Federal regulations · Through 2026-08-25 · Newer source version available

42 CFR 416.120: Basis for payment.

The basis for payment depends on where the services are furnished.
(a) Hospital outpatient department. Payment is in accordance with part 419 of this chapter.
(b) [Reserved]
(c) ASC—(1) General rule. Payment is based on a prospectively determined rate. This rate covers the cost of services such as supplies, nursing services, equipment, etc., as specified in § 416.61. The rate does not cover physician services or other medical services covered under part 410 of this chapter (for example, X-ray services or laboratory services) which are not directly related to the performance of the surgical procedures. Those services may be billed separately and paid on a reasonable charge basis.
(2) Single and multiple surgical procedures. (i) If one covered surgical procedure is furnished to a beneficiary in an operative session, payment is based on the prospectively determined rate for that procedure.
(ii) If more than one surgical procedure is furnished in a single operative session, payment is based on—
(A) The full rate for the procedure with the highest prospectively determined rate; and
(B) One half of the prospectively determined rate for each of the other procedures.
(3) Deductibles and coinsurance. Part B deductible and coinsurance amounts apply as specified in § 410.152 (a) and (i) of this chapter.

Where this section sits in the code

Title 42—Public Health
CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
SUBCHAPTER B—MEDICARE PROGRAM
PART 416—AMBULATORY SURGICAL SERVICES
Subpart E—Prospective Payment System for Facility Services Furnished Before January 1, 2008

The basis for payment depends on where the services are furnished.

(a) Hospital outpatient department. Payment is in accordance with part 419 of this chapter.

(b) [Reserved]

(c) ASC—(1) General rule. Payment is based on a prospectively determined rate. This rate covers the cost of services such as supplies, nursing services, equipment, etc., as specified in § 416.61. The rate does not cover physician services or other medical services covered under part 410 of this chapter (for example, X-ray services or laboratory services) which are not directly related to the performance of the surgical procedures. Those services may be billed separately and paid on a reasonable charge basis.

(2) Single and multiple surgical procedures. (i) If one covered surgical procedure is furnished to a beneficiary in an operative session, payment is based on the prospectively determined rate for that procedure.

(ii) If more than one surgical procedure is furnished in a single operative session, payment is based on—

(A) The full rate for the procedure with the highest prospectively determined rate; and

(B) One half of the prospectively determined rate for each of the other procedures.

(3) Deductibles and coinsurance. Part B deductible and coinsurance amounts apply as specified in § 410.152 (a) and (i) of this chapter.

Collected 2026-08-27T02:26:11Z. Source file · JSON

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