ASC Billing Basics

ASC billing (Ambulatory Surgery Center) is completely different than any other type of billing. Learn about the special rules and guidelines here...

Before we begin to examine the special needs of an Ambulatory Surgery Center biller, it's important to understand what an Ambulatory Surgery Center is.

An Ambulatory Surgery Center is a facility that, very simply, specializes in outpatient procedures.

Some of these procedures are surgeries, whereas others are pain management or diagnostic procedures (e.g. colonoscopies). Generally, the procedures done at an ASC are more extensive than those done at the typical provider's office, but are not so involved that they require a hospital stay.

In order for a facility to bill for ASC services, they first have to qualify by meeting certain requirements. They also have to enter into a written agreement with CMS.

For ASC services to be paid, the service must be determined to be medically necessary. However, the medically necessary procedure doesn't have to be performed at an ASC. This decision is up to both the provider and the patient.

Legal definition of an ASC

ASC billing is different to normal medical billing

According to Medicare, a facility must meet certain criteria to be qualified as an Ambulatory Surgery Center:

  1. An ASC is an entity which exists separate from any other facility, which operates for the sole purpose of providing outpatient surgical procedures to patients.

    This is different than hospitals. Hospitals provide care for any reason, whether outpatient, inpatient, or emergent.

    It's also different than physician's offices, which may perform only minor surgical procedures, such as removal of foreign bodies or drainage or abscesses.

  2. The ASC must enter into an agreement with CMS. This agreement shows that the ASC is willing to abide by CMS rules and regulations, and provide specific types of services to their patients.

  3. An ASC can either be independent of any other facility, or can be affiliated with a larger hospital or facility. If the ASC is affiliated with a hospital, it must meet additional criteria to be reimbursed at the ASC pay rates.

Lastly, each and every ASC that bills Medicare must be certified through a state-specific agency.

This certification, along with all of the above requirements, makes sure the ASC that they will receive the highest rate of reimbursement. It also assures the patient that they're receiving care from a qualified, certified agency.

ASC is NOT a medical specialty

ASC billing isn't a medical specialty!

Ambulatory Service Center billing isn't centered on a specific medical specialty. As such it doesn't revolve around specific types of services, procedures, or diagnoses.

This means that ASC billing is NOT like medical specialty billing, where you have to learn a few highly specialized guidelines or rules to make sure you are reimbursed for your services.

ASC billing is completely different than either regular physician billing or facility billing!

But this doesn't mean that to be an ASC biller you have to learn an entirely new set of codes or billing techniques. ASC billing does use all of the same codes, billing techniques, and many of the same billing and coding guidelines by the entire medical industry.

What makes ASC billing so different is that it's like billing hospital codes through a CMS-1500 claim form, which is not a facility claim form.

Whereas hospitals use the UB-04 claim form, doctor's offices and other outpatient healthcare providers use the CMS-1500 form. In this case, ASCs are no different, and use the typical provider form.

An easy way to think of it is like this: Ambulatory Service Centers are like having every medical specialty all rolled into one.

You can go there for a cast, a colonoscopy, or for surgical dressings. But, you can't go there for a sick visit and get a diagnosis from a primary care physician.

ASCs only provide services to those who already have a diagnosis from a primary care physician, and who need medically necessary procedures performed.

So, what kinds of services are covered?

What's covered depends on the type of facility.

Much of what is or isn't covered under ASC guidelines depends on the ASC facility status.

If the facility is fully credentialed, with every certified aspect of an ASC, they'll obviously be able to perform many more procedures than if they were minimally qualified to perform certain procedures.

There are also some services that can be provided by an ASC which are considered covered, even though they're not considered ASC services:

  • Ambulance Services
  • Artificial Legs, Arm, and Eyes
  • Implantable Durable Medical Equipment
  • Non-Implantable Durable Medical Equipment
  • Leg, Arm, Back and Neck Braces
  • Physician's Services
  • Prosthetic Devices
  • Independent Laboratory Services

Is an ASC billing career right for you?

With all these crazy guidelines and determinations, you may be wondering if ASC billing and coding is the right field for you.

But if you like learning about the newest surgical, diagnostic, and medical procedures, as well as learning the intricacies of a complex billing system, ASC billing may be the perfect choice.

Because ASC facilities see many outpatient procedures on a daily basis, you'll never get tired of the same old run-of-the-mill ear infection after ear infection. The many different procedures that ASC providers perform are constantly changing.

Furthermore, if you're a certified biller or coder, you'll have constant opportunities for learning the newest things about your ASC procedures, keeping you on your toes, and your providers on the cutting edge.

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