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.


As per 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 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.


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 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.

Published By - Medical Billers and Coders
Published Date - Feb-03-2016 Back

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