Billing Guidelines for Ambulatory Surgery Centers

July 15, 2015

Billing Guidelines for Ambulatory Surgery Centers

Healthcare in the USA has gotten complex with the constant updates, not just for the patients but also for the healthcare providers- including the Ambulatory Surgery Centers (ASC). According to a Healthcare Finance News report, about 69% of healthcare providers view that healthcare legislation and mandates will drive patients to the ASCs.

The universal standard for billing (as established by the HIPPAA) outpatients is done on a CMS-1500 claim form by professional billers. Certain billing guidelines for ASCs are crucial.



  1. Review Contracts & Payer Pre-authorization:
    For approval of ASC billing, ASCs must enter into a participating provider agreement with the Centers for Medicare & Medicaid Services (CMS). Moreover, if the payer does not have a contract with the ASC, it’s important that certain costs for procedures that are charged additionally over the basic facility fee be pre-authorized, as the Government agencies or carriers often delay such payments.
  2. Keep Updated:
    Some CPT codes are not reimbursable in an ASC, especially with respect to Medicare. Check out the “Approved’ list of procedures that CMS has proposed, published every quarter. ASC billing and reimbursements are subject to the Correct Coding Initiative (CCI). The file to interpret comments and indicators listed on Addenda AA (Final ASC-covered Surgical Procedures) and BB (Final Integral to Covered Surgical Procedures ) is a MUST HAVE.
  3. Evaluate Software programs:
    You should evaluate all software programs in which ICD 9 CM codes are entered and contact your vendors to determine their ICD 10 CM implementation schedule. Initiate a dialogue with timelines to get moving, so that they don’t affect your reimbursements
  4. Proactively seek Legal advice:
    You need to be aware of the state and federal laws where you are placed and how your state approaches ASC regulation. Some states require licensure of an ASC and some states require a Certificate of Need (CON). So be fully aware of all legal implications which could affect your billing.
  5. Stay alert of packaged payments:
    Payments are usually packaged or bundled for ASCs, but some items may not be included by CMS. Report supplies with the correct HCPCS Level II code and correct number of units on the claim form. Keep alert on supplies having pass-through status to avoid missing the correct reimbursement. Include the cost of the device in the procedure code and submit one line item. Remember the ASCs are not permitted to base price on the allowable code from the Medicare Physician Fee Schedule (MPFS).
  6. Staff Education:
    Based on your documentation and modifiers employed which could reflect how much of the service was performed, around 25% to 65% of the allowable amount could be paid. Thus, educating your staff to differentiate between commonly used modifiers and those unique to the ASC, could enhance your reimbursements directly.
  7. Self-Audits:
    It is always a good practice for self-auditing, to avoid expensive mistakes later on. If overpaid, return the stated amount, because if externally audited and the mistake unearthed, will be costly later.
  8. Be Competitive, Get Transparent:
    According to a Healthcare Finance News report the market for price transparency is expected to grow 55%by 2016 and be worth $3.09 billion. So advertise your rates and display your operative abilities, given the new surgeries that are now allowed in ASC practices, which will help in increasing your revenues

The legal issues that govern the reimbursement for ASC are complicated and nuanced. ASC's requires a specific set of codes reported in the billing situation that is different from other billers and coders. Following these simple guidelines will help ASCs’ avoid delays and pitfalls in payments!


Category : Best Billing and Coding Practices