Medicare Coverage for Outpatient Surgery

What is outpatient surgery?

Outpatient surgery is when you go to the hospital, have surgery, and go home the same day. You do not have to stay in the hospital overnight. It is also called ambulatory or same-day surgery. It may be done in:

• a special section of a hospital
• a doctor's office or clinic
• a surgical center.

After same-day surgery, you can usually go home in 2 to 4 hours.

What is Medicare?

Medicare is a federal government program. It provides healthcare coverage for people 65 or older, or for people of any age who have certain disabilities.

Medicare is divided into 2 parts: Part A and Part B. Each part covers different services. Both parts pay some of the costs for needed medical services. Both parts pay toward home healthcare if certain conditions are met.

Medicare Part A covers:

• inpatient hospital care
• skilled nursing facilities
• hospice care.

Medicare Part B covers:

• doctor visits
• lab and X-ray services
• durable medical equipment
• ambulance services
• outpatient hospital care.

Rules about what Medicare covers can be confusing. Rules also change from time to time. The premium (monthly amount of money you pay) for Medicare Part B can change every January. The deductibles (what you must pay before Medicare begins to pay), and the copayments (the percentage of costs you must pay) may also change. Your local Social Security office can answer your questions about Medicare.

Does Medicare cover outpatient surgery?

Outpatient surgery is covered under Part B of Medicare. Medicare covers surgery if it is medically necessary. The doctor must tell you if he or she thinks Medicare will judge the surgery to be medically necessary.

Medicare pays 80% of the approved charges. You must pay the other 20%, after you meet your yearly deductible.

If your doctor accepts Medicare assignment, it means that he or she agrees to accept the amount Medicare agrees to pay as payment in full.

If your doctor does not accept Medicare assignment:

• If the bill is for more than the amount Medicare pays, you will owe the rest.
• If your surgery is not an emergency the surgeon must give you a written estimate of the charges.

For more information, call Medicare at 1-800-638-6833.