This document addresses procedures performed in the ambulatory or outpatient surgery centers.

Ambulatory surgery refers to surgical or invasive procedures performed by qualified providers in ambulatory or dedicated surgical suites with pre-procedural and immediate post-procedural care on the same day or observation admissions without hospitalization (Patient Selection Criteria for Ambulatory [Same Day] Surgery VHA Handbook).

Note: Please see the following related documents for additional information:

• CG-MED-83 Site of Care: Specialty Pharmaceuticals
• CG-SURG-52 Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services

Clinical Indications

Note: The medical necessity of the procedure may be separately reviewed against the appropriate criteria.

Medically Necessary:

The use of an outpatient or ambulatory surgery center (ASC) facility, rather than an office-based setting, is considered medically necessary when any of the following criteria are met:

1. The procedure must be of a level of complexity that it may not be performed in a less intensive setting such as an office-based setting, but also not so complex as to require immediate access to specific services of a medical center/hospital setting or post-operative recovery in an inpatient facility. For example the procedure’s complexity requires one of the following, including but not limited to:
   1. Need for anesthesia or sedation beyond topical anesthesia, digital block, or local anesthesia with concomitant need for monitoring of physiologic parameters beyond intermittent checks of vital signs; or
   2. Need for recovery period of significant duration beyond the capacity of a physician’s office;
      OR
2. The individual has clinical conditions which may compromise the safety of an office-based procedure, including but not limited to:
   1. Conditions which require enhanced monitoring, medications or a prolonged recovery period; or
   2. Increased risk for complication due to severe comorbidity, such as that evidenced by an American Society of Anesthesiologist’s (ASA) class III or higher physical status.

Not Medically Necessary:

All other uses of outpatient or ASC facility, rather than an office-based setting, are considered not medically necessary.

Coding