ASC facility fee inclusive services and non inclusive services

Most covered Pain Management procedures fall into groups one or two. Some pain procedures are not on Medicare’s payment list for ASC facility reimbursement.  These procedures then fall under Medicare’s site of service differential rule, meaning professional fees are paid at the higher “office” site of service differential.  The place of service on the physician’s bill is still ASC -24.  It is important to monitor the explanation of benefits for correct site of service payment on these claims. 

Since a patient cannot be billed for facility fees from procedures not on the approved list, an ASC’s only advantage from supporting such “off list” cases may be to charge non-owner physicians rent for use of the ASC


These Medicare facility fees include:

    Use of the facility
    Nursing and technician services
    Drugs
    Biologicals
    Surgical dressings
    Materials for anesthesia
    Splints, casts and equipment directly related to the provision of the procedure
    Administrative, record-keeping and housekeeping items and services

In addition to facility fees in the ASC setting, the following are paid separately:

    Physician services (Professional fees)
    Laboratory expenses (Must be CLIA certified to perform lab tests or CLIA waived to perform minor labs such as glucose or pregnancy testing)
    X-Rays
    Diagnostic procedures other than those directly related to the surgical procedure
    Prosthetic devices
    Leg, arm, back and neck braces
    Artificial limbs
    DME for use in the patients home (typically not applicable in pain management) Implantables such as neuorstimulators and drug infusion pumps are paid by the Part B carrier-not the DME carrier).