Clarification of Ambulatory Surgery Center (ASC) Grouper Reimbursement
Ambulatory surgery facility charges fall into one of 11 TRICARE grouper rates. The rates established under this system apply only to the facility charges for ambulatory surgery. While it may not always be clear what is included in ambulatory surgery center (ASC) rates, the following tables illustrate what services are included in the ASC grouper reimbursement and for which services providers can expect additional payment above the ASC grouper allowable amount. The revenue code and service description is listed in the tables.
Services Included in ASC Grouper Reimbursement
Revenue Code |
Service Description |
25X |
Pharmacy |
26X |
Intravenous (IV) Therapy |
270-272 |
Supplies |
274-276 |
Supplies; excluding implants |
278-279 |
Supplies; excluding implants |
28X |
Oncology |
29X |
Durable Medical Equipment (DME) |
36X |
Operating room |
37X |
Anesthesia |
390, 399 |
Blood Storage and Processing |
560,569 |
Medical Social Services |
62X |
Medical Surgical Supplies |
630-633, 637 |
Drugs |
70X |
Cast Room |
71X |
Recovery Room |
720-721 |
Labor Room |
762 |
Observation Bed |
810,819 |
Organ Acquisition except corneal tissue transplant |
942 |
Education/Training |
Services Paid in Addition to ASC Grouper Reimbursement
Revenue Code |
Service Description |
274 |
Prosthetic |
275 |
Pacemaker |
276 |
Intraocular lenses (IOL) |
278 |
Other Implants |
279 |
Other Devices |
30X |
Lab |
31X |
Lab |
32X |
Diagnostic Radiology |
33X |
Therapeutic Radiology |
34X |
Nuclear Medicine |
35X |
CT Scan |
38X |
Blood |
39X |
Blood |
40X |
Other Imaging |
41X |
Respiratory Services |
42X |
Outpatient rehabilitation |
43X |
Outpatient rehabilitation |
44X |
Outpatient rehabilitation |
45X |
Emergency Room (ER) |
46X |
Pulmonary Function |
47X |
Audiology |
48X |
Cardiology |
51X |
Clinic |
54X |
Ambulance |
623 |
Surgical Dressings |
636 |
Detailed Drugs |
73X |
EKG/EEG |
74X |
EEG |
75X |
Gastrointestinal services (IF billed with a surgical code, it is included in the Grouper.) |
92X |
Other Diagnostic tests |
For additional information, ambulatory surgery providers can refer to www.tricare.mil/ambulatory, the TRICARE Reimbursement Manual at http://manuals.tricare.osd.mil/, the TriWest website at www.triwest.com or call 1-888-TRIWEST (1-888-874-9378).
Please note: OPPS will override this matrix upon OPPS implementation June 1, 2007.