Medical Billing Basics for ASCs’
Billing Basics for ASC
An ASC is defined as an entity that operates exclusively for furnishing outpatient surgical services to patients. To receive coverage of and payment for its services under this provision, a facility must be certified as meeting the requirements for an ASC and enter into a written agreement with CMS. Let’s discuss the medical billing basics for ASC in this article. There are two types of ASCs:
- Independent: Not part of a provider of services or any other facility
- Hospital: ASC under common ownership, licensure or control of a hospital
- Nursing services, services of technical personnel, and other related services: All services with covered procedures furnished by nurses and technical personnel who are employees of ASC. Patient care provided by orderlies and other personnel.
- Use by the patient of the ASC facilities: Operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by a patient or offered for use by patient’s relatives with surgical services.
- Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment: All supplies and equipment commonly furnished by ASC with surgical procedures. Drugs and biologicals that cannot be self-administered are exceptions. Coverage for surgical dressings is limited to primary dressings; i.e., therapeutic and protective coverings applied directly to lesions on the skin or on openings to the skin required as the result of surgical procedures. Items such as Ace bandages, elastic stockings and support hose, Spence boots and other foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for arms and hands are generally used as secondary coverings and are not covered as surgical dressings.
- Surgical dressings usually are applied first by a physician and are covered as “incident to” a physician’s service in a physician’s office setting. In the ASC setting, such dressings are included in the facility’s services. When a patient on a physician’s order obtain surgical dressings from a supplier, e.g., a drugstore, surgical dressing is covered under Part B. The same policy applies in case of dressings obtained by a patient on a physician’s order following surgery in an ASC; dressings are covered and paid as a Part B service by a local Part B contractor, included in the definition of facility services.
- Diagnostic or therapeutic items and services: Items and services furnished by ASC staff with covered surgical procedures. ASCs perform simple tests just before surgery, primarily urinalysis and blood hemoglobin or hematocrit, which are generally included in their facility charges. To the extent that such simple tests are included in ASC’s facility charges, they are considered facility services; however, under the Medicare program, diagnostic tests are not covered in laboratories independent of a physician’s office, rural health clinic, or hospital unless the laboratories meet regulatory requirements for conditions for coverage of services of independent laboratories. Therefore, diagnostic tests performed by ASC other than those generally included in the facility’s charge are not covered under Part B as such and are not billed to Medicare Administrative Contractor (MAC) as diagnostic tests.
- If ASC has its laboratory certified as meeting regulatory conditions, the laboratory itself bills for tests performed. ASC may make arrangements with an independent laboratory or other laboratories, such as a hospital laboratory, to perform diagnostic tests it requires prior to surgery. In general, however, necessary laboratory tests are done outside ASC prior to the scheduling surgery, since test results often determine whether a beneficiary should even have the surgery done on an outpatient basis in the first place.
- Administrative, recordkeeping, and housekeeping items and services: Items such as scheduling, cleaning, utilities, rent, etc.
- Blood, plasma, platelets, etc., except those to which blood deductible applies: Covered procedures limited to those not expected to result in extensive loss of blood, in some cases, blood or blood products are required. Usually blood deductible results in no expenses for blood or blood products being included under this provision; however, where there is a need for blood or blood products beyond the deductible, they are considered ASC facility services, and no separate charge is permitted to beneficiary or program.
- Materials for anesthesia: Includes anesthetic itself, and any materials, whether disposable or reusable, necessary for its administration.
- Intraocular lenses (IOLs): Implantable devices, with the exception of those devices with pass-through status under OPPS. Dressings applied during or after surgical procedures included in facility fees.
Covered Ancillary Items and Services
Ancillary items and services integral to a covered surgical procedure and for which separate payment to the ASC is allowed include the below:
- Brachytherapy sources
- Certain implantable items that have pass-through status under OPPS
- Certain items and services that CMS designates as contractor-priced, including by not limited to, procurement of corneal tissue
- Certain drugs, biologicals and radiology services for which separate payment is allowed under OPPS
Not Part of Facility Fee
- Physicians’ services
- Includes services of anesthesiologists administering or supervising the administration of anesthesia, beneficiary’s recovery from anesthesia and routine pre- or post-operative services such as office visits, removal of stitches, changing of dressings, etc.
- Sale, lease, or rental of Durable Medical Equipment (DME) for home use
- Prosthetic devices
- Non-implantable prosthetic devices
- Ambulance services
- Leg, arm, back and neck braces
- Artificial legs, arms, and eyes
- Services of independent laboratories
Two primary costs are involved in the surgical procedures performed in an ASC.
- Physician’s professional services for performing the procedure
- Cost of services furnished by the facility where the procedure was performed
The professional fee is paid to the physician and payment for facility costs are paid to the ASC.
- ASCs 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. Covered ancillary items and services, such as pass-through devices, brachytherapy sources, separately payable drugs, and biologicals and radiology procedures, should be billed on the same claim as the related ASC surgical procedure.
- Place of service (POS) 24 indicates an ASC, a freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.
- When a patient is in a Part A Skilled Nursing Facility (SNF) stay, any service provided by an ASC, during that time, is not paid as a Part B claim.
- ASCs are required to report the TC modifier when billing for facility charges associated with HCPCS codes that have both a technical component and a professional component under the Medicare Physician Fee Schedule (MPFS).
Terminated Surgical Procedures
Payment is made when a surgical procedure is terminated due to the patient having medical complications which would put them at risk to continue with the procedure. ASC claims that involve a terminated surgery must be accompanied by an operative report that specifies all the below.
- Reason for termination of surgery
- Description of services performed
- Description of supplies provided
- Services not performed that would have been if surgery had not been terminated
- Supplies that would have been provided if surgery had not been terminated
- Time spent in each stage (e.g., pre-op, operative, post-op)
- The time that would have been spent in each of these stages if surgery had not been terminated
- CPT codes for procedures that were scheduled to be performed
Two modifiers are associated with terminated procedures:
- Modifier 73: Procedure terminated before administration of anesthesia
- Modifier 74: Procedure terminated after administration of anesthesia
- Modifier 53 is for physician-use only and is not used by ASCs
We hope that this article has provided billing basics for ASC. If you are looking for overall ASC billing and coding services you can refer to E2E Medical Billing Services. Our accurate and affordable ASC billing services will eliminate billing and coding errors and will increase your insurance collection. To know more about our ASC medical billing and coding services, call us at 888-552-1290 or write to us at [email protected]