Sunday, July 10, 2016

Billing/coding guidelines for ASC billing

Bundled services

• FCHP only reimburses the more “intensive” CPT code when a procedure is considered to be part of a more comprehensive procedure or a single more comprehensive CPT code more accurately describes a group of procedures.

Multiple surgical services

• When multiple surgical services are performed at the same session, the procedure with the highest intensity is reimbursed at full payment; when allowed, others are reimbursed at 50% of the contracted fee or pursuant to contractual agreement.

• No additional payment is made beyond five services.

Attempted surgical procedure

• FCHP will review supporting documentation and will reimburse at a reduced rate of the contractual fee schedule based on the level of services provided when modifiers -73 or -74 are affixed to indicate discontinued outpatient procedures; the appropriate modifier must be appended and supporting documentation should be submitted with the claim.


The following is a list of modifiers often used in surgical billing for both ASC and Non-ASC:

• -25 Significant separately identifiable service on the same day as another E&M

• -50 Bilateral procedure

• -51 Multiple procedures

• -52 Reduced services

• -58 Staged or related procedure or service by same physician on same day

• -59 Distinct procedural service

• -73 Discontinued outpatient procedure prior to administration of anesthesia

• -74 Discontinued outpatient procedure after anesthesia administration

• -76 Repeat procedure or service by same physician

• -77 Repeat procedure by another physician

• -78 Unplanned return to the operating/procedure room for a related procedure on the same day

• -79 Unrelated procedure or service by the same physician on the same day

• -AS Services provided by PA, NP or CNS

• -FB Item provided without cost to provider, supplier or practitioner or full credit received for replacement device (e.g.: covered under warranty, replaced due to defect, free samples)

• -FC Partial Credit Received for Replaced Device


Outpatient Surgical Services (Non-ASC) provide surgical services that typically do not require an overnight stay. These services may include pain management and certain diagnostic services that can be performed in an outpatient setting. These services are billed utilizing CPT surgical codes. Facilities are reimbursed subject to all FCHP outpatient billing and payment, bundling and global package rules. Additionally, outpatient surgical services are defined as major or minor. Ambulatory Surgical Centers (ASCs) also specialize in providing surgery, pain management and certain diagnostic services in an outpatient setting. These services are also billed utilizing CPT surgical codes.

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