Surgical Billers

BILLING FORMATS FOR ASC SERVICES

The preparation of a billing document for an ASC is variable. As part of the contracting process that occurs between a payer and an ASC, the format for the transactions will be clarified. The standard industry format for Medicare and Medicaid is for services to be reported on a CMS-1500 form. It is imperative that the modifier SG be appended to every CPT code in order to inform the carrier that the claim is actually billing for a surgical facility as opposed to the professional component of care.

On the commercial insurance side, most carriers do not accept the CMS-1500 form. The more common method of reporting services to a commercial carrier is with a UB-92 form. This format requires similar demographics and also the precise CPT code and its matched ICD-9-CM code. Additionally, UB-92 formats use revenue codes. The revenue code that must be reported for an ambulatory surgery center is 490. This informs the carrier that the bill represents facility billing.

DIFFERENCES BETWEEN PROFESSIONAL BILLING & FACILITY BILLING

One of the most fundamental differences between billing for professional services and billing for ambulatory surgery center services is the concept of the global surgical package. The global package applies to the professional component of a surgical service that is performed when using a surgical CPT code. On the professional side, this typically encompasses a 90-day follow-up. In the ASC billing methodology, no such surgical package exists. Therefore, every time a patient enters the operating room, this represents a unique and separate encounter and has no historical relationship to previous encounters. This is a very important difference and
very often leads to the need for qualifying modifiers. Those modifiers listed above tend to clarify a situation such as return to the operating room on the same day, or return to the operating room by another doctor on a different date.

ASC BILLING FOR NON-COVERED SERVICES

There is considerable variation in the industry as to how ASC billing is performed for Medicare non-covered services. In general, most billing departments will assign an ASC grouper “0” to designate that a certain code or code sets are not on the ASC list, which automatically puts them in a self-pay status. The facility knows a bill will not be sent out to a third party carrier and that it will be the patient's responsibility. This methodology is appropriate for procedures that are not on the ASC list and do not have a practice expense built into the CPT code on the professional side. In such cases, Medicare has increased the RVU to include the practice expense and so the procedure cannot be performed in an ASC. Therefore, it is inappropriate to additionally bill the patient a facility fee. However, services that fall totally outside of the
coverage of Medicare and the ASC list can appropriately be billed at a usual and customary rate.

Surgical Billers takes all the guess work out of submitting your ASC claims. We will provide you with clear guidelines on billable and nonbillable surgical procedures, we know the revenue codes and modifiers, when to submit claims on HCFA's and when they must be submitted on UB92's. We are Ambulatory Surgery Center claim submission experts! Contact us today about billing for your ASC.