Understanding ASC Pricing

Sep 24th, 2026

Medicare uses a separate payment system when certain surgical services are provided in an Ambulatory Surgical Center (ASC). This system determines a rate for facility services based on Ambulatory Payment Classifications (APCs), similar to the Hospital Outpatient Prospective Payment System (OPPS), but there are differences.

Note: In 2019, CMS implemented changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS including the ASC payment system.

Only certain services are included in this payment model (e.g., nursing, recovery care, some drugs and biologicals [when a separate payment is not allowed under OPPS]). Physician services are reimbursed separately under the physician fee schedule. If a CPT or HCPCS code is NOT assigned to an APC group there will NOT be ASC pricing.

Note that covered services and components of the APC system are regularly updated to take into account changes in medical practice, changes in technology, and the addition of new services, new cost data, and other relevant information and factors. This can include revisions to the following:

• Groups
• Relative payment weights
• Geographic wage differences
• Conversion factors

TIP: Comprehensive information about this payment model can be found in the Medicare Claims Process Manual, Chapter 14. This document includes definitions, policies, and processes related to submitting a claim for procedures performed in an ASC.

Essential Elements of the ASC Pricer Program

The following are some of the essential components and the role they play in determining pricing:

• APCs: Each procedure approved for ASCs is assigned to an Ambulatory Payment Classification (APC) group, with all services within that APC receiving the same payment rate.
• Conversion Factor: A base payment amount (service portion) is multiplied by a dollar amount (conversion factor) which is then multiplied by the relative payment weights and adjusted for geographic wage differences (wage index) to determine the final payment.
• Indicators: APC Status indicators and ASC Payment indicators govern coverage and payments particularly when there is more than one code reported for the same encounter.

TIP: MedPac is the agency that advises Congress on Medicare payment and policy issues. They have published a helpful document about Ambulatory Surgical Center payments. If you have outstanding questions, please refer to their guide.

Where Does FindACode.com Get Their Ambulatory Surgical Center (ASC) Pricing?

We use the official ASC payment data files as the starting point for all our calculations. The ASC payment rates are a complicated formula which begins with the OPPS and APC payment rates which are further adjusted as explained above. Our calculations are based on the formula and published data files as obtained from CMS. We simplify the process for our customers through our ASC Payment Calculator.

Additional Payments Beyond ASC

Most ancillary items and services are considered inclusive (bundled) with the primary procedure; however, certain items and services may be billed separately such as:

• Corneal tissue acquisition
• Brachytherapy sources
• Certain radiology services, and
• Drugs that have OPPS pass-through status or per day costs exceeding a set amount (i.e., $140 for 2025).