Understanding ASC Billing and Coding

ASC (Ambulatory Surgical Center) billing and coding utilizes Current Procedural Terminology (CPT) codes to document and bill for procedures performed in the facility accurately. Here are some common CPT codes used in ASC billing and coding:

1. CPT codes for surgical procedures:
   • 10000 – 69999 range: These codes cover a wide range of surgical procedures performed in ASCs, including but not limited to:
     • Excision of lesions or tumors
     • Repair of fractures
     • Arthroscopy procedures
     • Endoscopic procedures
     • Laparoscopic procedures
2. CPT codes for diagnostic procedures:
   • 70000 – 79999 range: These codes are used for diagnostic procedures such as:
     • Diagnostic endoscopies
     • Diagnostic colonoscopies
     • Diagnostic arthroscopies
     • Diagnostic laparoscopies
3. CPT codes for anesthesia services:
   • 00100 – 01999 range: These codes cover anesthesia services provided during surgical procedures in the ASC.
4. CPT codes for ancillary services:
   • 80000 – 89999 range: These codes include various ancillary services such as:
     • Pathology and laboratory services
     • Radiology services
     • Rehabilitation services
5. CPT codes for supplies and materials:
   • 99000 – 99091 range: These codes are used to report supplies and materials used during procedures in the ASC.

ASC must use the appropriate CPT codes to accurately reflect the services provided, ensuring proper reimbursement and compliance with coding regulations and guidelines. ASCs may also use modifiers with CPT codes to provide additional information about the procedure or service rendered. Keep reading to learn about ASC billing and coding.

The CMS website provides the complete lists of ASC-covered surgical procedures and ancillary services, the applicable payment indicators, payment rates for each covered procedure, and ancillary service before adjustments for regional wage variations, wage-adjusted payment rates, and wage indices.

To be paid under this provision, a facility must be certified as meeting an ASC’s requirements and enter into a written agreement with CMS. ASCs must accept Medicare’s payment as payment in full for services with respect to those services defined as ASC services. The physician and anesthesiologist may bill and be paid for the professional component of the service.

Other services, such as lab or non-implantable DME, may be performed when billed using the appropriate certified provider/supplier UPIN/NPI. The basics of ambulatory surgery center billing aren’t hard to master, but they differ from physician and facility requirements. ASC billing and coding differ from regular physician or facility billing. Unlike physician medical billing, which requires adherence to a few highly specialized guidelines to get reimbursed, Ambulatory Surgery Centers’ billing and coding aren’t centered on a specific medical specialty.

The following overview will help you know what’s most important in the ASC Billing and Coding:

Medicare Claims Submissions

ASCs have a separate set of billing rules. While CMS may address some issues, most billing guidelines are best obtained from your local carrier or intermediary. Some carriers/intermediaries issue very detailed guides (e.g., Trailblazer), while others may provide a list of links to the CMS website (e.g., Empire).

To reiterate, an ASC must not report separate line items, HCPCS Level II codes, or any other charges for procedures, services, drugs, devices, or supplies packaged into the payment allowance for covered surgical procedures. The allowance for the surgical procedure itself includes these other services or items. However, CMS strongly encourages billing for drugs and biologicals eligible for separate payments. ASCs should report supplies with the correct HCPCS Level II code and number of units on the claim form.

Coding for ASC

Coding for Ambulatory Surgery Centers is a specialty unto itself. It is a facility service, but Medicare requires ASCs to send their bills to the professional fee (Part B) payers using the facility fee (Part A) claim form. There is a different set of regulations and bundling edits for ASCs. Many ASCs use the same codes as the surgeons, but that can be a revenue “kiss of death” and create compliance exposure for every shareholder or partner in the ASC.

The rules of the game are different for ASCs than for surgeons or hospitals; at times, ASCs must follow the rules for doctors, and at other times, they must adhere to the hospital’s rules. A simple modifier used incorrectly can deliver a “fatal blow” to an otherwise clean claim for thousands of dollars.

Approved Surgical Procedures

You cannot perform just any procedure in the ASC setting for Medicare patients. Medicare has an “approved” list of procedures for the ASC that CMS has determined does not pose a significant safety risk and does not expect an overnight stay following the surgical procedure. Medicare publishes this list of covered procedures annually and updates it quarterly or as necessary.

