The document discusses ASC coding and billing. It notes that ASCs use a combination of hospital and physician billing methods, using CPT and HCPCS codes like physicians but some payers allow ICD procedure codes like hospitals. It also discusses that unlike physician billing, ASC billing does not include a global surgical package. Each patient encounter in an ASC is unique. It also discusses the importance of modifiers in ASC billing to clarify situations like multiple procedures. Medicare requires the CMS-1500 claim form for ASC services paid under Part B. Procedures performed in ASCs must be on Medicare's approved list and meet certain safety criteria.

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ASC Coding And Billing: Knowing What’s Important
The basics of 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.

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ASC Coding And Billing: Knowing What’s Important
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 returning to the operating room on the same day or returning to the operating
room by another doctor on a different date.
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 ASC Coding And Billing:
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.

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ASC Coding And Billing: Knowing What’s Important
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 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.
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 What’s Important
Medicare Claims Submissions of ASC Coding And Billing:
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:
Medicare Claim Processing Manual. Retrieved from https://www.cms.gov/Regulations-and
Guidance/Guidance/Manuals/downloads/clm104c14.pdf