Georgia Medicare Ambulatory Surgical Center Services

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Georgia Medicare Ambulatory Surgical Center Services

By Brevy Care Team · Last verified May 13, 2026

Section 1833(i) of the Social Security Act establishes the Medicare Ambulatory Surgical Center payment system, and 42 CFR Part 416 sets out the conditions for coverage and the payment methodology. The ASC benefit was originally created by Section 934 of the Omnibus Budget Reconciliation Act of 1980, which authorized Medicare to certify freestanding surgical facilities separately from hospital outpatient departments. Section 4523 of the Balanced Budget Act of 1997 directed the replacement of the cost-based ASC payment methodology with a prospective payment system. The CY 2008 OPPS/ASC Final Rule completed the alignment of ASC payment with the Hospital Outpatient Prospective Payment System: ASC payments are calculated as approximately 58 percent of the corresponding OPPS Ambulatory Payment Classification rate, reflecting the lower overhead at freestanding facilities. The ASC Covered Procedures List, updated annually through the OPPS/ASC Final Rule, specifies which surgical procedures Medicare will pay for in an ASC setting. The CY 2021 Final Rule represented the largest single-year expansion, removing approximately 270 procedures from the inpatient-only list and adding many cardiovascular procedures (PCI, certain pacemaker procedures) to the ASC-CPL. The CY 2020 Final Rule added total knee arthroplasty effective January 1, 2020. The CY 2022 Final Rule added total hip arthroplasty effective January 1, 2022. The CY 2024 Final Rule added total shoulder arthroplasty effective January 1, 2024. This guide explains how the ASC framework operates, how ASC payments compare with hospital outpatient department payments, how beneficiary cost-sharing differs between settings, and how Georgia Medicare beneficiaries access the more than 250 Medicare-certified ASCs across the state. :::

::: callout Key Takeaways

1. Section 1833(i) of the Social Security Act establishes the ASC payment system. 42 CFR Part 416 sets out conditions for coverage and payment methodology.
2. The ASC benefit was created by Section 934 of the Omnibus Budget Reconciliation Act of 1980, authorizing Medicare to certify freestanding surgical facilities separately from hospital outpatient departments.
3. Section 4523 of the Balanced Budget Act of 1997 directed the replacement of the cost-based ASC payment system with a prospective payment system. The CY 2008 OPPS/ASC Final Rule completed the alignment of ASC payment with OPPS APC rates.
4. ASC payment is calculated as approximately 58 percent of the corresponding OPPS Ambulatory Payment Classification rate for most procedures, reflecting the lower overhead at freestanding facilities. Device-intensive procedures and certain drugs receive separate payment.
5. The ASC Covered Procedures List (ASC-CPL) is updated annually through the OPPS/ASC Final Rule. Procedures must meet safety criteria at 42 CFR 416.166 to be added.
6. CY 2020 Final Rule added total knee arthroplasty. CY 2021 Final Rule removed approximately 270 procedures from the inpatient-only list and added many cardiac procedures. CY 2022 Final Rule added total hip arthroplasty. CY 2024 Final Rule added total shoulder arthroplasty.
7. Beneficiaries owe 20 percent Part B coinsurance for ASC services, with the coinsurance cap mirroring the OPPS cap (no single coinsurance amount may exceed the Part A inpatient deductible of $1,676 in 2026). Plan G and Plan N Medigap cover the coinsurance.
8. Georgia has more than 250 Medicare-certified ASCs across the state, with substantial clusters in metro Atlanta, Savannah, Macon, Augusta, Columbus, Albany, and other regional centers. :::

The ASC Statutory and Regulatory Framework

Medicare Ambulatory Surgical Centers operate under a layered framework that combines a single statutory authority with extensive implementing regulations. Understanding how the pieces interact is essential for beneficiaries who want to make sense of facility fees, choose between ASC and Hospital Outpatient Department settings, and verify that procedures are covered.

Section 1833(i): The Statutory Foundation

Section 1833(i) of the Social Security Act establishes Medicare payment for facility services furnished in an Ambulatory Surgical Center in connection with surgical procedures specified by the Secretary of HHS. The provision separates three distinct payments associated with a single surgical episode:

• The ASC facility payment (paid under Section 1833(i) to the ASC for the operating room, nursing, supplies, and equipment)
• The surgeon's professional fee (paid under Section 1848 to the physician for the surgical service)
• The anesthesia service payment (paid under Section 1861(s)(1) or Section 1861(s)(11) using the ASA Relative Value Guide unit-based methodology described in the companion anesthesia article)

These three payments are separate and reflect distinct economic activities. Beneficiaries receive separate Explanation of Benefits statements for each.

OBRA 1980 Section 934: Establishment of the ASC Benefit

Public Law 96-499, the Omnibus Budget Reconciliation Act of 1980, signed December 5, 1980, included Section 934 which authorized Medicare to certify freestanding Ambulatory Surgical Centers and to pay them a separate facility fee for covered surgical procedures. Before OBRA 1980, ambulatory surgery was furnished either in hospital outpatient departments (where the hospital was paid through the hospital cost-based methodology) or in physician offices (where no separate facility fee was paid). OBRA 1980 created a third payment pathway: a Medicare-certified ASC operating outside of any hospital.

