Ambulatory Surgical Center

Billing procedures for ambulatory surgical centers (ASCs) depend on the place of treatment and the type of facility. This document describes HMSA's claims processing requirements for services performed in both freestanding and hospital-based ASCs.

Introduction

Choosing the correct billing form

The appropriate billing form depends on the type of facility. Hospital-based ASCs use the UB-04 form, while freestanding ASCs generally use the CMS 1500 form.

Payment policy

Payment for ASC services is HMSA's eligible charge less any member copayment and/or deductible.

The eligible charge for a covered service is a single, all-inclusive rate based on the highest established Outpatient Surgical Procedure-Related Group (PRG) category of the procedure code(s) billed. This eligible charge includes payment for services that are an integral part of the procedure being performed, such as the use of outpatient surgery facilities, supplies, medications, services of facility-employed nurse anesthetists and ancillary services (laboratory, X-ray, diagnostic tests).

Note: HMSA's eligible charge for ASC services does not include payment for physician services, routine preoperative laboratory services, take-home medications or certain prosthetic devices.

Outpatient Surgical Procedure-Related Groups

Outpatient Surgical Procedure-Related Groups (PRGs) refer to different groupings of services performed in ASCs. Each group includes surgeries that are similar in terms of facility usage, complexity and charge. A listing of Outpatient Surgical Procedure-Related Groups is included as an exhibit to the participating provider agreement between HMSA and the ASC.

Modifying the Outpatient Surgical Procedure-Related Groups

HMSA occasionally makes modifications to the Outpatient Surgical Procedure-Related Groups. Participating ASCs may also request modifications by submitting a written request to HMSA within 60 days of the date the center wishes to begin rendering the procedure as a covered service. The request should include a description of the procedure to be performed and an indication of the proposed charge.

Requests to modify Outpatient Surgical Procedure-Related Groups should be mailed or faxed directly to the facility's Field Representative. HMSA will evaluate the request and respond within 45 days of the date the request was received.

Coding

Using the correct combination of codes is the key to minimizing delays in claims processing. Revenue codes and procedure codes must reflect the diagnoses and services rendered. Subcategories for the revenue code are included in the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual.

Commonly billed services (hospital-based ASCs)

The table below depicts commonly billed services and acceptable code ranges that correspond to HMSA's claims processing requirements for hospital-based ASCs. The table represents a range of possible combinations and should not be viewed as comprehensive.

Hospital-based ASC

Notes:

If multiple procedures are performed in the same session, additional procedures may be billed on subsequent lines (also with -SG modifier).

If the correct provider number is not used when billing for a freestanding ASC, the claim will be denied.

Billing Tips

Diagnosis coding for principal diagnosis

For more information on the principal diagnosis code (form locator 67 on the UB-04 claim form), refer to Diagnosis Coding for Principal Diagnosis.

Type of Bill

Hospital-based ASCs should bill with 083X type of bill. When it is necessary to resubmit claims, the type of bill must accurately reflect the modifications made to the claim. Adhering to the guidelines in the UB-04 manual will expedite claims processing.

Late charges

HMSA does not accept late charges for ASC claims. Instead, please submit a replacement claim using code 837. For more information, refer to Replacements in the Common Claims Filing Error.

Bilateral Services

Entering "1" in form locator 46 of the UB-04 usually indicates a singular service. However, the number "1" also can indicate a bilateral service when the CPT code defines the service as bilateral. If the code is not defined as such, the provider may indicate a bilateral service by entering "1" on two separate service lines. In these instances, append modifier -RT to the CPT code on one line and modifier -LT to the CPT code on the other line.

Freestanding ASCs

Freestanding ASCs generally use the CMS 1500 form for billing purposes. Adhering to the CMS 1500 guidelines below will expedite claims processing, also refer to CMS 1500 Claim Form - General Instruction.

Precertification

Enter the nine-digit precertification number, when applicable, in block 23.

Place of Service

Enter "24" in block 24B to indicate an ASC setting.

SG Modifier

The -SG modifier should follow the procedure code in block 24D of the CMS 1500 claim form, which indicates a surgical code in an ASC setting.
Do not attach the -SG modifier to supplies or services such as implants or radiology services, and tax or reporting codes. Use the TC modifier when billing for the technical component of radiology services.

Multiple Surgical Procedures

If multiple procedures are performed in the same session, additional procedures may be billed on subsequent lines, also with the -SG modifier. However, the charge for additional procedures listed in bock 24F should be $0.00.

Payment for Supplies

Charges for miscellaneous supplies are considered part of the Procedure-Related Group (PRG) and are not paid separately. For providers submitting claims on the UB-04 claim form, the table below shows some of the nonspecific revenue codes for supplies, durable medical equipment, prosthetic devices, and implants and indicates which revenue code should be used for each type of supply. Please list the CPT or HCPCS code in form locator 44 of the UB-04 claim form along with the revenue code listed in form locator 42.

Payment for Supplies

Free-standing ASCs may bill using the CMS 1500 claim form. When submitting claims using the CMS 1500, bill the appropriate CPT or HCPCS codes for services, supplies and other items. It is not necessary to use revenue codes.

Place of Treatment Program

Many inpatient procedures may be safely and effectively performed in an ASC or in a physician's office without compromising the quality of patient care. HMSA's Place of Treatment program lists such procedures.

Affected Plans

The Place of Treatment program applies to HMSA's Preferred Provider Plans, Health Plan Hawaii and HMSA's other HMO plans, and HMSA's QUEST Integration Plan. The program does not apply to HMSA's Medicare-based plans such as HMSA Akamai Advantage®, which follow the medical policies of Medicare.

Medical Review

HMSA's medical directors review utilization data to determine the recommended places of treatment. Specialty societies and participating physicians on HMSA's various physician advisory committees also provide input.

Precertification

When a physician selects a more acute setting than the recommended place of treatment, the physician must request precertification from HMSA's Pre-authorization Unit. The facility should always verify with the physician that precertification has been obtained.

If the physician indicates that precertification is pending, the facility may call HMSA's Pre-authorization Unit prior to the date of service. HMSA's Pre-authorization Unit can be reached at 948-6464 on Oahu or 1 (800) 344-6122 from the Neighbor Islands, from 8 a.m. to 4 p.m., Monday through Friday. For more information, refer to Precertification - Medical.

Payment Implications

The physician is responsible for obtaining precertification. If the physician does not request precertification but the service is still rendered, HMSA will not pay the facility charges. The member may be billed for the noncovered charges only if the member signed a waiver accepting financial responsibility prior to the procedure. (The Agreement of Financial Responsibility - Medical form may be used for this purpose.) Please be sure that HMSA members are fully apprised of their financial responsibility in this situation.

If the physician's request for precertification is denied, the member is responsible for the denied charges shown on the Report to Provider (RTP).

Revision History