Ambulatory surgical centers (ASCs) are some of the fastest-growing medical services today. Unlike physician- surgeon or hospital billing, there are some things that you as well as your billing department need to know before filing a claim for services rendered through an ASC. Medicare often has different guidelines than some payers, for one thing, and the payers themselves often differ regarding medical necessity, approved procedures, or other filing requirements.
If you’re new to ASC billing, knowing these five important things about ASC billing and filing claims up front will get you off to a better start, and increase your likelihood of faster, more complete reimbursement. Even experienced billers find that due to the ever-changing nature of payers, and Medicare in particular, the challenge of staying current on the latest changes can be daunting without the support of third-party claims management services.
Ambulatory surgical centers defined (using CMS guidelines)
The Medicare Carriers Manual defines an ASC as a separate and distinct institution, with the sole purpose of providing out patient surgical treatment and services (although this strict definition is changing – see the note below)
Under these rules, a hospital-run facility may for Medicare’s purposes be either a provider-based department of a hospital or an ASC. Medicare requires that ASCs enter into a participating-provider agreement with CMS to be eligible for payments.
Note: newer trends fueled by the CMS’s push for cost-reduction are moving toward the “bed-less hospital” with most services, including surgery performed the same day and patients recuperating at home in touch with providers via phone, etc. These centers will redefine the meaning of ambulatory care, offering surgery, such as that of a recently-opened children’s hospital in Detroit, as well as a pharmacy and related one-stop-shop services. Most patients, who are bearing a larger share of healthcare costs, surveyed prefer to spend as little time in-hospital as possible and strongly approve of any changes that keep their expenses and down-time low.
How are basic ASC charges coded and billed?
An ASC uses a combination of physician and hospital or clinical billing, employing the CPT and HCPCS level codes (as do most physicians), some insurance carriers permit an ASC to bill using ICD-10 procedure codes as does a hospital.
Some “packaged” services such as medical or surgical supplies not on a “pass-through” status, surgical dressings, splints, casts and related items, supervision of an anesthesiologist by the operating surgeon, and so on.
(Watch out for “not on pass-through” items, such as supplies like those listed above or other “carved out” charges, may be otherwise reported and paid separately. You could be leaving money on the table by not taking advantage of identifying these itemization.)
Device-intensive procedures, such as inserting a pacemaker, pay the ASC for the device but not as a separate line item. The center would include the device’s cost in the procedure code and submit as one line item. As a rule, most ASCs are not permitted to base their price on the Medicare Physician Fee Schedule’s allowable code.
Medicare currently requires all ASC charges to be filed electronically using the CMS-1500 form, with most other insurers using the UB92 form.
Medicare requires the use of modifier SG when submitting charges to indicate that services were performed from an ASC. Other payers also may prefer to see the SG modifier to help distinguish between the facility’s bill and that of a physician. Always check with a particular insurer to determine their ASC billing requirements.
What are CMS’s regulations for determining which procedures are covered?
When dealing with Medicare, centers need to be aware that not all procedures that would be are allowed in a hospital are permissible in an ASC setting.
To be “approved” by Medicare, CMS has determined that a given procedure does not pose a significant safety risk nor of incurring an overnight admission following the procedure. If in doubt, contact Medicare.
The approved procedures list is based on the following criteria:
- - They cannot be life-threatening or of an emergency nature, such as reattaching a severed limb or a heart transplant.
- - The procedures cannot be safely performed in a physician’s office
- - They can be urgent
- - They can be elective
Common ASC coding errors
First, be sure that the ASC''s charges match with what was actually performed.
- One of the most common coding mistakes is coding based on a procedure’s headings instead of the actual surgical report. Many ambulatory surgical centers and other freestanding outpatient facilities wisely wait for the complete surgeon’s report rather than bill immediately for what were scheduled services, as sometimes fewer (or different) procedures are actually noted in the final report.
This is bound to result in a denial once it reaches the payer, so a coder should always take the time to thoroughly read the entire operative report, with any discrepancies questioned.
- Other common errors include misreporting open and arthroscopic techniques as one procedure. This happens when a procedure is started arthroscopically then for whatever reason is converted to an open procedure. Many coders mistakenly bill for both, when only the open procedure is the correct procedure to be coded. (Note that this does not apply in cases where the provider does one procedure arthroscopically with another one using the open technique. As long as they are two different procedures, they can be billed as such, instead of as one.
The benefits of working with an experienced practice management service
While many freestanding surgical centers and similar facilities have their own dedicated billing departments, more complicated billing and reimbursement questions often require the attention of experienced billing professionals. M-Scribe has been helping practices of all sizes and specialties improve their billing accuracy and reimbursement rates since 2002. Our experienced billing and coding staff are on top of the latest CMS and payer changes, including handling ASC claims. Reach us at 770-666-0470 or by email to learn how we can save you time and money while improving your revenue cycle.