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July/August 2005

Savvy Coder: Coding & Reimbursement

Test Your Billing Knowledge: Take the ASC Challenge
By Nancy Faires, OCS, John Haley, MD, Evelyn Kelly, OCS, F. Hampton Roy, MD,
Sue Vicchrilli, COT, OCS, and Trexler M. Topping, MD

This month we cover some of the core information that you’ll need when billing for ASC services. Next month, we’ll describe the site-of-service differential and what to do when the ASC’s claims differ from those of the surgeon. And don’t forget that an updated ASC list went into effect on July 5 (see June's Savvy Coder at

What the Facility Fee Covers
The following items and services are included in the ASC facility fee:

  • Use of ASC facilities, which includes the operating and recovery rooms and patient preparation areas.
  • Administrative, record keeping and housekeeping items and services.
  • Anesthesia supplies and materials.
  • Drugs.
  • Surgical dressings, surgical trays, supplies, silicone oil.
  • Intraocular lenses. (An additional payment is made for the latest presbyopia-correcting IOLs. See page 13 for more information.)

However, corneal tissue (V2485) and gold weights (L8610) are not included. They are separately billable by the ASC.

If a Procedure Is Terminated
Before anesthesia.
Partial payment of the facility rate will be made if a medical condition arises that causes the procedure to be terminated prior to the administration of anesthesia. (Use modifier –73, discontinued outpatient hospital/ ASC procedure prior to administration of anesthesia.) The reasoning is that, although supplies and resources are expended, they are not consumed to the same extent had anesthesia been fully induced and the surgery completed.

After anesthesia. Full payment of the facility rate will be made if a medical complication arises that causes the procedure to be terminated after the anesthesia has been given. (Use modifier –74, discontinued outpatient hospital/ ASC procedure after administration of anesthesia.) This is because the resources of the facility are consumed in essentially the same manner and to the same extent as they would have been had the surgery been completed.

Documentation. Your documentation should include the CPT code for the anticipated surgery appended by modifier –73 or –74; reason for the termination of the surgery; services and supplies that were actually performed and provided; and time spent in each stage (pre-, in- and postoperative).

Test Your ASC IQ
1. ASC-covered procedures are those that generally don’t exceed ___ minutes, don’t require more than ___ hours of convalescent time and do/don’t require extended care as a result of the procedure.

2. Place of service (POS) for ASC claims and physician claims should be documented as ___.

3. ASC facility claims are processed as assigned/nonassigned.

4. Physician services provided in an ASC may be submitted as assigned/ nonassigned.

5. Noncovered ASC services will be denied. An Advance Beneficiary Notice should/shouldn’t be used.

6. ASC procedures must be reported with modifier ___.

7. Many non-Medicare payers require form ___; not form HCFA 1500.

8. All the general coverage rules regarding the medical necessity of a given procedure for a given patient do/don’t apply to ASC services in the same manner as all other covered services.

9. Correct Coding Initiative (CCI) edits do/don’t apply to ASC facility services.

Answers. 1) 90; four; don’t 2) 24 3) Assigned 4) Either assigned (participating) or nonassigned (nonparticipating) 5) Shouldn’t 6) –SG 7) UB92 8) Do 9) Do