The initial implementation used a cost-based methodology for ASC payment: ASCs reported their costs, CMS calculated payment rates based on average costs for each surgical group, and beneficiaries paid 20 percent coinsurance. This cost-based methodology persisted from 1982 until the BBA 1997 reforms.

BBA 1997 Section 4523: Prospective Payment System

Section 4523 of the Balanced Budget Act of 1997 (Public Law 105-33) directed CMS to replace the cost-based ASC payment methodology with a prospective payment system. The transition took more than a decade due to methodology disputes, litigation, and the parallel development of the Hospital Outpatient Prospective Payment System under BBA 1997 Section 4523's companion provisions. CMS issued multiple proposed and interim rules between 1998 and 2007 before the modern methodology was finalized.

CY 2008 OPPS/ASC Final Rule: Alignment with OPPS

The CY 2008 OPPS/ASC Final Rule, published in November 2007 and effective January 1, 2008, completed the alignment of ASC payment with the Hospital Outpatient Prospective Payment System. Under the CY 2008 methodology:

• Surgical procedures are classified into Ambulatory Payment Classifications (APCs) that mirror the OPPS APCs
• The ASC payment rate equals approximately 58 percent of the corresponding OPPS APC rate for most procedures
• Device-intensive procedures (TKA, TSA, PCI with stent, pacemaker insertion, etc.) receive a separate device payment component
• Certain drugs and biologicals receive separate payment when their cost exceeds a threshold
• Beneficiary coinsurance is 20 percent of the ASC payment, with the same coinsurance cap that applies in OPPS

The 58 percent ratio reflects the lower overhead at freestanding ASCs versus hospital outpatient departments. Hospital outpatient departments carry hospital overhead (administrative, regulatory, on-call infrastructure, the broader emergency capabilities of the hospital) that freestanding ASCs do not. The ratio is recalibrated periodically based on Medicare cost report data.

42 CFR Part 416: ASC Regulations

The implementing regulations at 42 CFR Part 416 govern ASC certification, conditions of coverage, and payment:

• Subpart A (42 CFR 416.1 to 416.2): General provisions and definitions
• Subpart B (42 CFR 416.30 to 416.52): Conditions for coverage
• Subpart C (42 CFR 416.60 to 416.83): Coverage and payment
• Subpart F (42 CFR 416.160 to 416.179): Revised payment system and the ASC Covered Procedures List criteria

42 CFR 416.2: ASC Definition

An Ambulatory Surgical Center is defined as a distinct entity that:

• Operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization
• Has an agreement with CMS to participate in Medicare as an ASC
• Meets the conditions for coverage at 42 CFR 416.40 through 416.52

The "exclusively for the purpose of providing surgical services" criterion distinguishes ASCs from hospital outpatient departments (which provide many other services in addition to surgery) and from physician offices (which typically provide non-surgical evaluation and management services as the primary service).

Conditions for Coverage at 42 CFR 416.40 to 416.52

The Conditions for Coverage govern ASC operations and patient care. Major requirements include:

• State licensure compliance: The ASC must comply with state licensure laws and regulations
• Governing body: The ASC must have a governing body legally responsible for operations and policies
• Surgical services: Performed by physicians with appropriate privileges
• Quality assessment and performance improvement (QAPI): Ongoing QAPI program
• Environment: Physical environment safe, sanitary, well-maintained
• Medical staff: Appointment and credentialing process
• Nursing services: Adequately staffed
• Medical records: Accurate medical record for each patient
• Pharmaceutical services: Provision of drugs in accordance with state and federal law
• Laboratory and radiologic services: Available either directly or under contract
• Patient admission, assessment, and discharge: Patient assessment and discharge criteria
• Infection control: Active program for prevention, control, and investigation
• Patient rights: Notification of rights including advance directives

42 CFR 416.65 ASC Payment Methodology

The current ASC payment methodology has these components:

• Payment is based on the procedure performed, classified into APCs that mirror OPPS APCs
• The ASC rate equals approximately 58 percent of the OPPS APC rate for most surgical procedures
• Device-intensive procedures receive separate payment for the device portion
• Certain drugs and biologicals receive separate payment when costs exceed the threshold
• Beneficiary coinsurance equals 20 percent of the ASC payment after the annual Part B deductible, with the coinsurance cap mirroring the OPPS cap (no single coinsurance amount may exceed the Part A inpatient deductible of $1,676 in 2026)

42 CFR 416.166: ASC Covered Procedures List Criteria

The regulation specifies the criteria for adding procedures to the ASC Covered Procedures List (ASC-CPL):

• The procedure must be classified as a surgical procedure
• The procedure must not be on the OPPS inpatient-only list
• The procedure does not pose a significant safety risk if performed in an ASC
• The procedure does not require an overnight stay
• The procedure does not involve invasive procedures with substantial risk of major complications

CMS updates the ASC-CPL annually through the OPPS/ASC Final Rule. Procedures may be added or removed based on safety evidence, claims data, and provider feedback.

