physcian billing in ASC setup

Definition of Services in ASCs That Are Not ASC Facility Services Physicians’ Services

This category includes most covered services performed in ASCs which are not considered ASC facility services. Physicians who furnish services in ASCs may bill for and receive separate payment under Part B. Physicians’ services include the services of anesthesiologists administering or supervising the administration of anesthesia to beneficiaries in ASCs and the beneficiaries’ recovery from the anesthesia. The term physicians’ services also includes any routine pre- or post-operative services, such as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings and other services which the individual physician usually includes in the fee for a given surgical procedure.

Physician Payment for Non-Covered ASC Procedures
Prior to January 1, 2008, physicians were paid for furnishing non-covered procedures in ASCs at the non-facility amount. Beginning January 1, 2008, Medicare revised this policy to require payment to physicians at the facility payment amount, which is an agreement with both the policy under the hospital OPPS and the revised ASC payment policy related to the list of covered services. The revised ASC payment system is based on the Ambulatory Payment Classification (APC) groups and payment weights of the OPPS.
CMS believes that ASC facilities are similar, insofar as the delivery of surgical and related non-surgical services, to hospital outpatient departments. Specifically, when services are provided in ASCs, the ASC, not the physician, bears the responsibility for the facility costs associated with the service. This situation parallels the hospital facility resource responsibility for hospital outpatient services.

Under the revised ASC payment system, CMS adopted a policy that identifies, and excludes from ASC payment, only those services that could pose a significant risk to beneficiary safety or that would be expected to require an overnight stay.

CMS believes that it would be inconsistent with the revised ASC payment system policies to pay the typically non-facility rate to physicians who furnish excluded ASC procedures. Because the excluded procedures have been specifically identified by CMS as procedures that could pose a significant risk to beneficiary safety or that would be expected to require an overnight stay, CMS does not believe it would be appropriate to provide a payment based on the non-facility rate to physicians who furnish them in the ASC setting.
In addition, the proposed revision to the Code of Federal Regulations (42 CFR 414.22(b)(5)(i)(A) and (B); see http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=/ecfrbrowse/Title42/42cfr414_main_02.tpl imposes beneficiary liability for facility costs associated with surgical procedures that are not Medicare-covered surgical procedures when performed in ASCs.

Under the revised ASC payment system, CMS has determined that the only surgical procedures excluded from ASC payment are those that pose a significant safety risk to beneficiaries or that are expected to require an overnight stay when furnished in an ASC. Therefore, CMS provides no payment to ASCs for these procedures.