There are about 35 million outpatient procedures conducted in the United States annually. This has led to a sudden boom of ambulatory surgical centers over the recent years. Recently, a significant number of outpatient procedures conducted globally have shifted from hospitals to free-standing ambulatory surgical facilities. As a result ASC’s have been flourishing as premier surgicenters that deliver quality care, improved patient convenience, and enhanced provider productivity -all at reduced costs per episode. The increasing focus on containment of healthcare costs and growing expenditure of Medicare on ASCs are driving the world-wide ambulatory surgical centre market. More recently, the Improvement, and Modernization Act (MMA) and the Outpatient Prospective Payment Policy (OPPS) in accordance with the Medicare Prescription Drug have led to the proliferation of ASC while bringing about radical changes in the outpatient payment policy.

However when it comes to claiming a reimbursement, even the most seasoned billers could break out in cold sweat with Medicare’s regulations, the variable nature of the payers and the challenge of keeping abreast with the latest updates. Therefore, when it comes to claiming a reimbursement, there are a few things we must be aware of before filing a claim for services rendered through an ASC.

So, let’s take a look at what billers must know about the ASC and its Billing System in order to hasten your chances of a swifter and more complete reimbursement:

The ASC Billing System

This is a new payment system that is primarily linked to the hospital outpatient prospective payment system (OPPS). The system involves payments for procedures using a set of comparable weights, a conversion factor (or base payment amount), and adjustments input prices based on locations. 20 % of the ASC amount is paid by the Beneficiaries.

The Criteria to Avail Medicare in an ASC

Medicare publishes a list of 3,500 approved surgical procedures that cover ancillary services on an annual basis. This list is updated quarterly, or as necessary. A hospital-run facility may for Medicare’s purposes be either a provider-based department of a hospital or an ASC. In order to avail Medicare, ASCs require participating-provider enter into an agreement with CMS to qualify for payments on the following criteria: 

  • The medical case must not be life threatening (for example, a heart transplant or reattachment of a severed limb)
  • The procedure cannot be performed in a physician’s office
  • It must be elective
  • The procedure performed could be an emergency but must not involve prolonged invasion of a body cavity, an incision of major blood vessels or result in a major blood loss

The Billing and Coding of ASC Fees

The ASC employs the method of clinical billing, using the CPT and HCPCS level codes. There are however some insurance carriers that allow an ASC to use ICD-10 procedure codes as part of its billing process similar to a hospital. Implants and device-intensive procedures would pay the ASC for the device which in turn would add the price of the device to the procedure code and submit it as one line item in the bill. By rule of thumb, ASCs are banned from basing their cost on the Medicare Physician Fee Schedule’s allowable code. As a result, Medicare now emphasizes that all ASC payments are to be filed electronically by claimers by utilizing the CMS-1500 form, with most other insurers using the UB92 form.

Medicare utilizes a modifier ‘SG’ to denote submissions charged, thereby indicating procedures that were carried out in an ASC. The modifier also helps other payers distinguish between the facility’s bill and that of a physician’s fee.

The wise thing to do before undertaking a procedure is to check with an insurer in prior to learn of their ASC billing requirements.

Read AlsoIncreasing Patient Responsibility Requires a Modern Medical Billing and Collection Approach

Common ASC Errors While Billing

The financial well-being of an ASC depends on the effectiveness of its Revenue Management Cycle. Any error in the Revenue Management Cycle can impact the bottom line of a facility negatively.

Errors to Look out For

  • Any mismatch in the procedure performed and the amount billed
  • Bills that include the phases in the surgery instead of the actual procedure.
  • Coding mistakes that generate bills for both the technique and the procedure used by the surgeon
  • Incomplete patient information
  • Unnecessary discounts or waivers that can seem compassionate but can be financial vampires


Given the complications associated with the reimbursement of claims and the errors encountered while billing, ASC’s of all sizes are now looking up to Billing and Coding software to minimize errors. Likewise, a vast majority of ASCs are increasingly relying on specialized offshore teams to improve the overall efficiency of the revenue cycle. The best, therefore, lies in embracing a blended approach. Medbilling Experts specializes in leveraging its experience and the latest software suites to provide efficient ASC billing services. To know more contact us now.



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