ASC Covered Procedures List: Major Expansion Milestones

The ASC-CPL has expanded substantially over the past decade. Major milestones:

CY 2011 Final Rule

Added cataract procedures and other ophthalmology procedures to the ASC-CPL. Cataract surgery quickly became the dominant ASC procedure by volume.

CY 2018 Final Rule

Began the migration of total knee arthroplasty (TKA) and total hip arthroplasty (THA) toward the outpatient setting. TKA was removed from the OPPS inpatient-only list in the CY 2018 rule, allowing outpatient performance in HOPD (but not yet in ASC).

CY 2020 Final Rule

Added total knee arthroplasty (TKA) to the ASC-CPL effective January 1, 2020. Six TKA-related codes were added. This was a major operational shift: TKAs could be performed in freestanding ASCs for appropriately selected lower-risk patients.

CY 2021 Final Rule

Largest single-year expansion in ASC history. Effective January 1, 2021, CMS:

• Removed approximately 270 musculoskeletal procedures from the OPPS inpatient-only list
• Added many cardiovascular procedures to the ASC-CPL, including:
  • Selected percutaneous coronary intervention (PCI) procedures with and without stent
  • Selected pacemaker and implantable cardioverter-defibrillator procedures
  • Selected vascular access procedures
• Added several spine and orthopedic procedures

The cardiovascular expansion was particularly significant because it allowed many elective cardiac procedures to migrate from the hospital outpatient department or inpatient setting to the ASC setting.

CY 2022 Final Rule

Added total hip arthroplasty (THA) to the ASC-CPL effective January 1, 2022. Continued targeted additions in orthopedics and spine.

CY 2024 Final Rule

Added total shoulder arthroplasty (TSA) to the ASC-CPL effective January 1, 2024. Reflected clinical evidence that TSA can be performed safely in the outpatient setting for appropriately selected patients.

CY 2025 and CY 2026 Final Rules

Continued annual review of the ASC-CPL with targeted additions in orthopedics, spine, cardiology, and gynecology, alongside removal of procedures that data suggest may not be safe in the ASC setting.

ASC vs Hospital Outpatient Department Payment Comparison

For the same surgical procedure, Medicare payments and beneficiary cost-sharing differ between ASC and Hospital Outpatient Department settings. Representative comparison (approximate 2026 rates for the Atlanta locality):

Device-intensive procedures (TKA, THA, TSA, PCI with stent, pacemaker) have ratios closer to 70-80 percent of OPPS rates because the device payment component partly offsets the lower overhead.

The lower ASC payment translates directly into lower beneficiary coinsurance. Example: a cataract procedure costing $2,180 in the HOPD versus $1,260 in the ASC saves the beneficiary $184 in coinsurance ($436 versus $252) under Original Medicare without Medigap.

Coinsurance Cap

Both OPPS and ASC have a coinsurance cap: no single coinsurance amount for a single service may exceed the Part A inpatient deductible ($1,676 in 2026). For high-cost procedures like TKA, THA, TSA, or complex cardiac, this cap protects beneficiaries from owing more than the inpatient deductible amount as 20 percent coinsurance.

ASC Coverage Conditions

For a surgical procedure to be paid in an ASC by Medicare, all of the following must be true:

1. The ASC is Medicare-certified under 42 CFR Part 416
2. The procedure is on the ASC Covered Procedures List (ASC-CPL)
3. The procedure is medically necessary
4. The procedure is performed by a physician with appropriate credentials and ASC privileges
5. The patient meets the ASC's patient selection criteria for outpatient surgery
6. Pre- and post-operative documentation is complete

If a procedure is performed in an ASC but is not on the ASC-CPL, Medicare will not pay the facility fee, and the beneficiary owes the entire facility fee (although the surgeon's professional fee and anesthesia fee are still paid separately under their respective fee schedules).

ASC Accreditation

ASCs may obtain Medicare certification through state survey (conducted by the Georgia Department of Public Health Healthcare Facility Regulation Division) or through deemed-status accreditation by one of three CMS-approved accrediting organizations:

• AAAHC (Accreditation Association for Ambulatory Health Care)
• AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities)
• The Joint Commission

Deemed-status accreditation means the accrediting organization conducts the survey on behalf of CMS, satisfying the Medicare certification requirement. Most modern ASCs use deemed-status accreditation for the efficiency it offers.

Georgia ASC Landscape

Major Hospital-Affiliated ASC Networks

Emory Healthcare operates a substantial ASC network including the Emory Eye Center ASC (Atlanta), Emory Saint Joseph's Surgery Center, Emory Surgery Center at Decatur, Emory University Hospital Surgery Center, and multiple specialty surgery centers across the Emory network.

Piedmont Healthcare operates the Piedmont Atlanta Surgery Center, Piedmont Fayette Surgery Center, Piedmont Henry Surgery Center, Piedmont Newnan Surgery Center, Piedmont Columbus Surgery Center, Piedmont Macon Surgery Center, and Piedmont Athens Surgery Center.

