Type of Service (TOS) Indicator F: Ambulatory Surgical Center (Facility Usage for Surgical Services)

Special Considerations/Exceptions
Surgical services billed for dates of service through December 31, 2007, containing the ASC facility service modifier SG must be reported as TOS F. Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services. ASC providers should discontinue applying the SG modifier on ASC facility claims. The indicator 'F' does not appear in the TOS table because its use depends upon claims submitted with POS 24 (ASC Facility) from an ASC (specialty 49). This became effective for dates of service January 1, 2008 and after.

HCPCS codes

CodeDescription
C1748  Endoscope, single-use (i.e. disposable), upper gi, imaging/illumination device (insertable)  
C1849  Skin substitute, synthetic, resorbable, per square centimeter  
C9033  Injection, fosnetupitant 235 mg and palonosetron 0.25 mg  
C9034  Injection, dexamethasone 9%, intraocular, 1 mcg  
C9040  Injection, fremanezumab-vfrm, 1mg  
C9041  Injection, coagulation factor xa (recombinant), inactivated (andexxa), 10 mg  
C9042  Injection, bendamustine hcl (belrapzo), 1 mg  
C9043  Injection, levoleucovorin, 1 mg  
C9044  Injection, cemiplimab-rwlc, 1 mg  
C9045  Injection, moxetumomab pasudotox-tdfk, 0.01 mg  
C9046  Cocaine hydrochloride nasal solution for topical administration, 1 mg  
C9047  Injection, caplacizumab-yhdp, 1 mg  
C9048  Dexamethasone, lacrimal ophthalmic insert, 0.1 mg  
C9049  Injection, tagraxofusp-erzs, 10 mcg  
C9050  Injection, emapalumab-lzsg, 1 mg  
C9051  Injection, omadacycline, 1 mg  
C9052  Injection, ravulizumab-cwvz, 10 mg  
C9053  Injection, crizanlizumab-tmca, 1 mg  
C9055  Injection, brexanolone, 1mg  
C9056  Injection, givosiran, 0.5 mg  
C9057  Injection, cetirizine hydrochloride, 1 mg  
C9058  Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo) 0.5 mg  
C9059  Injection, meloxicam, 1 mg  
C9060  Fluoroestradiol f18, diagnostic, 1 mci  
C9061  Injection, teprotumumab-trbw, 10 mg  
C9062  Injection, daratumumab 10 mg and hyaluronidase-fihj  
C9063  Injection, eptinezumab-jjmr, 1 mg  
C9064  Mitomycin pyelocalyceal instillation, 1 mg  
C9065  Injection, romidepsin, non-lypohilized (e.g. liquid), 1mg  
C9066  Injection, sacituzumab govitecan-hziy, 10 mg  
C9067  Gallium ga-68, dotatoc, diagnostic, 0.01 mci  
C9122  Mometasone furoate sinus implant, 10 micrograms (sinuva)  
C9141  Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl (jivi), 1 i.u.  
C9462  Injection, delafloxacin, 1 mg  
C9463  Injection, aprepitant, 1 mg  
C9464  Injection, rolapitant, 0.5 mg  
C9465  Hyaluronan or derivative, durolane, for intra-articular injection, per dose  
C9466  Injection, benralizumab, 1 mg  
C9467  Injection, rituximab and hyaluronidase, 10 mg  
C9468  Injection, factor ix (antihemophilic factor, recombinant), glycopegylated, rebinyn, 1 i.u.  
C9469  Injection, triamcinolone acetonide, preservative-free, extended-release, microsphere formulation, 1 mg  
C9489  Injection, nusinersen, 0.1 mg  
C9490  Injection, bezlotoxumab, 10 mg  
C9491  Injection, avelumab, 10 mg  
C9492  Injection, durvalumab, 10 mg  
C9493  Injection, edaravone, 1 mg  
C9494  Injection, ocrelizumab, 1 mg  
C9745  Nasal endoscopy, surgical; balloon dilation of eustachian tube  
C9746  Transperineal implantation of permanent adjustable balloon continence device, with cystourethroscopy, when performed and/or fluoroscopy, when performed  
C9747  Ablation of prostate, transrectal, high intensity focused ultrasound (hifu), including imaging guidance  
C9749  Repair of nasal vestibular lateral wall stenosis with implant(s)  
C9750  Insertion or removal and replacement of intracardiac ischemia monitoring system including imaging supervision and interpretation and peri-operative interrogation and programming; complete system (includes device and electrode)  
C9761  Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with lithotripsy (ureteral catheterization is included) and vacuum aspiration of the kidney, collecting system and urethra if applicable  
C9768  Endoscopic ultrasound-guided direct measurement of hepatic portosystemic pressure gradient by any method (list separately in addition to code for primary procedure)  
C9769  Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts  
G0260  Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography  
Q1001  NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 1 AS DEFINED IN FEDERAL REGISTER NOTICE, VOL 65, DATED MAY 3, 2000  
Q1002  NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 2 AS DEFINED IN FEDERAL REGISTER NOTICE, VOL 65, DATED MAY 3, 2000  
Q1003  New technology intraocular lens category 3 (reduced spherical aberration)  
Q1004  New technology intraocular lens category 4 as defined in federal register notice  
Q1005  New technology intraocular lens category 5 as defined in federal register notice  
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