Ambulatory Surgical Centers (ASCs) are facilities that provide outpatient surgical procedures that do not require overnight hospital stays. ASCs bill private insurers and Medicare using specific forms and billing criteria, including using revenue codes and CPT codes to identify procedures. Common ASC procedures include endoscopy, cataract surgery, colonoscopy, and nerve procedures. ASCs are reimbursed by Medicare based on an outpatient payment system that assigns payment weights to procedures to determine reimbursement amounts. ASCs can also bill separately for certain ancillary services like implantable devices or drugs.

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How Ambulatory Surgical Centers are Paid
Ambulatory Surgical Centers (ASCs) are modern healthcare centers which provide surgical facilities that do
not require an over-night stay. Also known as outpatient surgery centers or same day surgery centers,
facilities include diagnostic and preventive procedures as well.
Forms' criteria:
ASCs are usually in provider agreement for billing with Centers for Medicare and Medicaid Services (CMS)
or other private payers. ASCs use the CMS-1500 or the UB04 form for claiming. Criteria for claiming are:
Bill to be used (TOB) 0831, identical from and through dates to be mentioned in form locator (FL) 6,
procedures should use revenue codes 0490 or 0360, CPT-4 code for a procedure should be entered in
FL 44, and National Drug codes must be used for chemotherapy related services.
Procedural norms:
Common procedures conducted in ASCs are endoscopy, cataract, colonoscopy and nerve procedures.
Criteria that must be met for claiming of procedures and ancillary services conducted under ASCs are -
procedures should not be life-threatening but can be elective and urgent, cannot be performed in a
general physicians healthcare facility, cannot include major blood loss procedures or an extended invasion
of body cavity.
Modifiers:
As per aapc.com: Modifiers recognized for ASC claim filing are: 52 Reduced services, 59 Distinct separate
procedure, 73 Procedure discontinued after prep for surgery, 74 Procedure discontinued after anesthesia
administered, RT Right side, LT Left side, TC Technical component, FB Device furnished at no cost/full

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credit, FC Device furnished at partial credit, PT Screening service converted to a diagnostic or therapeutic
service, PA Wrong body part, PB Surgery wrong patient, PC Wrong surgery on patient, GW Surgery not
related to hospice patient’s terminal condition.
Reimbursement:
ASCs are reimbursed according to the OPPS (Outpatient Payment System) by Medicare that uses relative
payment weights as a guide. This defines a set of payments for procedures. Anything above this, is billed to
Medicare Part B. Codes are assigned to services once they are billed. Appropriate fees (ascertained by:
average costs determined by a weighted formula, conversion factor or base payment and/or adjustments
for geographical differences in input costs) are determined for each HCPCS code as per items such as
nursing, recovery care, anesthetics, drugs, equipment, surgical supplies, implantable devices, radiology
services etc. for a single procedure. Around 3700 procedures are classified as per Ambulatory Payment
Classification (APC). Beneficiaries pay 20% of the ASC payment charges. ASCs are also paid for
recordkeeping, housekeeping, intraocular lenses, anesthesia materials and other administrative services.
As many ancillary services are packaged into one primary service, certain illnesses such as brachytherapy
sources, radiology services, certain drugs and corneal tissue acquisition can be billed and paid for
separately; along with pass-through payments for services such as implantable devices.
ASC payments are 'packaged' implying that one lump sum is paid for services. Also, awareness to
categories under 'not on pass-through status/pass through' status is required as ASCs should be able to
obtain reimbursements of services given. Apart from drugs and biologicals, all services such as procedures,
devices and supplies are packaged into one payment.
Payment:
Payment weights are set by CMS equivalent to OPPS relative payment weights for the same services. It
then scales the ASC weights to maintain budget neutrality, as authorized by the MMA. ASC payment
weights are scaled to remove any disparity in the entire payment weight from current year to upcoming
year. The weight scaler or the ratio of the current year is applied to the upcoming year.