Wellstar Health System operates the Wellstar Kennestone Surgery Center, Wellstar Spalding Surgery Center, Wellstar West Georgia Surgery Center, and Wellstar Cobb Surgery Center.

Northeast Georgia Health System operates the NGMC Surgery Center Gainesville and NGMC Surgery Center Braselton.

Memorial Health (HCA Healthcare) operates the Memorial Health Surgery Center in Savannah.

AU Health / Wellstar MCG operates the AU Surgery Center in Augusta.

Atrium Health Navicent operates the Atrium Navicent Surgery Center in Macon.

Major National ASC Operators in Georgia

United Surgical Partners International (USPI): The largest ASC operator in the United States, USPI operates dozens of ASCs across Georgia, often in joint ventures with physician groups and hospital systems.

SCA Health (Surgical Care Affiliates): Owned by Optum/UnitedHealth Group, SCA Health operates multiple Georgia ASCs in partnership with physicians and hospital systems.

Surgery Partners: Several Georgia ASCs.

AmSurg (Envision Healthcare): Multiple Georgia GI endoscopy and ophthalmology ASCs.

Specialty ASCs in Georgia

Ophthalmology ASCs: Emory Eye Center, Eye Consultants of Atlanta, Georgia Eye Partners, Atlanta Eye Institute, and multiple regional ophthalmology surgical centers across all major Georgia cities. Cataract surgery is the dominant volume driver.

Gastroenterology Endoscopy ASCs: Atlanta Gastroenterology Associates Endoscopy Centers, Digestive Healthcare of Georgia Endoscopy Centers, and multiple regional GI endoscopy centers. Screening colonoscopy and upper endoscopy are the dominant procedures.

Orthopedic ASCs: Resurgens Orthopaedics Surgery Centers, Peachtree Orthopaedic Clinic Surgery Centers, Hughston Clinic Surgery Centers (Columbus area). Total joint replacement (TKA, THA, TSA) has migrated substantially to these orthopedic ASCs following the CY 2020, CY 2022, and CY 2024 expansions of the ASC-CPL.

Pain Management ASCs: Multiple pain management surgery centers across Georgia for spine injections, radiofrequency ablation, and similar interventional pain procedures.

Cardiac ASCs: Following the CY 2021 expansion of the ASC-CPL to include PCI and pacemaker procedures, a small but growing number of cardiac ASCs have emerged in metro Atlanta and other major Georgia cities.

Georgia ASC Regulation

The Georgia Department of Community Health licenses ASCs in Georgia. The Department of Public Health Healthcare Facility Regulation Division conducts state surveys. Georgia has a Certificate of Need (CON) regulatory framework administered by the DCH Office of Health Strategy and Coordination that applies to ASCs, regulating facility expansion and new construction.

The Georgia Composite Medical Board regulates physician practice in ASCs. The Georgia Board of Nursing regulates nursing practice in ASCs.

Georgia ASC Coverage

Georgia has more than 250 Medicare-certified ASCs as of 2026. The geographic distribution is uneven:

• Metro Atlanta concentrates the majority of ASCs
• Savannah, Macon, Augusta, Columbus, and Albany serve as regional centers
• Rural Georgia has fewer ASCs; rural beneficiaries often travel to the nearest regional center for elective surgery, with hospital outpatient departments serving as the local alternative

Worked Examples

Example 1: Margaret, 78, Atlanta, Cataract Phacoemulsification at Emory Eye Center ASC

Margaret has Original Medicare with Plan G Medigap. She undergoes outpatient phacoemulsification cataract extraction at Emory Eye Center ASC in Atlanta. The ASC facility fee, the anesthesiologist's fee, the CRNA fee, and the ophthalmologist's professional fee are all billed separately.

ASC facility fee:

• Procedure: CPT 66984 (cataract extraction with IOL insertion), APC 5491
• 2026 ASC payment rate (Atlanta locality): approximately $1,260
• Margaret's 20% coinsurance: $252
• Plan G covers the $252 coinsurance
• Margaret's out-of-pocket for ASC facility fee: $0

Comparison if performed at hospital outpatient department:

• HOPD facility rate: approximately $2,180
• 20% coinsurance: $436
• Plan G would still cover the $436
• Margaret's out-of-pocket would still be $0, but Medicare and Plan G together would have paid roughly $920 more in the HOPD setting

For beneficiaries without Medigap coverage, the ASC setting yields direct out-of-pocket savings of $184 ($436 versus $252) per cataract.

Example 2: Robert, 82, Savannah, Outpatient Screening Colonoscopy at Memorial Health Endoscopy Center

Robert undergoes a routine screening colonoscopy at the Memorial Health Endoscopy Center (an HCA-affiliated ASC). He has Original Medicare with no Medigap.

