Ambulatory Surgical Billing

Introduction

ASC is a typical outpatient hospital setup where minor surgeries and other surgeries/procedures are performed and which does not expect the patient to be admitted into the hospital for an inpatient stay. The expansion for ASC is Ambulatory Surgery Center. In other terms ASC is a setup where outpatient surgical procedures are performed. Some of the examples of outpatient surgeries are cataract surgeries, endoscopic procedures; orthopedic surgeries which do not warrant an in patient stay etc.

Various Components of ASC Billing

In an ideal scenario, ASC should be a separate entity by itself under a separate Tax ID. The professional component of the ASC billing could be combined with the routine clinical billing. In a typical ASC setup the billing would be done for three components – the facility component or the technical component, the professional component or the doctor’s component and anesthesia component. All of these would be submitted under one Tax ID and the billing process for each of these three components differs from the other.

The professional component of the billing would be sent to the respective insurance in a CMS 1500 claim form. The Anesthesia component would also be submitted in a CMS 1500 claim form. But the facility claim would be sent in a UB92 claim or CMS 1450 claim form. The UB92 claim forms would be accepted only by certain non federal carriers and for the federal carriers like Medicare, Medicaid, RR Medicare, Champus, and Champva etc. the claim would still be submitted in a CMS 1500 claim form. The professional component claim is also called as the Doctor’s claim since this component is directly reimbursed to the doctor. The Anesthesia component of the billing will have to be done based on the type of anesthesia administered and the duration administered. The facility or the technical component claim will be directly reimbursed to the facility.

The precaution that the billing team has to take is that the treatment and the diagnosis in all the three components should reflect the other and match the combination. In other words, the facility claim cannot be submitted for a cataract surgery when the professional claim is for a colonoscopy or something else other than cataract surgery. Similarly, the type of anesthesia administered and the duration administered should be appropriate for the facility and doctor’s claim and not otherwise.

ASC Billing – Reimbursement basics


The ASC billing is a bit complicated and if we have the basics right – it is the easiest of the billing. Coming to the reimbursement part of these three components, the doctor’s claim and the facility claim should be submitted before the anesthesia claim is submitted. The doctor’s claim and the facility claims would be reimbursed first and only after these reimbursements, the anesthesia claim would be reimbursed. If by chance we submit the anesthesia claims even before the doctor’s claim and the facility claim, the same would be pended for want of the other two component claims.

Professional Component in ASC


The professional component billing or the doctor’s billing is submitted to the respective insurances in a CMS 1500 claim form. The CPT codes in ASC are classified in 8 groups and each group has a set of CPT codes which are assigned to a specific group based on various criteria. The Fee Schedule for each of these groups differs and they are not the normal Medicare Fee Schedule that are released by the Medicare on a yearly basis. These claims would have modifier 26 reported on them to denote that these services are doctor’s professional component of the claim.

Technical Component in ASC


The technical component part of the ASC billing is submitted in both the CMS 1450 and CMS 1500 claim forms. For all the federal carriers the claims would have to be submitted in a CMS 1500 claim form and for all the non federal carriers the claims would have to be submitted in a CMS 1450 claim form. The fee schedule is as it is in Medicare but for the technical component which will be denoted as TC in the Medicare Fee Schedule. The technical component claims would have modifier TC reported on them that the claim is for the technical component.

Anesthesia Billing in ASC


The anesthesia part of the billing is quite simple and straightforward. The list of CPTs representing the anesthesia codes range from 00100 to 01999. All these codes are further sub-classified into the type of anesthesia administered. For every anesthesia CPT a base unit would be pre-fixed by the CMS and the respective state’s Medicare. This base unit is the minimum dosage to be administered for that type of a procedure. For example, the minimum dosage that could be administered for a colonoscopy could range anywhere between 15 minutes to 1 hour. The first 15 minutes would constitute a specific base unit value which will be calculated by the CMS on a yearly basis. Every additional 15 minutes would be calculated as one additional unit. If a patient is administered anesthesia with a CPT carrying a base unit of “5” and if the duration of anesthesia administered is 30 minutes, then the total units would be billed as “5” for the initial 15 minutes and “1” for the subsequent 15 minutes. Hence a total of 6 units would be billed.



Filing UB-04 Claims for Ancillary Providers and Facilities

Ambulatory Surgery Centers/ Outpatient Claims Filing

Must file claims electronically or submit bill on UB-04 claim form.
Must file claims electronically or bill CPT-4 HCPCS code for each surgical procedure in form locator 44.
Can bill with ICD-10 CM procedure codes and date procedure(s) was performed in form locator 74 and if applicable 74a-e.
Must bill standard retail rates.
Use correct NPI in field 56.
Modifiers are not recognized on the UB-04.
When using the following revenue codes, the claim is considered to be an outpatient surgery admission, except if revenue code 0481 (Cardiac Cath Lab) is billed in conjunction with the following:
036X – Operating Room Services (Exclude 0362/0367)
049X – Ambulatory Surgery
075X – GI Lab
079X – Lithotripsy

Note: When revenue code 0481 (Cardiac Cath Lab) is billed in conjunction with the above revenue codes, the claim is considered to be a Cardiac Cath claim and would be reimbursed based on the Provider’s contract.

If multiple services are rendered, each service must be billed on a separate line with the respective CPT or HCPCS code and a detailed charge. This does include surgical procedures. For example: bilateral procedures would be billed on two separate lines with the same revenue code and the respective CPT/HCPCS codes.

Incidental Procedures, as defined in the agreements for Ancillary providers, are not allowed in an ASC setting.

Primary procedures will be reimbursed at 100% of the allowed amount; secondary and subsequent procedures will be reimbursed as stated in the provider’s contract.

Outpatient day surgery claims with a prosthetic/orthotic and/or an implant will be reimbursed based on the provider’s contract.
0274 – Prosthetic/Orthotic Devices
0275 – Pacemaker
0278 – Other Implants

Ambulatory surgery center billing
ASC Modifier SG
ASC Modifiers

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