Services included and not included in ASC billing

Ambulatory Surgery Center (ASC) Payment Guidelines

When contracting directly with an Ambulatory Surgery  Center (ASC), Insurance contracts using various payment methodologies. Please refer to your provider agreement for specifics.

For codes that do not have an ASC allowed amount published by CMS, Insurance will establish such values for its maximum rate determination.

The SG modifier must be used to bill services provided in an ASC.


Services included in the ASC

Facility Payment:

Nursing services, services of technical personnel, and other related services: These services include any nurses, orderlies, technical personnel, and others involved in patient care.

Patient use of the ASC facilities: Use of the operating room, recovery room, patient prep areas, waiting room, and other areas used by the patient or offered for use to the patient’s relatives in connection with the procedure are all included within the facility payment.

Drugs and biologicals: These include drugs or biologicals commonly furnished by the ASC in connection with Surgical procedures. It is limited to those items that cannot be selfadministered.

Surgical dressings: This includes primary surgical dressings applied at the time of the surgery, and therapeutic and protective coverings applied to lesions or openings  in the skin that were required for the surgical procedure. (Ace bandages, pressure garments, Spence boots, and similar items are considered secondary dressings.) Surgical dressings for reapplication by the patient or other caregiver obtained on a provider’s order from a supplier, i.e., drugstore, are not included in the facility payment and are separately reimbursable to the supplier.

Supplies, splints, and casts: Only those supplies, splints and casts applied at the time of surgery are included in the facility fee. However, such items furnished later are generally furnished “incident to” a physician’s service and are not an ASC facility service. Items provided “incident to” a provider’s services are subject to other regulations and definitions, and are generally included in the provider fee. Supplies include all those required for the patient or ASC personnel, such as gowns, drapes, masks, and scalpels.

Appliances and equipment: Appliances and equipment used within the surgical procedure are included within the facility payment. However, prosthetics and orthotics (other than IOLs) are not included and will be separately reimbursed. IOLs are included in the facility payment.DME furnished to the patient is separately reimbursable to enrolled DME providers.

Diagnostic or therapeutic items and services: Diagnostic services performed by the ASC may be included in the ASC facility payment. However, if the laboratory of the ASC is not certified, items such as routine simple urinalysis or hemograms should not be billed. Tests performed by a certified ASC laboratory are billed by the laboratory and are 80 Insurance Health Plans Revised September 9, 2016. Replaces all prior versions. separately reimbursable. Similarly, tests performed under
an arrangement with an independent or hospital laboratory are billed directly by the provider. Radiology, EKGs, and other preoperative tests are generally not included in the facility payment when used to determine the suitability of an ASC setting. Other diagnostic and therapeutic tests directly connected to the procedure are included in the facility
payment.

Administrative, recordkeeping, and housekeeping items and services: These include administrative functions necessary to run the facility.

Materials for anesthesia: These include any supplies, drugs, or gases are included within the facility payment.

Unless otherwise noted in your agreement, Insurance will not pay for services or supplies specifically outlined by CMS as included in the Case Rate, or in which CMS has deemed non-reimbursable. These can be found on the CMS Web page at www.cms.gov/Medicare/Medicare-Fee-for-  Service-Payment/ASCPayment/index.html. Refer to your specific payment schedule outlined in your agreement.

Procedures that have an “N1” payment indicator listed in Addendum AA will not be reimbursable. Services and supplies outlined in Addendum EE, “Surgical Procedure to be Excluded from Payment,” will be reimbursed if prior approved by Insurance.


Services not included in the ASC 

Facility Payment:

• Physician services: This includes services of anesthesiologists administering or supervising the administration of and recovery from anesthesia. Physician services also include any routine preor postoperative services, such as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other services that the individual physician usually includes in a set global fee for a given surgical procedure.

• DME: Includes items for the sale, lease, or rental to ASC patients for use in their home.

• Prosthetic and orthotic devices; and leg, arm, back, and neck braces (except IOLs).

• ASC furnished ambulance services.

• Diagnostic tests performed directly by an ASC.

• Physical and occupational therapy services.