The ASC grouper listing has been updated. Claims may be submitted for approved ASC procedures by freestanding ASCs and hospitals for outpatient surgery.
In this file, the red font represents changes made; the grey lines are inactive lines; and the white lines are active lines
Pursuant to direction from TRICARE Management Activity (TMA), TriWest has grouped additional ASC codes that have not been grouped by TRICARE. The reimbursement for TriWest-grouped procedures are the same as TRICARE-grouped procedures within that same grouper. However, new TRICARE groupings will supersede any groupings assigned by TriWest.
Important points to remember about ASC groupers and reimbursement:
- Providers should bill the surgeries performed and not use unclassified codes, unless the code was preauthorized by TriWest.
- TRICARE multiple surgery guidelines "as well as ClaimCheck® guidelines" may be applied.
- ASC claims are reimbursed based on a grouper rate or billed charges, as appropriate.
- TriWest reimburses some services in addition to the grouper rate (e.g., certain lab, x-ray, implants and drugs). All services require appropriate HCPCS/CPT coding. Unlisted codes require authorization if over $100 and must include a complete description.