ASC facility fee:

• Procedure: G0121 (screening colonoscopy), mapped to APC 5311
• 2026 ASC payment rate (Rest of Georgia): approximately $420
• Beneficiary cost-sharing waived under ACA Section 4104 for screening colonoscopy facility fee, even if a polyp is detected and removed
• Robert's out-of-pocket for the ASC facility fee: $0

The anesthesia fee follows the same waiver under the preventive screening framework. The pathology fee (if a polyp is removed and sent to pathology) is billed separately under the Clinical Laboratory Fee Schedule and may have standard cost-sharing depending on circumstances.

Example 3: Linda, 75, Macon, Trigger Finger Release at Atrium Navicent Surgery Center

Linda undergoes outpatient trigger finger release at the Atrium Navicent-affiliated freestanding surgery center in Macon. She has Original Medicare with Plan N Medigap.

ASC facility fee:

• Procedure: CPT 26055 (trigger finger release), mapped to a hand surgery APC
• 2026 ASC payment rate (Rest of Georgia): approximately $720
• Linda's 20% coinsurance: $144
• Plan N covers the $144 (the trigger finger release is not an office visit or ER visit, so neither the $20 office copay nor the $50 ER copay applies)
• Linda's out-of-pocket for the ASC facility fee: $0

Example 4: Charles, 80, Augusta, Knee Arthroscopy at AU Surgery Center

Charles undergoes outpatient knee arthroscopy with meniscal repair at the AU Surgery Center in Augusta. He has Original Medicare with Plan G.

ASC facility fee:

• Procedure: CPT 29882 (knee arthroscopy with meniscal repair), mapped to APC 5114
• 2026 ASC payment rate (Rest of Georgia): approximately $2,250
• Charles's 20% coinsurance: $450
• Plan G covers the $450
• Charles's out-of-pocket for the ASC facility fee: $0

Example 5: Patricia, 73, Columbus, Elective PCI at Piedmont Columbus Cardiac ASC (CY 2021 Expansion)

Patricia has stable angina, and elective single-vessel PCI is recommended. Under the CY 2021 Final Rule, PCI was added to the ASC Covered Procedures List, allowing elective PCI to be performed in the ASC setting rather than the hospital outpatient department or inpatient setting. The cardiologist performs the elective PCI at a Piedmont-affiliated cardiac ASC in Columbus. Patricia has Original Medicare with Plan G.

ASC facility fee:

• Procedure: CPT 92928 (PCI with intracoronary stent), mapped to a high-resource cardiac APC
• 2026 ASC payment rate (Rest of Georgia): approximately $6,200 (device-intensive separate payment for the stent included)
• Patricia's 20% coinsurance: approximately $1,240
• Coinsurance cap: $1,676 (the Part A inpatient deductible); $1,240 is below the cap, so the full 20% applies
• Plan G covers the $1,240 coinsurance
• Patricia's out-of-pocket for the ASC facility fee: $0

Comparison if performed at HOPD:

• HOPD facility rate: approximately $9,800
• 20% coinsurance: $1,960, but capped at $1,676 (the inpatient deductible)
• Plan G covers the $1,676 capped coinsurance
• Patricia's out-of-pocket: $0
• Medicare and Plan G together would have paid roughly $3,600 more in the HOPD setting

This example illustrates how the CY 2021 expansion of the ASC-CPL to include cardiac procedures generates real savings for Medicare and for beneficiaries without Medigap, while leaving beneficiaries with Medigap protected from out-of-pocket exposure in either setting.

Example 6: Henry, 85, Athens, Total Shoulder Arthroplasty at NGMC Orthopedic Surgery Center (CY 2024 Expansion)

Henry undergoes elective total shoulder arthroplasty at a Northeast Georgia Medical Center-affiliated orthopedic surgery center in Athens. Under the CY 2024 Final Rule, TSA was added to the ASC Covered Procedures List effective January 1, 2024. Henry has Original Medicare with Plan G.

ASC facility fee:

• Procedure: CPT 23472 (total shoulder arthroplasty), mapped to a device-intensive orthopedic APC
• 2026 ASC payment rate (Rest of Georgia): approximately $14,800 (device-intensive separate payment for the shoulder implant included)
• Henry's 20% coinsurance: approximately $2,960, but capped at the Part A inpatient deductible of $1,676
• Plan G covers the $1,676 capped coinsurance
• Henry's out-of-pocket for the ASC facility fee: $0

Comparison if performed at HOPD:

• HOPD facility rate: approximately $18,500 (still outpatient under OPPS)
• Coinsurance: capped at $1,676 (the inpatient deductible)
• If performed as inpatient under DRG: Part A deductible of $1,676 applies to the entire admission
• Plan G covers the deductible in all cases

The CY 2024 expansion of the ASC-CPL to include TSA reflects clinical evidence that TSA can be performed safely in the outpatient setting for appropriately selected patients (younger, healthier, lower-risk).

Common Mistakes and Pitfalls

1. Confusing the ASC Facility Fee with the Surgeon's Fee

The ASC facility fee compensates the facility for the operating room, nursing staff, surgical supplies, and equipment. The surgeon's professional fee is paid separately under the Medicare Physician Fee Schedule (Section 1848). Anesthesia services are paid separately under the ASA Relative Value Guide unit-based methodology (Section 1861(s)(1) for anesthesiologists, Section 1861(s)(11) for CRNAs). These are three distinct payments associated with a single surgical episode.

