 3. Hematocrit;
      4. 4. Urinalysis;
      5. 5. Blood sugar;
      6. 6. Lee white coagulant; and
      7. 7. Bleeding time.

2. (2) Services requiring prior authorization. Any surgical procedure under s. DHS 107.06 (2) requires prior authorization.

   Note: For more information on prior authorization, see s. DHS 107.02 (3).

3. (3) Other limitations.

   1. (a) A sterilization is a covered service only if the procedures specified in s. DHS 107.06 (3) are followed.

   2. (c) Reimbursement for ambulatory surgical center services shall include but is not limited to:

      1. 1. Nursing, technician, and related services;
      2. 2. Use of ambulatory surgical center facilities;
      3. 3. Drugs, biologicals, surgical dressings, supplies, splints, casts and appliances, and equipment directly related to the provision of a surgical procedure;
      4. 4. Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;
      5. 5. Administrative, recordkeeping and housekeeping items and services; and
      6. 6. Materials for anesthesia.

4. (4) Non-covered services.

   1. (a) Ambulatory surgical center services and items for which payment may be made under other provisions of this chapter are not covered services. These include:

      1. 1. Physician services;
      2. 2. Laboratory services;
      3. 3. X-ray and other diagnostic procedures, except those directly related to performance of the surgical procedure;
      4. 4. Prosthetic devices;
      5. 5. Ambulance services;
      6. 6. Leg, arm, back and neck braces;
      7. 7. Artificial limbs; and

      8. 8. Durable medical equipment for use in the recipient’s home.

         Note: For more information on non-covered services, see s. DHS 107.03.

History

History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; correction in (3) (b) made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636; CR 20-039: r. (3) (b) Register October 2021 No. 790, eff. 11-1-21.