Covid -19 ASC Update: CMS Issues Guidance For Ambulatory Surgery Centers Enrolling As Hospitals During The Covid-19 Pandemic

On Monday, April 6, 2020, CMS issued guidance regarding Ambulatory Surgery Centers (ASCs) that choose to temporarily enroll with Medicare as a hospital during the COVID-19 Public Health Emergency. ( CMS previously announced on March 30, 2020 several temporary new rules and CMS waivers adopted under 1135 emergency waiver authority that allow ASCs to either contract with hospitals to provide services to hospital patients in ASC facilities or to enroll and bill as hospitals and provide inpatient and outpatient hospital services during the COVID-19 Public Health Emergency (PHE).

The temporary new rules and waivers issued by CMS present options and opportunities for ASCs and other healthcare facilities during the COVID-19 pandemic. However, new waivers and rules regarding state licensing requirements need to still be addressed.

Background – CMS Hospital Without Walls Initiative

CMS announced several temporary new rules and waivers of federal requirements on March 30th to address concerns of whether local hospitals and health systems would have the capacity to effectively manage potential surges of COVID-19 patients. Important to ASCs, CMS announced its “Hospitals Without Walls” initiative that allows healthcare systems and hospitals to provide services in locations beyond their existing walls in other facilities, such as ASCs.

Under this initiative, Medicare-certified ambulatory surgery centers have the option: (1) to contract with local healthcare systems or hospitals to provide services to their hospital patients; or (2) to enroll and bill as a hospital to Medicare during the emergency declaration as long as they are not inconsistent with their state’s emergency preparedness or pandemic plan. CMS commented that the new flexibilities from these temporary rules will leverage these types of sites to provide services typically provided by hospitals such as cancer procedures, trauma surgeries, and other essential surgeries.

ASCs will need to check with state agencies, such as the Louisiana Department of Health, regarding state licensing requirements, as they consider possibly contracting with a local hospital, or enrolling as a hospital with Medicare during the COVID-19 pandemic. Although the blanket waivers announced by CMS on March 30th apply to services for Medicare patients, additional guidance and an additional 1135 waiver may be needed for clarification on services for Medicaid beneficiaries.

In regard to ASCs in Louisiana providing hospital services for commercially insured patients, the Louisiana Department of Insurance issued Emergency Rule 41 last week to address coverage of transfers of patients from an acute care hospital to a Step-Down Facility. A Step-Down Facility is defined as “any health care facility serving as the recipient of inpatient transfers for the purpose of reducing occupancy of or providing overflow capacity for an acute care hospital during the state of emergency” of the COVID-19 outbreak. Emergency Rule 41 requires health insurance issuers (HMOs, PPOs, MCOs, etc…) to cover the remainder of a patient’s inpatient stay needed after being transferred to a Step-Down Facility under the same cost sharing terms as if the patient had stayed at the acute care hospital.

CMS Enrollment Guidance for ASCs as Hospitals During COVID-19

The guidelines issued by CMS on April 6th outlines the steps for existing Medicare-certified ASCs that choose to temporarily enroll as a hospital during the COVID-19 Public Health Emergency. To enroll as a hospital, an ASC should contact the COVID-19 Provider Enrollment Hotline for the Medicare Administrative Contractor (MAC) that serves its jurisdiction to complete and sign an attestation form. CMS will review all of the ASC’s survey activity from the previous three years to determine whether the facility received any Immediate Jeopardy-level deficiency citations.

An on-site survey is not required prior to approval for enrollment as a hospital. CMS may subsequently authorize a survey to ensure quality and safety, including infection control and appropriate personal protective equipment. If the ASC has not been cited for Immediate Jeopardy-level deficiencies, or if any Immediate Jeopardy-level deficiencies were removed through normal survey processes, CMS will review and approve the attestation form and assign a hospital CMS Certification Number (CCN). An ASC may not enroll as a hospital if the ASC received an Immediate Jeopardy-level deficiency citation within the last year and enforcement activities are ongoing.

CMS will temporarily deactivate an ASC’s billing privileges that enrolls as a hospital during the COVID-19 pandemic,. CMS will terminate the provider’s hospital CCN and reinstate its ASC billing privileges when the Secretary determines the COVID-19 public health emergency has ended or the ASC provides written notice to its MAC requesting reinstatement of its ASC billing privileges.

The Ambulatory Surgery Center Association (ASCA) released on April 6th a useful checklist to assist ASCs with identifying the basic elements then need to consider if they are considering enrolling as a hospital with Medicare during the national emergency declared in response to the COVID-19 pandemic. (This checklist is available at

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