2. Assuming All Surgical Procedures Can Be Performed in an ASC

Only procedures on the ASC Covered Procedures List (ASC-CPL) are eligible for ASC facility payment. The ASC-CPL is updated annually by CMS through the OPPS/ASC Final Rule. Procedures not on the ASC-CPL must be performed in a hospital outpatient department or inpatient setting for Medicare to pay the facility fee.

3. Believing the ASC Rate Is the Same as the HOPD Rate

The ASC rate is approximately 58 percent of the OPPS APC rate for most procedures, reflecting lower overhead at freestanding facilities. Higher-cost device-intensive procedures (TKA, TSA, PCI, pacemaker) have ratios closer to 70 to 80 percent due to device payment.

4. Overlooking the Coinsurance Cap

No single ASC coinsurance amount for a single service may exceed the Part A inpatient deductible ($1,676 in 2026). For very expensive procedures like TKA or PCI, this cap matters: the beneficiary owes the cap amount rather than 20 percent of the full payment.

5. Treating Cosmetic Surgery as ASC-Covered

Medicare does NOT cover cosmetic procedures (cosmetic rhinoplasty, cosmetic breast augmentation, cosmetic blepharoplasty without functional indication). When a non-covered procedure is performed in an ASC, the beneficiary pays the entire facility fee, the entire surgeon's fee, and the entire anesthesia fee.

6. Forgetting the Screening Colonoscopy Waiver

Beneficiary cost-sharing is waived for screening colonoscopy facility fees under ACA Section 4104 and the BBA 2018 Section 53113 phased reduction. The waiver applies whether the screening is performed at an ASC or HOPD. The waiver continues to apply even if a polyp is detected and removed during the screening procedure.

7. Assuming the ASC Is In-Network for a Medicare Advantage Plan

Medicare Advantage plans have their own provider networks. An ASC certified by Medicare under 42 CFR Part 416 is not automatically in-network for any specific MA plan. Verify network status with your MA plan before scheduling elective surgery.

8. Missing the Surgeon's Hospital Privileges Question

Some surgeons have privileges at certain ASCs but not at others. Choosing an ASC depends on whether your surgeon has privileges there, not just on Medicare certification of the ASC.

9. Confusing ASC Certification with Accreditation

ASC certification means the ASC has a Medicare provider agreement and meets the Conditions for Coverage at 42 CFR Part 416. Accreditation (by AAAHC, AAAASF, or The Joint Commission) is a separate process that may grant deemed status for survey purposes.

10. Believing PCI Is Always Inpatient

Under the CY 2021 Final Rule, many PCI procedures are now on the ASC-CPL. Whether a particular PCI is performed inpatient or outpatient depends on clinical factors (acute vs elective, complexity, patient risk), not on a categorical rule.

11. Treating TKA as Always Inpatient

Under the CY 2020 Final Rule, TKA was added to the ASC-CPL effective January 1, 2020. Many TKAs are now performed as outpatient surgeries at ASCs for appropriately selected lower-risk patients. The same applies to THA (CY 2022 expansion) and TSA (CY 2024 expansion).

12. Misunderstanding Device-Intensive Procedure Payment

For device-intensive procedures (TKA, TSA, PCI, pacemaker), the ASC payment includes a separate device portion in addition to the surgical service portion. The total payment reflects both the surgical service and the device cost.

13. Overlooking the Part B Deductible

The annual Part B deductible ($278 in 2026) applies to ASC services like other Part B services. If the deductible has not been met for the year, the beneficiary owes the deductible before coinsurance begins.

14. Not Asking for a Cost Estimate in Advance

Most ASCs can provide a written cost estimate before elective surgery. Knowing the expected facility fee, anesthesia fee, surgeon fee, and any device costs allows beneficiaries to budget, to compare ASC versus HOPD versus inpatient options, and to ask informed questions about coverage.

Brevy and How We Can Help

Brevy (brevy.com) is an eldercare advocacy organization that helps Georgia Medicare beneficiaries and their families understand Medicare coverage rules, including Ambulatory Surgical Center services. We can help you read your ASC explanation of benefits, distinguish facility fees from surgeon fees and anesthesia fees, verify that the procedure was billed under the correct APC, compare ASC and HOPD payment amounts, and decide whether to appeal a denied ASC claim. We do not provide medical care; we provide information and advocacy.

::: accordion Q1: What is an Ambulatory Surgical Center?

An Ambulatory Surgical Center (ASC) is a freestanding facility that performs same-day surgical procedures without overnight stays. Under Section 1833(i) of the Social Security Act and 42 CFR Part 416, Medicare certifies ASCs separately from hospital outpatient departments and pays them a facility fee for covered surgical procedures on the ASC Covered Procedures List.

Q2: Who created the ASC benefit?