The list of approved procedures is based on the criteria:

• They are NOT emergent or life-threatening (for example, a heart transplant or reattachment of a severed limb).
• They cannot be performed safely in a physician’s office.
• They can be electives.
• They can be urgent.
• Procedures also do not involve major blood vessels or result in major blood loss and cannot involve prolonged invasion of a body cavity.

Device Intensive Procedures

A modified payment methodology is used for device-intensive procedures (i.e., procedures done specifically to insert a device, such as a pacemaker). The ASC will get paid for the device but will not submit a separate line item. Instead, the ASC would include the cost of the device in the procedure code and submit one line item.

ASCs cannot base prices on the allowable code from the Medicare Physician Fee Schedule (MPFS). For example, if a device-intensive procedure is performed, and the formula is to bill the Medicare allowable plus 10 percent, you may leave money on the table. If the 10 percent increase does not cover the cost of the device, the money will not be recouped. It is important to know the cost to the ASC and add the cost of the device into the allowable.

Modifiers in the ASC

Some modifiers used in the ASC are the same as those used by physicians, while others are unique to the ASC facility.  ASCs have their modifiers for discontinued procedures. Modifier 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure before anesthesia is used when preparing for surgery has begun, but anesthesia has not been administered.

The patient has returned to the “prep” area and completed the paperwork. The reason may be that the patient has a low-grade temperature or has eaten within the past four hours. The facility charges for the preparation, etc., but adds the modifier to show that the procedure was not completed.

Modifier 74 Discontinued outpatient hospital/ambulatory surgery centers (ASC) procedure after the administration of anesthesia is used when the procedure is terminated after anesthesia is administered. Plans can pay from 25 percent to 65 percent of the allowable amount, based on the modifier and documentation of how much of the service was performed.

New modifier PT Colorectal cancer screening test; converted to diagnostic test or other procedure designates that screening colonoscopy was converted to a diagnostic or therapeutic service. For example, a patient presents to the ASC for a screening colonoscopy. He is not high-risk and has no symptoms or complaints. During the colonoscopy, a polyp is found in the sigmoid.

The ASC reports 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple instead of 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without the collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) or G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk. Modifier PT designates the procedure as a screening but results in a diagnostic procedure. For Medicare patients, this allows the procedure to be paid as a screening with no co-insurance.

If you feel staffing a skilled revenue cycle team for your ASC is challenging, consider outsourcing. Partnering with a vendor that offers leading technology solutions and services throughout the continuum of care can realize significant efficiencies and bottom-line improvements.

Medical Billers and Coders (MBC) offer complete transparency and control of the ASC revenue cycle along with key analytics, actionable insights, recommendations, and proven strategies. Such offerings will maximize the ASC’s efficiency, profitability, and physician disbursements. To know more about ASC billing and coding, contact us at 888-357-3226/ info@medicalbillersandcoders.com

FAQs

• What is ASC billing and coding?

ASC billing and coding is accurately documenting and billing for medical procedures and services performed in Ambulatory Surgical Centers (ASCs). It involves using specific codes to describe the procedures and services provided to patients.

• Why is ASC billing and coding important?

Proper billing and coding ensure that ASCs receive appropriate reimbursement for their services. It also helps maintain compliance with regulations and guidelines set by insurance companies and government agencies.

• What are CPT codes, and how are they used in ASC billing and coding?

CPT (Current Procedural Terminology) codes are standardized codes used to describe medical procedures and services. In ASC billing and coding, specific CPT codes are assigned to each procedure or service performed in the ASC. These codes help identify the services provided for billing purposes.

• What are some common CPT codes used in ASC billing and coding?

Common CPT codes used in ASC billing and coding include those for surgical procedures, diagnostic procedures, anesthesia services, ancillary services (such as pathology and radiology), and supplies and materials.

• What are modifiers, and why are they used in ASC billing and coding?

Modifiers are additional codes that provide more information about a procedure or service. They may indicate, for example, that a procedure was performed on multiple sites or that a service was provided under unusual circumstances. Modifiers help ensure accurate billing and reimbursement.

• How do ASCs ensure accurate billing and coding?

ASCs ensure accurate billing and coding by employing trained staff familiar with coding guidelines and regulations. They also conduct regular audits and reviews of coding practices to identify and address any errors or discrepancies.