- Includes services of anesthesiologists administering or supervising administration of anesthesia, beneficiary's recovery from anesthesia and routine pre- or post-operative services such as office visits, removal of stiches, changing of dressings, etc.
Reimbursement
Two primary costs are involved in the surgical procedures performed in an ASC.
- Physician's professional services for performing procedure
- Cost of services furnished by facility where procedure was performed
The professional fee is paid to the physician and payment for facility costs are paid to the ASC.
Claim Submission
ASCs must not report separate line items, HCPCS Level II codes, or any other charges for procedures, services, drugs, devices, or supplies that are packaged into the payment allowance for covered surgical procedures. The allowance for the surgical procedure itself includes these other services or items. Covered ancillary items and services, such as pass-through devices, brachytherapy sources, separately payable drugs and biologicals and radiology procedures, should be billed on the same claim as the related ASC surgical procedure.
Place of service (POS) 24 indicates an ASC, a freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis.
When a patient is in a Part A Skilled Nursing Facility (SNF) stay, any service provided by an ASC, during that time, is not paid as a Part B claim.
ASCs are required to report the TC modifier when billing for facility charges associated with HCPCS codes that have both a technical component and a professional component under the Medicare Physician Fee Schedule (MPFS).
Terminated Surgical Procedures Documentation
Payment is made when a surgical procedure is terminated due to the patient having medical complications which would put them at risk to continue with the procedure. ASC claims that involve a terminated surgery must be accompanied by an operative report that specifies all the below.
- Reason for termination of surgery
- Description of services performed
- Description of supplies provided
- Services not performed that would have been if surgery had not been terminated
- Supplies that would have been provided if surgery had not been terminated
- Time spent in each stage (e.g., pre-op, operative, post-op)
- Time that would have been spent in each of these stages if surgery had not been terminated
- CPT codes for procedures that were scheduled to be performed
Two modifiers are associated with terminated procedures.
- Modifier 73: Procedure terminated before administration of anesthesia
- Allows 50 percent
- Allows full payment
Modifier 53 is for physician-use only and is not used by ASCs.
Implanted Devices
ASC surgery allowed amount includes the costs of implanted devices. Sometimes the device is being provided at no or partial cost to the ASC. To indicate this, use modifier FB.
- Modifier FB: Device provided at no cost or will be fully credited
- Device provided with partial credit of 50% or higher of cost
Resources
- CMS ASC Approved Codes and Payment Rates - Addenda
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 260
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 14
- CMS Survey & Certification - Guidance to Laws & Regulations
Related Articles
The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.
paginationType noridianArticles Source Posted January 2024 Update to the Ambulatory Surgical Center (ASC) Payment System 01/10/2024 ASC Payment System: October 2022 Update - Revised CR12915 11/10/2022 Contact
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