Public Law 96-499 Section 934 (the Omnibus Budget Reconciliation Act of 1980), signed December 5, 1980, created the Medicare ASC benefit. Before OBRA 1980, ambulatory surgery was performed either in hospital outpatient departments or in physician offices, with no separate ASC facility payment. OBRA 1980 authorized Medicare to certify and pay freestanding ASCs.

Q3: How is ASC payment calculated?

Under the current methodology (CY 2008 OPPS/ASC Final Rule), the ASC payment equals approximately 58 percent of the corresponding OPPS Ambulatory Payment Classification (APC) rate for most procedures. Device-intensive procedures (TKA, TSA, PCI, pacemaker) have higher ratios because the device payment partly offsets the lower overhead.

Q4: What is the ASC Covered Procedures List?

The ASC Covered Procedures List (ASC-CPL) is the list of surgical procedures Medicare will pay for in an ASC setting. CMS updates the ASC-CPL annually through the OPPS/ASC Final Rule. Procedures must meet safety criteria at 42 CFR 416.166 to be added.

Q5: What major procedures have been added to the ASC-CPL recently?

Recent major additions:

• CY 2020: Total knee arthroplasty (TKA)
• CY 2021: Approximately 270 musculoskeletal procedures from the inpatient-only list; many cardiac procedures including PCI and pacemaker procedures
• CY 2022: Total hip arthroplasty (THA)
• CY 2024: Total shoulder arthroplasty (TSA)

Q6: Why is the ASC rate lower than the HOPD rate?

The ASC rate is approximately 58 percent of the OPPS HOPD rate because freestanding ASCs have lower overhead than hospital outpatient departments. HOPDs carry hospital overhead (administrative, regulatory, on-call infrastructure, emergency capability) that freestanding ASCs do not. The lower payment reflects the lower cost structure.

Q7: How much will I pay out-of-pocket at an ASC?

You owe the 20 percent Part B coinsurance after the annual Part B deductible ($278 in 2026). The coinsurance cap mirrors OPPS: no single coinsurance amount may exceed the Part A inpatient deductible ($1,676 in 2026). Medicare Supplement Plans G and N typically cover the 20 percent coinsurance.

Q8: How does ASC cost-sharing compare with HOPD?

For the same procedure, ASC cost-sharing is typically lower than HOPD cost-sharing because the ASC payment rate is lower. For a cataract, the ASC coinsurance might be $252 versus $436 at an HOPD, a difference of $184 per procedure under Original Medicare without Medigap.

Q9: Is anesthesia billed separately from the ASC facility fee?

Yes. The ASC facility fee covers the operating room, nursing, supplies, and equipment. Anesthesia services are paid separately under the ASA Relative Value Guide unit-based methodology (Section 1861(s)(1) for anesthesiologists, Section 1861(s)(11) for CRNAs). The surgeon's professional fee is paid separately under the Medicare Physician Fee Schedule.

Q10: Are screening colonoscopies covered in ASCs?

Yes. Beneficiary cost-sharing for screening colonoscopy facility fees is waived under ACA Section 4104 and BBA 2018 Section 53113. The waiver applies at both ASCs and HOPDs. The waiver continues to apply even if a polyp is detected and removed during the screening procedure.

Q11: Can total knee arthroplasty be performed at an ASC?

Yes. Effective January 1, 2020, TKA was added to the ASC-CPL under the CY 2020 Final Rule. TKA at an ASC is appropriate for lower-risk, healthier patients who meet the ASC's patient selection criteria.

Q12: Can total hip arthroplasty be performed at an ASC?

Yes. Effective January 1, 2022, THA was added to the ASC-CPL under the CY 2022 Final Rule. THA at an ASC is appropriate for selected patients meeting outpatient surgery criteria.

Q13: Can total shoulder arthroplasty be performed at an ASC?

Yes. Effective January 1, 2024, TSA was added to the ASC-CPL under the CY 2024 Final Rule.

Q14: Can elective PCI be performed at an ASC?

Yes. Effective January 1, 2021, many PCI procedures were added to the ASC-CPL under the CY 2021 Final Rule. Elective single-vessel PCI in stable angina patients is the typical ASC indication.

Q15: What is the ASC coinsurance cap?

No single ASC coinsurance amount for a single service may exceed the Part A inpatient deductible ($1,676 in 2026). For very expensive procedures, this cap protects beneficiaries from owing more than the inpatient deductible amount as 20 percent of a single high-priced procedure.

Q16: How many ASCs are there in Georgia?

Georgia has more than 250 Medicare-certified ASCs as of 2026, with substantial clusters in metro Atlanta, Savannah, Macon, Augusta, Columbus, Albany, and other regional centers.

Q17: Who licenses ASCs in Georgia?

The Georgia Department of Community Health licenses ASCs in Georgia. The Department of Public Health Healthcare Facility Regulation Division conducts state surveys. Most ASCs use deemed-status accreditation by AAAHC, AAAASF, or The Joint Commission instead of state survey.

Q18: How does Medicare Advantage cover ASC services?

