Some surgeries will automatically be covered by Medicare Part A but others will be covered by Medicare Part B.
The difference could add up to thousands more in out-of-pocket expenses.
You should not undergo any elective surgery or procedure without addressing these issues beforehand.
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This affects not only how much you will pay, but where your surgery can be performed.
These procedures tend to be more complex and have a higher risk for complications.
They are also likely to need post-operative monitoring overnight and often have a long recovery time.
In fact, most types ofspinal fusionsanddiscectomiesare not on the Inpatient Only list.
Other common procedures were once on the list, but have since been removed.
Both are now considered Part B procedures.
The first group of surgeries298 musculoskeletal and spinal procedureswere removed from the list in 2021.
You may also need to pay 20% for any Part B-covered services.
That does not mean that other surgeries cant be performed in a hospital setting.
These surgeries will be covered by Medicare Part B.
Many times, however, payments may be bundled into one amount.
In fact, CMS publishes a specific list of outpatient surgeries that can be performed at an ASC.
This list is referred to as Addendum AA.
By definition, an ASC is an outpatient medical facility where surgeries are performed.
It may or may not be affiliated with a hospital.
You may also hear ASCs referred to as same-day surgery centers.
Staffing in a hospital is very different than that in an ASC.
Whereas a hospital has 24-hour resources, an ASC may have reduced staff overnight.
Most ASCs will not have a physician onsite after hours.
This may necessitate transferring a patient to a nearby hospital.
For these reasons, all procedures on the Inpatient Only list must be performed in a hospital.
Insurance companies may also have internal processes that determine how they will cover different surgeries.
Now, the Inpatient Only list must also be taken into consideration.
There could be advantages to having a Medicare Advantage plan.
Consider rehabilitation care after your surgery.
Medicare Advantage plans have the option ofwaiving the three-day rule.
This could save you considerably in rehabilitation costs if your hospital stay is shorter than that.
Summary
Medicare does not treat all surgeries the same.
An Inpatient Only surgery list is released every year by CMS.
These procedures are automatically approved for Part A coverage and must be performed in a hospital.
All remaining outpatient surgeries must be performed in a hospital for anyone on Medicare.
Whether Part A or Part B covers your surgery affects how much you will pay out of pocket.
Centers for Medicare & Medicaid Services.FY 2024 IPPS final rule home page.
Centers for Medicare & Medicaid Services.Medicare claims processing manual.
Chapter 14 - ambulatory surgical centers.
April 12, 2023.
