Billing the Facility Fee for Your ASC

To bill a facility fee as an ambulatory surgical center (ASC) (place of service — 22), the entity must meet the requirements cited in the State Operations Manual, Appendix L - Guidance for Surveyors: Ambulatory Surgical Centers, (Rev. 56, 12-30-09) Transmittals for Appendix L, Part I - Ambulatory Surgical Center Survey Protocol, summarized as follows:

The ASC must be a distinct entity. An ASC satisfies the criterion of being a “distinct” entity when it is wholly separate and clearly distinguishable from any other health-care facility or office-based physician practice. The ASC is not required to be housed in a separate building from other health-care facilities or physician practices, but, in accordance with National Fire Protection Association life safety code requirements (incorporated by cross reference at §416.44(b)), it must be separated from other facilities or operations within the same building by walls with at least a one-hour separation. If there are state licensure requirements for more permanent separations, the ASC must comply with the more stringent requirement.

An ASC does not have to be completely separate and distinct physically from another entity if, and only if, it is temporally distinct. In other words, the same physical premises may be used by the ASC and other entities, so long as they are separated in their usage by time. For example:

Adjacent physician office: some ASCs may be adjacent to the office(s) of the physicians who practice in the ASC. Where permitted under state law, CMS permits certain common, non-clinical spaces, such as a reception area, waiting room or restrooms to be shared between an ASC and another entity, as long as they are never used by more than one of the entities at any given time and as long as this practice does not conflict with state licensure or other state law requirements. In other words, if a physician owns an ASC that is located adjacent to the physician’s office, the physician’s office may, for example, use the same waiting area, as long as the physician’s office is closed while the ASC is open and vice versa. The common space may not be used during concurrent or overlapping hours of operation of the ASC and the physician office. Furthermore, care must be taken when such an arrangement is in use to ensure that the ASC’s medical and administrative records are physically separate. During the hours that the ASC is closed, its records must be secure and not accessible by non-ASC personnel.

It is not permissible for an ASC during its hours of operation to “rent out” or otherwise make available an operating room or procedure room, or other clinical space, to another provider or supplier, including a physician with an adjacent office.

Facilities with diagnostic imaging and surgery capability: some facilities are equipped to perform both ambulatory surgeries and diagnostic imaging. However, Medicare regulations do not recognize a non-hospital institutional health-care entity that performs both types of services, and actually requires an ASC to operate exclusively for the purpose of providing surgical services.

The Medicare independent diagnostic testing facility (IDTF) payment regulations at 42 CFR 410.33(g) prohibit IDTFs that are not hospital-based or mobile from sharing a practice location with another Medicare-enrolled individual or organization. As a result, ASCs may not share space, even when temporally separated, with a Medicare-participating IDTF.

NOTE: Certain radiology services integral to surgical procedures may be provided when the facility is operating as an ASC.

For billing purposes, the ASC should be identified by Medicare and other payors as a separate entity with its own provider number. The Medicare claim for the facility fee is billed on the CMS 1500. Some private payors require the facility fee to be billed on a UB form.

The current procedural terminology and health-care common procedure coding system procedure codes and the ICD-9 diagnosis codes used for billing the facility fee should mirror the codes and modifiers used to bill the physician fee. Medicare no longer requires the use of the SG modifier for the facility fee. The one distinction between the billing for the physician fee and the facility fee is for a service that is not completed or is aborted. For the physician fee, the modifiers that are used are the 53 (when a procedure is discontinued due to “an extenuating circumstance or one that threatens the well-being of the patient,”) or 52 (when a physician elects to partially reduce or eliminate a procedure) modifiers. For the facility fee, the modifiers that are used are the 73 (discontinued procedure prior to the administration of anesthesia) and 74 (discontinued procedure after the administration of anesthesia).

Always bill your full fee for each procedure code and let the payor determine the allowed amount. Payment from Medicare will be 100 percent of the ASC fee-schedule amount for the highest valued procedure and 50 percent for each additional procedure. The beneficiary co-insurance for ASC-covered surgical procedures and covered ancillary services is 20 percent of the Medicare ASC payment after the yearly Part B deduct­ible has been met, with the exception of a beneficiary co-insurance of 25 percent of the ASC payment for screening colonoscopies and screening flexible sigmoidoscopies.

Included in the payment for the facility fee are the following:

  • Nursing services, services furnished by technical personnel and other related services.
  • Patient use of ASC facilities.
  • Drugs and biologicals for which separate payment is not made under the outpatient prospective payment system (OPPS).
  • Surgical dressings, supplies and equipment.
  • Administrative, recordkeeping and housekeeping items and services.
  • Blood, blood plasma and platelets, with the exception of those to which the blood deductible applies.
  • Materials for anesthesia.
  • Radiology services for which payment is packaged under the OPPS.

The payment rate for the Medicare facility fee for ASCs in calendar year (CY) 2010 consists of 75 percent of the CY 2010 revised ASC rate plus 25 percent of the CY 2007 ASC rate.

Read additional information about ASCs and the ASC payment system.