ASC CODING AND BILLING: KNOWING WHAT’S IMPORTANT

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ASC CODING AND BILLING KNOWING WHATS
IMPORTANT
The basics of ambulatory surgery center (ASC)
coding and billing arent hard to master, but
they do differ from physician and facility
requirements. The following overview will help
you know whats most important in the ASC
setting. ASCs use a combination of hospital and
physician billing. Although ASCs use CPT and
HCPCS Level II codes to bill most of their
services (as do physicians), some payers will
allow an ASC to bill ICD-10-CM procedure codes
(like a hospital). Some payers even base implant
reimbursement on revenue code classification. One
of the most fundamental differences between
billing for professional services and billing for
ambulatory surgery center services is the concept
of the global surgical package. The global
package applies to the professional component of
a surgical service that is performed when using a
surgical CPT code. On the professional side, this
typically encompasses a 90-day follow-up. In the
ASC billing methodology, no such surgical package
exists. Therefore, each time a patient enters the
operating room represents a unique and separate
encounter and has no historical economic
relationship to previous encounters. This is a
very important difference and very often leads to
the need for qualifying modifiers. Those
modifiers tend to clarify a situation such as
return to the operating room on the same day or
return to the operating room by another doctor on
a different date. Its important to use the
proper form when submitting claims. Medicare pays
for ASC services under Part B and requires the
CMS-1500 claim form. Some third-party carriers
will accept the CMS-1500 form, while others allow
the UB04.
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ASC CODING AND BILLING KNOWING WHATS
IMPORTANT

• Approved List of 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. The list of approved procedures is
  based on the criteria
• They are NOT emergent or life-threatening (for
  example, a heart transplant or reattachment of a
  severed limb).
• They CANNOT be performed safely in a physicians
  office.
• They can be elective.
• 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.
• Medicare publishes this list of covered
  procedures annually. Updates are published
  quarterly, or as necessary. The file consists of
  two addenda listing approved surgical procedures
  and covered ancillary services.

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ASC CODING AND BILLING KNOWING WHATS
IMPORTANT

• 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 (e.g., Trailblazer), while others may
  simply provide a list of links to the CMS website
  (e.g., Empire). 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.
• References
• Brenda Chidester-Palmer (2012, Oct 01). Retrieved
  from https//www.aapc.com/blog/24327-asc-coding-a
  nd-billing-know-whats-important/
• Medicare Claim Processing Manual. Retrieved from
  https//www.cms.gov/Regulations-and
  Guidance/Guidance/Manuals/downloads/clm104c14.pdf