Understanding ASC Pricing

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
November 22nd, 2017

ASCs (Ambulatory Surgical Centers) have a separate fee schedule with a base allowed amount that is adjusted for each state using Core Based Statistical Areas (CBSA). Under the ASC payment system, Medicare pays facilities for specific ASC covered surgical procedures, however, there are only certain types of procedures that are eligible for payment under an ASC payment. For this reason, some supply and procedure codes reflect ASC pricing while others do not. 

Some of the services included in an ACS payment are nursing services, technical personnel, patient use of the facility, some drugs and biologicals (when a separate payment is not made under OPPS),  supplies, dressings, splints, casts as well as administrative fees, blood, anaesthesia, and many other services and supplies. ASC's may also furnish services and be paid under Medicare part B for services that at not considered ASC. 

APC Status Indicator Codes 

When there is more than one CPT code reported with a status indicator, payment will be based on the weight of the indicator, the description next to the indicator explains how they will be paid.  For example, status indicator T indicates if there are multiple procedures reported for the same patient encounter they will be paid at a lower cost, this applies to any service with a status indicator of T. Any procedure(s) reported with an S indicator will be paid with full reimbursement, it does not matter how many procedures were done that reflects the S status indicator.    

For example services with status indicators of K,S,T,V and X are paid under ASC, other services/supplies are either not covered, paid separate from ASC payment or paid by another method.

The status indicators below are used with appropriate CPT® and supply codes.

A

Services Paid under Fee Schedule or Payment System other than OPPS (Non -APC payment system)

B  

Codes Not Recognized by OPPS when submitted on Outpatient Hospital Part B Bill Type (12x/13x)

C  

Inpatient Procedures, not paid under OPPS (Inpatient only list)

D  

Discontinued Codes

E1  

Non-Covered Service, not paid under OPPS

E2  

Items and Services for which pricing information and claims data are not available

F  

Corneal, CRNA and Hepatitis B

G  

Pass-Through Drugs and Biologicals

H

Pass-Through Device Categories

J1  

Hospital Part B services paid through a comprehensive APC

J2  

Hospital Part B Services That May Be Paid Through a Comprehensive APC

K  

Nonpass-Through Drugs and Nonimplantable Biologicals, Including Therapeutic Radiopharmaceuticals

L  

Influenza Vaccine; Pneumococcal Pneumonia Vaccine

M

Items and Services Not Billable to the Fiscal Intermediary/MAC

N  

Items and Services Packaged into APC Rates (Not paid -Considered incidental and is bundled with other APC payments)

P  

Partial Hospitalization

  Q1

STVX-Packaged Codes

  Q2

T-Packaged Codes

  Q3

Codes That May Be Paid Through a Composite APC

  Q4

Conditionally packaged laboratory tests

  R

Blood and Blood Products

  S

Significant Procedure, Not Discounted When Multiple (outpatient surgery, always paid full reimbursement)

  T

Significant Procedure, Multiple Reduction Applies (Payable by APC but subject to multiple proc discount) 

  U

Brachytherapy Sources

  V

Clinic or Emergency Department Visit (Outpatient E/M service)

  X

Ancillary Services

  Y

Non-Implantable Durable Medical Equipment

APC Payment Indicators

CMS uses defined “Payment Indicators” to identify each eligible covered service for ASC payment, as well as the payment methodology used for calculating payment amounts. 

Using defined Payment indicators assigned to ASC's allows us to see which services’ costs are packaged into the payment for other services and which surgical procedures are excluded from Medicare payment under the ASC payment schedule.

Payment indicators below are used with appropriate CPT® and supply codes.

A2

Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.

D5  

Deleted/discontinued code; no payment made.

F4  

Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable cost.

G2  

Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight.

H2

Brachytherapy source paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate.

H9  

Device-intensive procedure on ASC list in CY 2007; paid at an adjusted rate.

J7

OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC list; payment contractor-priced.

J8

Device-intensive procedure added to ASC list in CY 2008 or later; paid at an adjusted rate.

 K2

Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate.

K7

Unclassified drugs and biologicals; payment contractor-priced.

L1

Influenza vaccine; pneumococcal vaccine.   Packaged item/service; no separate payment made.  

L6

New Technology Intraocular Lens (NTIOL); special payment.

N1

Packaged service/item; no separate payment made.

P2

Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based on OPPS relative payment weight.

P3

Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based on MPFS non-facility PE RVUs.

  R2

Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS non-facility PE RVUs; payment based on OPPS relative payment weight.

  Z2

Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight.

  Z3

Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on MPFS non-facility PE RVUs.

 

Services that are integral to covered ASC procedures:

In addition, Medicare may make a separate payment for some ancillary services that are integral to a covered surgical procedure, such as:

Just like there are services that are covered there are also items and services that are not included in ASC payments or ancillary services.

See the items or services listed below for a better understanding of items or services not included in an ASC payment. 

Items or Services Not Included Who Receives Payment Where to Submit Bills
Physicians’ Services Physician Medicare Administrative Contractor (MAC)
Purchase or Rental of Non-Implantable Durable Medical Equipment (DME) to ASC Patients for Use in Their Homes DME supplier A supplier of DME must have a DME supplier number from the National Supplier Clearinghouse (NSC) and a separate National Provider Identifier (NPI) An ASC may not simultaneously be a DME supplier Durable Medical Equipment Medicare Administrative Contractor (DME MAC)
Non-Implantable Prosthetic Devices DME supplier A supplier of DME must have a DME supplier number from the NSC and a separate NPI An ASC may not simultaneously be a DME supplier DME MAC
Ambulance Services Certified ambulance supplier  MAC
Leg, Arm, Back, and Neck Braces DME supplier DME MAC
Artificial Legs, Arms, and Eyes DME supplier DME MAC
Services Furnished by Independent Laboratory Certified laboratory (ASC can receive laboratory certification and a Clinical Laboratory Improvement Amendments number) MAC
Facility Services for Surgical Procedures Excluded From the ASC List (listed in Addendum EE to the OPPS/ASC Final Rule with Comment Period) Not covered by Medicare Patient is liable

References:

Understanding ASC Pricing. (2017, November 22). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/asc-pricing-and-what-is-included-32519.html

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