Commercial
Advanced Search

Site of Care for Elective Procedures [Hospital Outpatient Setting to Ambulatory Surgical Center (ASC)]
12.06.00

Policy

​The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition.


POLICY EXCEPTIONS


This policy does not apply to the services listed below:

  • ​Emergency claims

  • Pediatric claims​​ (age less than 18 years old)

MEDICALLY NECESSARY​


There are certain planned elective procedures that generally do not support a hospital outpatient admission but may be appropriate for an ambulatory surgical center (ASC) if the anticipated postoperative care requirements can be met in an ASC. When there are multiple options for the site of care, and in the absence of any clinical contraindication, the most appropriate and cost-effective setting with the proper equipment and level of support to perform the service will be approved.


The services included in the coding section of this policy require precertification if they are performed in a hospital​ outpatient​ site of service. ​


Certain planned elective procedures performed in a hospital​ outpatient department may be considered medically necessary when the individual has one of the following clinical conditions that puts them at an increased risk for complications (this is not an all-inclusive list):​


Anesthesia Risk

  • ASA classification III or higher

  • History of complication of anesthesia

  • Documentation of alcohol dependence or history of cocaine use

  • Prolonged surgery (> 3 hours)

Cardiovascular Risk

  • Cardiac arrhythmia (symptomatic arrhythmia despite medication)

  • Coronary artery disease (CAD)/peripheral vascular disease (PVD) [ongoing cardiac ischemia requiring medical management or recently placed (within 1 year) drug-eluting stent]

  • History of cerebrovascular accident (CVA) or transient ischemic attack (TIA) (recent event [< 3 months])

  • History of myocardial infarction (MI) (recent event [< 3 months])

  • Individuals with drug-eluting stents (DES) placed within 1 year or bare metal stents (BMS) or plain angioplasty within 90 days unless acetylsalicylic acid and antiplatelet drugs will be continued by agreement of surgeon, cardiologist, and anesthesia

  • Ongoing evidence of myocardial ischemia

  • Resistant hypertension (poorly controlled)

  • Severe valvular heart disease

  • Uncompensated chronic heart failure (CHF) (NYHA class III or IV)

Liver Risk

  • Advanced liver disease (MELD Score > 8)

Pulmonary Risk

  • Chronic obstructive pulmonary disease (COPD) (FEV1 < 50%)

  • Poorly controlled asthma (FEV1 < 80% despite medical management)

  • Sleep apnea (moderate to severe obstructive sleep apnea [OSA])

Metabolic, Hepatic or Renal Risk

  • End-stage renal disease (hyperkalemia above reference range) receiving peritoneal or hemodialysis

  • Uncontrolled diabetes with recurrent diabetic ketoacidosis (DKA) or severe hypoglycemia within the last 6 months.

  • Morbid obesity (BMI greater than or equal to 50)

Hematologic/Immunologic Risk

  • Hereditary bleeding disorder such as factor VIII, IX, or von Willebrand's disease

  • The procedure being performed carries a high risk of significant blood loss that requires transfusion.

Other

  • Advance surgical planning determines an individual requires overnight recovery and care following a surgical procedure

  • Developmental stage or cognitive status warranting use of a hospital outpatient department

  • Pregnancy​

​​

REQUIRED DOCUMENTATION


The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service​.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, use of the ambulatory surgical center may be covered under the medical benefits of the Company's products when the medical necessity criteria listed in the medical policy are met.

 

AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL STATUS CLASSIFICATION SYSTEM


  • ASA I: A normal, healthy individual
  • ASA II: An individual with mild systemic disease
  • ASA III: An individual with severe systemic disease
  • ASA IV: An individual with severe systemic disease that is a constant threat to life
  • ASA V: A moribund individual who is not expected to survive without the operation
  • ASA VI: A declared brain-dead individual whose organs are being harvested​

New York Heart Association (NYHA) Functional Classification
Class​​Patient Sym​ptoms
I​
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation or shortness of breath.
IISlight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, shortness of breath or chest pain.
IIIMarked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, shortness of breath or chest pain.
IVSymptoms of heart failure at rest. Any physical activity causes further discomfort.                                                                                                  
                                                                                                                                                        Source- AHA website 2026​

Description

AMBULATORY SURGICAL CENTER 


An ambulatory surgery center, or ASC, is a freestanding ambulatory ​healthcare facility, other than a physician's office, that provides same-day surgical care, including diagnostic and surgical procedures on an ambulatory basis. The surgeries conducted in ASCs are typically less invasive than those conducted in a hospital outpatient setting.
 

