What is ASC billing

Definition of ASC

An ASC for Medicare purposes is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. The ASC must enter into a “participating provider” agreement with CMS. An ASC is either independent (i.e., not a part of a provider of services or any other facility) or operated by a hospital (i.e., under the common ownership, licensure or control of a hospital). If an ASC is the latter type, it has the option either of being covered under Medicare as an ASC or of continuing to be covered as a hospital-affiliated outpatient surgery department as such entities were covered prior to the enactment of ASC legislation on December 5, 1980. To be covered as an ASC operated by a hospital, a facility:

• Elects to do so and continues to be so covered unless CMS determines there is good cause to do otherwise.
• Is a separately identifiable entity – physically, administratively and financially independent and distinct from other operations of the hospital with costs for the ASC treated as a non-reimbursable cost center on the hospital’s cost report.
• Meets all the requirements with regard to health and safety and agrees to the assignment, coverage and payment rules applied to independent ASCs.
• Is surveyed and approved as complying with the conditions for coverage for ASCs in 42 CFR 416.40-49 (http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr416_06.html).

Related survey requirements are published in the State Operations Manual. If a facility meets the above requirements, it bills the Medicare contractor on Form CMS-1500 or the related electronic data set and is paid the ASC payment amount.

If a hospital-based facility decides not to become a certified ASC, it bills the Fiscal Intermediary (FI) on Form CMS-1450 or the related EDI data set and is subject to hospital outpatient billing and payment rules. It is also subject to hospital outpatient certification and participation requirements.

Certain Indian Health Services (IHS) and tribal hospitals may elect to enroll and be paid as a certified ASC. See Pub. 100-04, Chapter 19 for more information at:
http://www.cms.hhs.gov/manuals/downloads/clm104c19.pdf