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1. Understanding ASC Coding
and Billing

2. 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.
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.

3. 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.
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.

4. The following overview will help you know what’s most
important in the ASC setting:
• Medicare Claims Submissions
• Coding for ASC
• Approved Surgical Procedures
• Device Intensive Procedures
• Modifiers in the ASC

5. 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. CMS does, however, strongly
encourage billing for drugs and biologicals that are eligible for separate
payment. ASCs should report supplies with the correct HCPCS Level II
code and the correct number of units on the claim form.

6. Coding for ASC
Coding for Ambulatory Surgery Centers is a specialty unto itself. It is
a facility service, but Medicare requires ASC’s to send their bills to
the professional fee (Part B) payers but 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 can deliver a “fatal blow” to an otherwise
clean claim for thousands of dollars.

7. 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.

8. 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 physician’s 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.

9. 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 price 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.

10. 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 facility. ASCs have their
own modifiers for a discontinued procedure. 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.

11. Modifier 74 Discontinued outpatient hospital/ambulatory surgery
centers (ASC) 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.

12. 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 as 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.

13. Email : info@medicalbillersandcoders.com
Fax no: 888-316-4566
Toll Free no: 888-357-3226