Ambulatory Surgery Center Billing

ASC billing differs significantly from traditional physician and facility billing. Unlike physician billing, which must adhere to specialized rules for reimbursement, ASC coding and billing are not tied to specific medical specialties. ASCs encompass various medical specialties in one facility, so their coding system is not centered on particular treatments, procedures, or diagnoses. Therefore, outsourcing ASC billing is highly advisable to avoid complexities and ensure efficient financial management in this diverse healthcare setting. For this purpose, you don't need to search for a trusted billing company because MedsIT Nexus billing company is at your doorstep.

Ambulatory Surgery Centers (ASC) Billing Guide

What is an ASC?

Ambulatory surgical centers, also known as ASCs, are specialized outpatient medical facilities where a wide range of surgical procedures are performed.
The Medicare Carriers Manual, section 10, says that an Ambulatory Surgical Center (ASC) is formally described as a distinct establishment solely dedicated to providing outpatient surgical services.
According to the Ambulatory Surgery Center Association, these centers are designed to provide patients with high-quality care while allowing them to return home within a short timeframe, typically within 24 hours of their procedure (same-day procedure).
Patients visit ASCs for various procedures, such as cataract surgery, colonoscopies, and orthopedic surgeries. ASCs offer several advantages, including reduced costs, faster recovery, and lower infection rates, making them an attractive option for patients and healthcare providers.
An Ambulatory Surgery Centre employs a dual billing approach, which combines physician and clinical or hospital billing methodologies.
It's worth noting that Medicare Part B, which falls under Medical Insurance, extends its coverage to encompass the facility service fees associated with approved surgical procedures conducted in these ASCs. This ensures that eligible beneficiaries can access the necessary medical services and facilities while receiving the benefits of Medicare coverage.

Medicare Criteria for Ambulatory Surgery Centers

To operate effectively, ASCs must establish formal agreements with the Centers for Medicare & Medicaid Services (CMS). These agreements signify the ASC's commitment to adhere to the stringent regulations and guidelines set forth by CMS. This dedication is fundamental to delivering exceptional healthcare services.
ASCs come in two primary forms: independent facilities or those affiliated with larger hospitals or medical institutions. If an ASC is affiliated with a hospital, it must meet additional criteria to receive reimbursement at ASC pay rates. This affiliation can bring added resources and expertise to enhance patient care.
Furthermore, every ASC billing Medicare must obtain certification through a state-specific agency. This certification, coupled with the previously mentioned requirements, serves multiple purposes. Firstly, it guarantees that the ASC is entitled to receive the highest reimbursement rate for its services. Secondly, it assures patients that they are receiving care from a reputable and qualified healthcare agency.

Guidelines for ASC Charges Billing & Coding

ASC billing strategy utilizes CPT and HCPCS (Healthcare Common Procedure Coding System) level codes, a practice commonly adopted by medical professionals.
Now, it is essential to know which codes CMS add to the ASC-covered procedure list in 2023. According to the CMS update of 2023, CMS approved three novel medical devices for inclusion in the Outpatient Prospective Payment System (OPPS). Simultaneously, CMS has introduced new device categories within the Ambulatory Surgical Center (ASC) payment system. These changes became effective on 1 January 2023, coinciding with the implementation of HCPCS codes C1747, C1826, and C1827.
Another essential guideline is ensuring precise adherence to submission protocols, which is paramount when processing claims. Medicare extends coverage for Ambulatory Surgical Center (ASC) services through Part B, necessitating the utilization of the CMS-1500 claim form. However, it's noteworthy that specific third-party carriers exhibit variance in their form preferences. While some third-party carriers readily accept submissions via the CMS-1500 form, others favor the UB04 form for claim processing.

Approved List of Surgical Procedures

In 1982, the Centers for Medicare and Medicaid Services (CMS) initially established a list of approved medical procedures and a payment structure consisting of nine classifications for Ambulatory Surgery Centers (ASCs). To be eligible for reimbursement from Medicare, ASCs must adhere to Medicare's specific criteria for ASC facility accreditation.
Medicare patients seeking surgical These criteria pertain to a curated list of approved procedures that meet specific safety and post-operative stay criteria.
The criteria for procedures eligible for ASC coverage are as follows:
Non-Emergent and Non-Life-Threatening: Covered procedures are neither emergent nor life-threatening. This excludes highly critical surgeries such as heart transplants or limb reattachments.
Unable to Safely Perform in a Physician's Office: Procedures eligible for ASC must be deemed unsafe or impractical to perform within the confines of a physician's office.
Elective and Urgent Procedures: ASC-approved surgeries can be either elective or urgent, providing flexibility to accommodate various patient needs.
Absence of Major Blood Vessel Involvement: Covered procedures must not involve significant blood vessels or result in substantial blood loss, thereby minimizing potential complications.
Limited Invasion of Body Cavities: Eligible procedures do not entail prolonged invasion of a body cavity, ensuring they can be safely conducted in an outpatient setting.

