The basics of the ambulatory surgery center (ASC) coding and billing aren’t hard to master, but they do differ from physician and facility requirements. The following overview will help you know what’s most important in the ASC setting. ASCs use a combination of hospital and physician billing.

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ASC CODING AND BILLING: KNOWING WHAT’S IMPORTANT
The basics of the ambulatory surgery center (ASC) coding and billing aren’t hard to master, but
they do differ from physician and facility requirements. The following overview will help you
know what’s 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.

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It’s 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.
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 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.
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.
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.

3. Call now 888-357-3226 (Toll Free)
info@medicalbillersandcoders.com
www.medicalbillersandcoders.com
Copyright ©-2018 MBC. All Rights Reserved3
References:
1. Brenda Chidester-Palmer (2012, Oct 01). Retrieved from
https://www.aapc.com/blog/24327-asc-coding-and-billing-know-whats-important/
2. Medicare Claim Processing Manual. Retrieved from https://www.cms.gov/Regulations-
and Guidance/Guidance/Manuals/downloads/clm104c14.pdf