Understanding ASC billing and coding
                     
Understanding ASC billing and coding
Beginning January 1, 2008, the CMS publishes updates to the list of procedures for which an ASC may be paid 
each year. In addition, CMS publishes quarterly updates to the lists of covered surgical procedures and covered 
ancillary services to establish payment indicators and payment rates for newly created Level II HCPCS and 
Category III CPT Codes. Keep reading to learn ASC billing and coding.
The complete lists of ASC-covered surgical procedures and ASC-covered ancillary services, the applicable 
payment indicators, payment rates for each covered surgical procedure and ancillary service before adjustments 
for regional wage variations, the wage-adjusted payment rates, and wage indices are accessible on the CMS 
Web site.
To be paid under this provision, a facility must be certified as meeting the requirements for an ASC and must 
enter into a written agreement with CMS. ASCs must accept Medicare’s payment as payment in full for services 
with respect to those services defined as ASC services. The physician and anesthesiologist may bill and be paid 
for the professional component of the service also.
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Understanding ASC billing and coding
Certain other services such as lab services or non-implantable DME may be performed when billed using the 
appropriate certified provider/supplier UPIN/NPI. The understanding basics of ambulatory surgery center billing
 aren’t hard to master, but they do differ from physician and facility requirements. ASC billing is quite different 
from either regular physician billing or facility billing. Unlike physician medical billing, which requires adherence 
to a few highly specialized guidelines in order to get reimbursed, ASC billing and coding aren’t centered on a 
specific medical specialty.
The following overview will help you know what’s most important in the ASC billing and 
coding:
Medicare Claims Submissions
There is a separate set of billing rules for ASCs. While some issues may be addressed by CMS, most billing 
guidelines are best obtained from your local carrier or intermediary. Some carriers/intermediaries issue very 
detailed guides, while others may simply provide a list of links to the CMS website.
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Understanding ASC billing and coding
To reiterate, an ASC must not report separate line items, HCPCS Level II codes, or any other charges for 
procedures, services, drugs, devices, or supplies that are packaged into the payment allowance for covered 
surgical procedures. The allowance for the surgical procedure itself includes these other services or items. CMS 
does, however, strongly encourage billing for drugs and biologicals that are eligible for separate payments. ASCs 
should report supplies with the correct HCPCS Level II code and the correct number of units on the claim form.
Coding for ASC
Coding for Ambulatory Surgery Centers is a specialty unto itself. It is a facility service, but Medicare requires 
ASCs to send their bills to the professional fee (Part B) payers using the facility fee (Part A) claim form. There is a 
whole different set of regulations and bundling edits to use for ASCs. Many ASCs use the same codes as the 
surgeons, but that can be a revenue “kiss of death” and create compliance exposure for every shareholder or 
partner in the ASC.
The rules of the game are different for ASCs than for surgeons or for hospitals; at times ASCs must follow the 
rules for doctors, and at other times they must adhere to the hospital’s rules. A simple modifier used incorrectly 
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Understanding ASC billing and coding
can deliver a “fatal blow” to an otherwise clean claim for thousands of dollars.
Approved Surgical Procedures
For Medicare patients, you cannot perform just any procedure in the ASC setting. Medicare has an “approved” 
list of procedures for the ASC that CMS has determined not to pose a significant safety risk, and that is not 
expected to require an overnight stay following the surgical procedure. Medicare publishes this list of covered 
procedures annually. Updates are published quarterly, or as necessary.
The list of approved procedures is based on the criteria:
• They are NOT emergent or life-threatening.
• They cannot be performed safely in a physician’s office.
• They can be electives.
• They can be urgent.
• Procedures also do not involve major blood vessels or result in major blood loss, and cannot involve 
prolonged invasion of a body cavity.
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Understanding ASC billing and coding
Device Intensive Procedures
A modified payment methodology is used for device-intensive procedures (i.e., procedures done specifically to 
insert a device, such as a pacemaker). The ASC will get paid for the device but does not submit a separate line 
item for the device. The ASC would instead include the cost of the device in the procedure code and submit one 
line item.
ASCs are not allowed to base prices on the allowable code from the Medicare Physician Fee Schedule (MPFS). 
For example, if a device-intensive procedure is performed, and the formula is to bill the Medicare allowable plus 
10 percent, you may be leaving money on the table. If the 10 percent increase does not cover the cost of the 
device, the money will not be recouped. It is important to know the cost to the ASC and add the cost of the 
device into the allowable.
Modifiers in the ASC
Some modifiers used in the ASC are the same as those used by physicians, while others are unique to the ASC
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Understanding ASC billing and coding
facility.  ASCs have their own modifiers for discontinued procedures. Modifier 73 Discontinued outpatient 
hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia is used when 
preparing for surgery has begun, but anesthesia has not been administered.
The patient is taken back to the “prep” area and has completed paperwork, etc. The reasons may be the patient 
has a low-grade temperature, or has eaten within the past four hours. The facility charges for the preparation, 
etc., but adds the modifier to show the procedure was not completed.
Modifier 74 Discontinued outpatient hospital procedure after the administration of anesthesia is used when the 
procedure is terminated after anesthesia is administered. Plans can pay from 25 percent to 65 percent of the 
allowable amount, based on the modifier and documentation of how much of the service was performed.
New modifier PT Colorectal cancer screening test; converted to diagnostic test or other procedure designates 
that screening colonoscopy was converted to a diagnostic or therapeutic service. For example, a patient 
presents to the ASC for a screening colonoscopy. He is not high-risk and has no symptoms or complaints. During 
the colonoscopy, a polyp is found in the sigmoid.
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Understanding ASC billing and coding
The ASC reports 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple instead 
of 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without the collection of 
specimen(s) by brushing or washing, with or without colon decompression (separate procedure) or G0121 
Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk. Modifier PT designates 
the procedure was planned as a screening but resulted in a diagnostic procedure. For Medicare patients, this 
allows the procedure to be paid as a screening with no co-insurance.
If you feel staffing a skilled revenue cycle team for your ASC, is a challenge, consider outsourcing. Significant 
efficiencies and bottom-line improvements can be realized by partnering with a vendor that offers leading 
technology solutions and services throughout the continuum of care.
Medical Billers and Coders (MBC) offer complete transparency and control of the ASC revenue cycle along with 
key analytics, actionable insights, recommendations, and proven strategies. Such offerings will maximize the 
ASC’s efficiency, profitability, and physician disbursements. To know more about ASC billing and coding contact 
us at 888-357-3226/[email protected]
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