Medicare Advantage plans must cover the same ASC services as Original Medicare under the Medicare Advantage parity rule. However, MA plans have their own provider networks. Verify the ASC is in-network before scheduling elective surgery. MA plans may charge facility copays or percentage coinsurance per surgical episode rather than the standard 20 percent.

Q19: How does Plan G compare with Plan N for ASC services?

Plan G covers the full 20 percent coinsurance for ASC facility fees and also covers Part B excess charges. Plan N covers the 20 percent coinsurance except for the $20 office-visit copay and the $50 ER copay; ASC services are not office visits or ER visits, so Plan N covers the ASC coinsurance in full. Plan G and Plan N are functionally equivalent for ASC facility fees.

Q20: What if my surgeon doesn't have ASC privileges?

Each ASC credentials and grants privileges to specific surgeons. Choosing an ASC depends on whether your surgeon has privileges there. Your surgeon's office can tell you which ASCs they use for outpatient surgery.

Q21: Can I appeal a denied ASC claim?

Yes. Under Original Medicare, you have five levels of appeal: redetermination by Palmetto GBA Jurisdiction J, reconsideration by a Qualified Independent Contractor, ALJ hearing, Medicare Appeals Council, and federal district court. Medicare Advantage and Part D have similar five-level appeals frameworks. GeorgiaCares SHIP, the Medicare Rights Center, the Center for Medicare Advocacy, Atlanta Legal Aid, and Georgia Legal Services Program offer free assistance.

Q22: What is a device-intensive procedure?

A device-intensive procedure is a procedure in which the cost of the device or implant is a substantial portion of the total procedure cost (TKA, THA, TSA, PCI with stent, pacemaker, ICD). Under both OPPS and ASC payment, device-intensive procedures receive a separate device payment in addition to the surgical service payment.

Q23: Does the Part B deductible apply to ASC services?

Yes. The annual Part B deductible ($278 in 2026) applies to ASC services. If the deductible has not been met for the year, the beneficiary owes the deductible before coinsurance begins.

Q24: Are cosmetic procedures covered in ASCs?

No. Medicare does not cover cosmetic procedures. When a non-covered cosmetic procedure is performed in an ASC, the beneficiary pays the entire facility fee, the entire surgeon's fee, and the entire anesthesia fee. The ASC may charge market rates rather than Medicare-approved amounts.

Q25: How can Brevy help me with ASC questions?

Brevy (brevy.com) is an eldercare advocacy organization that helps Georgia Medicare beneficiaries understand Medicare coverage rules. We can help you read your ASC explanation of benefits, distinguish facility fees from surgeon fees and anesthesia fees, verify the APC and payment amount, compare ASC and HOPD options, and decide whether to appeal a denied claim. We can also connect you with GeorgiaCares SHIP and other free counseling resources. :::

Standard Disclaimers

This article is for general informational purposes only and does not constitute legal, medical, financial, or insurance advice. Medicare rules, payment rates, APCs, and the ASC Covered Procedures List change periodically. Verify all information with the relevant Medicare Administrative Contractor, the Centers for Medicare and Medicaid Services, your provider, and your Medicare Supplement or Medicare Advantage plan before making decisions. Brevy (brevy.com) provides advocacy and information services; we do not provide medical care or legal representation, and the content of this article does not establish any provider-patient or attorney-client relationship.

::: cta Contact Resources for Georgia Medicare Ambulatory Surgical Center Services

1. Medicare : 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, medicare.gov
2. Palmetto GBA Jurisdiction J (Georgia Medicare Administrative Contractor) : 1-877-567-9230
3. Kepro QIO (Beneficiary and Family-Centered Care Quality Improvement Organization) : 1-844-455-8708
4. GeorgiaCares SHIP (Georgia's State Health Insurance Assistance Program) : 1-866-552-4464
5. Georgia DCH Medicaid Member Services : 1-866-211-0950
6. Georgia Department of Public Health Healthcare Facility Regulation Division : 404-657-5450
7. Ambulatory Surgery Center Association (ASCA) : 703-836-8808, ascassociation.org
8. AAAHC (Accreditation Association for Ambulatory Health Care) : 847-853-6060
9. AAAASF (American Association for Accreditation of Ambulatory Surgery Facilities) : 888-545-5222
10. The Joint Commission : 630-792-5000
11. Georgia Composite Medical Board : medicalboard.georgia.gov
12. Social Security Administration : 1-800-772-1213, TTY 1-800-325-0778, ssa.gov
13. HHS Office for Civil Rights : 1-800-368-1019, TTY 1-800-537-7697
14. HHS Office of Inspector General Hotline : 1-800-447-8477 (1-800-HHS-TIPS)
15. Medicare Rights Center : 1-800-333-4114, medicarerights.org
16. Center for Medicare Advocacy : 1-860-456-7790, medicareadvocacy.org
17. Atlanta Legal Aid Society : 404-377-0701, atlantalegalaid.org
18. Georgia Legal Services Program : 1-800-498-9469, glsp.org
19. Eldercare Locator : 1-800-677-1116
20. 211 Georgia (United Way of Greater Atlanta) : dial 2-1-1 :::