ASC Physician services payment

Physician Services

Physicians’ services include the services of anesthesiologists administering or supervising the
administration of anesthesia to ASC patients and the patients’ recovery from the anesthesia.
The term physicians’ services also includes any routine pre- or postoperative services, such
as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and
other services which the individual physician usually performs.

The carrier pays the facility fee from the MPFS to the physician. The facility fee is for services
done in a facility other than the physician’s office and is less than the nonfacility fee for services
performed in the physician’s office. Physician services for ASC surgical services will be
reimbursed at 80% of the Medicare Physician Fee Schedule (MPFS) with deductible and
coinsurance applied.

Note: For procedures with dates of service prior to January 1, 2008, the carrier pays the
nonfacility fee from the MPFS to the physician for codes not on the ASC list.

Use place of service code 24 (Ambulatory Surgical Center) for physician charges for services
provided in the ASC facility. The Medicare global fee policies will be applied to physician
services provided in an ASC. In a past audit of claims processed by NHIC , the Office of
Inspector General (OIG) discovered that physicians incorrectly coded the place of service on 81 of
100 sampled claims by using the “office” place of service even though they performed the
services in an outpatient hospital setting or an ambulatory surgical center. This resulted in an
overpayment to the physician. Medicare has established different RVUs (Relative Value Units)
for services performed in a facility versus a nonfacility setting. The correct place of service code
ensures that Medicare is not duplicating payment to the physician and the facility for any part of
the practice expense incurred to perform a Medicare service. The payments to the physicians are
higher when the services are performed in non-facility settings.

Physicians are required to submit a separate claim for their professional service. Under no
circumstances should a physician’s bill for their professional services be included on the same
claim as the ASC facility charge.

Note: Although the physician can be reimbursed for a procedure performed in an ASC not on
the ASC list, no facility payment will be made to the ASC.

Rebundling of CPT Codes

The national correct coding initiative (NCCI) rebundling instructions apply to processing claims
from ASC facilities. In general, if an ASC bills a CPT code that is considered to be part of another
more comprehensive code that is also billed for the same beneficiary on the same date of service,
only the more comprehensive code is covered, provided that code is on the list of ASC approved
codes.