Ambulatory Surgery Grouper Rates
Ambulatory surgery facility payments fall into one of 11 TRICARE grouper rates. All procedures identified by the TRICARE Management Activity (TMA) for reimbursement under this methodology can be found in the TRICARE Reimbursement Manual, Chapter 9, Addendum B. TRICARE payment rates established under this system apply only to the facility charges for ambulatory surgery.
Ambulatory Surgery Center Charges
Effective April 1, 2008, all hospitals or freestanding ambulatory surgery centers (ASCs) must submit claims for surgery procedures on a UB-04 claim form. Prior to this date, freestanding ASCs could submit on a CMS-1500 claim form with an SG modifier. All hospitals must submit claims on a UB-04 claim form.
ASC Reimbursement Inside/Outside of Grouper
Multiple Procedures
When all procedures performed during the same operative session are on the TRICARE ASC Addendum B, multiple ambulatory surgeries are processed according to multiple surgery guidelines. Reimbursement is based upon the sum of the following:
- 100 percent of the payment amount for the surgical procedure with the highest ASC payment grouper amount; only one surgery in an ASC episode is paid at 100 percent.
- 50 percent of the ASC grouper payment amount for each of the other surgical procedures performed during the same session
No reimbursement is made for incidental procedures performed during the same operative session in which other covered surgical procedures were performed.
In some instances of multiple ambulatory surgeries, one procedure may be on Addendum B and one may not. These claims are processed as follows:
- If the procedure on Addendum B has the highest allowable amount, the claim will be processed under the multiple ambulatory surgery guidelines, as noted previously.
- If the billed charge for the procedure that is not on Addendum B is the highest allowable amount, the claim will be reimbursed as an ASC claim. However, the non-Addendum B procedure (the highest allowed) will be reimbursed at 100 percent and the ASC approved procedure will be reimbursed at 50 percent, as noted previously. Facility charges for procedures that are not on Addendum B are reimbursed at the billed charge less any contracted discounts.
Ambulatory Surgery Rate Lookup Tool
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