Modifiers in the ASC

Modifier 73 - Discontinued Pre-Anesthesia Procedure
Modifier 73 comes into play when surgical preparations have commenced, including paperwork completion, but anesthesia hasn't been administered due to factors like a mild fever or recent eating. It signifies that despite preparation efforts, the procedure wasn't finalized, allowing for appropriate billing.
Modifier 74 - Discontinued Post-Anesthesia Procedure
On the other hand, Modifier 74 is employed when a procedure gets terminated post-anesthesia administration. Payment from insurance plans varies between 25% to 65% of the allowable amount, contingent on the modifier and documented details of the service extent.
PC Modifier (Incorrect Surgery on Patient)
In ASC claims, the PC modifier is applied when a surgical procedure is performed on a patient that is not the intended recipient. This modifier serves to rectify billing discrepancies arising from incorrect surgeries.
New Modifier PT - Colorectal Screening Conversion
A novel addition is Modifier PT, pertaining to colorectal cancer screening. It signifies that a screening colonoscopy, intended for low-risk individuals with no symptoms, transitions into a diagnostic or therapeutic procedure due to findings, such as the discovery of a polyp during the colonoscopy. This modifier ensures accurate billing and documentation of the service change. Understanding and correctly applying these modifiers is vital for compliance and reimbursement in ASCs. Modifier PT signifies that the procedure was initially intended as a screening but transformed into a diagnostic procedure. This modifier is particularly beneficial for Medicare patients as it enables the procedure to be reimbursed as a screening without co-insurance.
GW Modifier (Surgery Unrelated to Hospice Patient's Condition)
The GW modifier is employed in ASC claims when surgical procedures are performed on a patient under hospice care but are unrelated to the patient's terminal condition. This modifier helps ensure accurate billing and reimbursement for non-hospice-related surgeries.
PA Modifier (Wrong Body Part Surgery)
When a surgical procedure in an ASC involves an incorrect body part, the PA modifier is utilized to highlight this error. This ensures precise billing in such cases.
LT Modifier (Left Side) and RT Modifier (Right Side)
These modifiers specify whether a procedure was performed on the left (LT) or right (RT) side of the body. They enhance precision in documentation and billing.

Challenges with documentation in ASC billing

Increase in the number of AR days
Based on VMG Health data, Becker's ASC Review reports that Ambulatory Surgery Centers (ASCs) typically experience an average Accounts Receivable (A/R) turnover period of 32 days. It is a great challenge to maintain AR and requires expertise.
Surprise billing
Surprise billing is the highlighting concern faced by patients and healthcare providers. For this purpose, it is better to preauthorize the treatment.
Staying updated on coding changes
A paramount issue demanding meticulous attention from ASCs is the continuous monitoring and adaptation to changes in CPT and ICD-10 codes. An illustrative example of the magnitude of this challenge can be found in the practices of the American Medical Association. In January 2018, the AMA introduced a substantial overhaul, encompassing an impressive 170 new codes, the revision of 60 existing codes, and the removal of 82 codes from the coding system.
To deal with all the challenges faced by your ASC billing and coding, MedsIT Nexus is offering a comprehensive solution.

Unlock Seamless ASC Billing with MedsIT Nexus

We are introducing MedsIT Nexus, the cutting-edge solution for ASC billing. Elevate your revenue cycle management with our comprehensive platform designed exclusively for Ambulatory Surgery Centers. With its intuitive interface and robust features, MedsIT Nexus streamlines billing processes, ensuring accuracy and compliance at every step. Experience seamless claim submission, real-time tracking, and detailed reporting, all tailored to the unique needs of ASCs. Say goodbye to billing headaches and hello to optimized revenue. Choose MedsIT Nexus for ASC billing and take your financial operations to the next level.