HOSPITAL OUTPATIENT SETTING


​A hospital outpatient setting is defined as a setting where an individual arrives and is registered at a hospital without the need for an acute in​patient setting to undergo the procedure, and is discharged on the same date of the procedure or within the timeframe for observation. This includes on-campus outpatient and off-campus outpatient setting. 

AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL STATUS CLASSIFICATION SYSTEM


The American Society of Anesthesiologists (ASA) physical status classification system, and/or significant comorbidities may be taken into account. The ASA risk scoring system is regarded by hospitals, legal firms, accrediting bodies, and other healthcare groups as a preoperative health grading system for individuals undergoing a surgical procedure.

References

Ambulatory Surgery Center Association (ASC). What is an ASC? [ASCA website] 2025. Available at: https://www.ascassociation.org/asca/about-ascs/surgery-centers. Accessed January 26, 2026.


American Academy of Otolaryngology–Head and Neck Surgery Position Statement: Ambulatory Procedures (2021). Available at: https://www.entnet.org/resource/position-statement-ambulatory-procedures/. Accessed on January 26, 2026.

 
American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP®). Surgical risk calculator. [ACS Web site]. 06/2023. Available at: https://riskcalculator.facs.org/RiskCalculator/. Accessed January 26, 2026.

 
American Heart Association (AHA). Classes and stages of heart failure. [AHA Web Site] 2026. Available at:  https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/classes-of-heart-failure. Accessed January 07, 2026.


American Society of Anesthesiologists (ASA). Statement on ASA physical status classification system. [ASA Web site]. 12/13/2020. Updated 10/15/2025. Available at: https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system. Accessed January 7, 2026.

Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2016;149(3):631-638.


Chung F, Subramanyam R, Liao P, et al. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012 May;108(5):768-775. 


Farney RJ, Walker BS, Farney RM, et al. The STOP-Bang equivalent model and prediction of severity of obstructive sleep apnea: relation to polysomnographic measurements of the apnea/hypopnea index. J Clin Sleep Med. 2011;7(5):459B-465B.


Federation of State Medical Boards (FSMB). Report of the special committee on outpatient (office-based) surgery. 2002. Available at: https://www.fsmb.org/siteassets/advocacy/policies/outpatient-office-based-surgery.pdf. Accessed January 26, 2026.​

 

Fleisher LA, Pasternak LR, Herbert R, et al. Inpatient hospital admission and death after outpatient surgery in elderly patients: importance of patient and system characteristics and location of care. Arch Surg. 2004;139(1):67-72.


Gupta R, Pyati S. Controversies in office-based anesthesia: obstructive sleep apnea considerations. Minerva Anestesiol. 2018;84(9):1102-1107.


Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia consensus statement on preoperative selection of adult patients with obstructive sleep apnea scheduled for ambulatory surgery. Anesth Analg. 2012;115(5):1060-1068.


Practice guidelines for moderate procedural sedation and analgesia 2018: a report by the American Society of Anesthesiologists task force on moderate procedural sedation and analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology. 2018;128(3):437-479.


Whippey A, Kostandoff G, Ma HK, et al. Predictors of unanticipated admission following ambulatory surgery in the pediatric population: a retrospective case–control study. Paediatr Anaesth. 2016;26(8):831-837.


Whippey A, Kostandoff G, Paul J, et al. Predictors of unanticipated admission following ambulatory surgery: a retrospective case-control study. Can J Anaesth. 2013;60(7):675-683.​

Coding

CPT Procedure Code Number(s)
See Attachment A.
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
See Attachment A.
Revenue Code Number(s)
N/A

Coding and Billing Requirements

Policy History

Revisions From 12.06.00​:

06/01/2026​
This new policy wil​l become effective 06/01/2026.

​This new policy has been developed to communicate the Company's coverage criteria for certain planned elective medically necessary procedures performed in a hospital outpatient site of care and/or an ambulatory surgical center site of care. 

6/1/2026
6/1/2026
12.06.00
Medical Policy Bulletin
Commercial
{"8386": {"Id":8386,"MPAttachmentLetter":"A","Title":"CPT/HCPCS Codes","MPPolicyAttachmentInternalSourceId":10489,"PolicyAttachmentPageName":"e6c76b78-f372-4093-9c3f-746ef78421b3"},}
No