What claim form should use for ASC services ?

Claims Information

Freestanding ASC claims must be submitted to TMHP in an approved electronic claims format or on a CMS-1500 paper claim form. Providers must purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply them. Information about the performing surgeon must be supplied in Block 17 of the CMS-1500 claim form for the claim to be processed. Hospital-based ASCs file a UB-04 CMS-1450. When completing a CMS-1500 claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. To bill for nurse anesthetists’ services, an ASC must enroll as a nurse anesthetist group provider and indicate the CRNA performing provider identifier on claims for those services.


National Drug Codes (NDC)

ASCs must submit an NDC for professional or outpatient electronic and paper claims submitted with physicianadministered prescription drug procedure codes. Procedure codes in the A series do not require an NDC.

N4 must be entered before the NDC on claims. The NDC is an 11-digit number on the package or container from  hich the medication is administered. The unit of measurement codes for all three forms are:

• F2–International unit
• GR–Gram
• ML–Milliliter
• UN–Unit

Unit quantities must also be provided on the claim. The NDC information must be submitted on the CMS-1500 claim form as indicated below:

                  Block No.                Description           Guidelines

                   24A                            Dates of services                      In the shaded area, enter the NDC qualifier of N4 and the 11-digit NDC number (number onthe package or container from which the medication was administered).Do not enter hyphens or spaces within this number. Example: N400409231231
       
24D Procedures,services, or supplies In the shaded area, enter a 1-through 12-digit NDC quantity of unit. A decimal point must be used for fractions of a unit.

24G Days or units In the shaded area, enter the NDC unit of measurement code