Medicare Coverage of Outpatient Surgery
What It Is
Surgery performed without the patient being admitted to the hospital
Medicare Part B or a Medicare Part C plan covers the services of doctors who participate in the surgery. Medicare Part B or a Medicare Part C plan also covers separate charges by a clinic or hospital outpatient department if the surgery is performed there.
If you have a Medicare Part C Medicare Advantage plan: Co-payments with a Medicare Part C Medicare Advantage plan may be different than those under Medicare Part B. To find out whether your plan has different co-payments for outpatient surgery, contact the plan directly.
What Medicare Pays
Medicare Part B pays 80 percent of the Medicare-approved amount for a doctor's services for surgery performed in a hospital outpatient department, outpatient clinic, or doctor's office. If the surgery is performed in a hospital outpatient department, Medicare Part B pays the full Medicare-approved amount for all nondoctor services provided by the hospital, except for a patient co-payment amount that varies with each type of service.
Important: Regardless of the rules regarding any particular type of care, in order for Medicare Part A, Medicare Part B, or a Medicare Part C plan to provide coverage, the care must meet two basic requirements:
The care must be "medically necessary." This means that it must be ordered or prescribed by a licensed physician or other authorized medical provider, and that Medicare (or a Medicare Part C plan) agrees that the care is necessary and proper. For help getting your care covered, see FAQ: How Can I Increase the Odds That Medicare Will Cover My Medical Service?
The care must be performed or delivered by a healthcare provider who participates in Medicare.
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