Pricing for ASC’s and APC’s

August 27th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Categories:   Billing   Practice Management   Reimbursement   Accounts Receivable|Payments   Denials & Denial Management   Compliance  
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ASC's

For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that Medicare pays for facility services furnished in connection with a covered procedure. Payment under the ASC system is like the OPPS payment system suing a set of relative weights, a conversion factor and adjustments for location. For more detailed information about ASC Fee schedule information visit the Medicare Learning Network “Ambulatory Surgical Center Fee Schedule”.

To bill for a service in an ASC setting the code must be an approved ASC Code, to avoid denials be sure to view covered and non-covered codes in Find-A-Code under “Code Sets”on the ASC Resource page.

Ambulatory Surgical Center Resources

Visit the resource center for ASC Ambulatory Surgical Centers for tools showing covered or non-covered procedures as well as The ASC Homepage offers tools for covered surgical procedurescovered ancillary services as well as excluded surgical procedures.

ASC Payment Calculator

There are several tools commonly used to project pricing and are available to Find-A-Code subscribers. Another tool to assist in projecting fees in the ASC setting use the ASC Calculator

Price a claim for ASC using the ASC Payment calculator. The calculator Is used to calculate payments from the Outpatient Prospective Payment System (OPPS) fee schedule for Ambulatory Surgical Centers, use modifiers and number of units to calculate ASC services according to geographic location.

Search for Codes with a payment indicator using List-A-Code download to a CSV file or view them online.

TIP: A common question often asked is “How do I know what is covered as an ancillary service?”

Using the information provided on the HAC home page you can quickly find a list of all covered ancillary services.

ASC Payment Indicator Codes (PI)

The payment indicator is often not considered yet is an important part of the code and will identify how a code should be used for processing payments. To view codes payment indicator, look under Additional Code information on the selected code.

ASC payment group determines the amount that Medicare pays for facility services furnished in connection with a covered procedure.

There are constant changes with payment indicators, these are usually changed quarterly, and some may be retroactive, Keep an eye on your codes to validate codes or changes.

Example:

  • L1- Influenza vaccine; pneumococcal vaccine.   Packaged item/service; no separate payment made.  

  • N1- Packaged service/item; no separate payment made

APC's

Ambulatory Payment Classifications (APCs) have no inherent hierarchy; however, they usually correspond similarly to CPT® or HCPCS codes. Thus, the APC codes are divided into a hierarchy corresponding to the CPT® or HCPCS codes that reference the APC.

For APC Payment calculation refer to the APC Payment Calculator on any APC Classification. Payment rates and Copayments are listed if there is a fee available, as well as the Status indicator associated with the APC and the relative weight.

Detailed information is available on the estimation of APC payment(s) by using the APC Payment Calculator on the code page.

APC Packager/Pricer

TOOLS>APC Packager/Pricer

One of the most popular tools used for APC is the APC Packager and Pricer, this tool comes with the hospital add-on tools. Enter all claim information to get payment details for date ranges, based on a specific hospital, patient information as well as diagnosis codes..

Medicare Physician Fee Schedule (MPFS) Indicators

Every procedure is assigned indicators indicating how a code can be used. Correctly using a code will avoid denials and support a consistent revenue cycle.

Look at the Medicare Physician Fee Schedule Indicators (MFPS) on CPT code for an application of a skin substitute reported with CPT 15271. The MFPS indicators will identify important information payment information pertaining to how Medicare’s payment processing rules.

- 15271 Application of skin substitute graft…

APC Status Indicator: APC T Significant Procedure, Multiple Reduction Applies

ASC Payment Indicator: ASC G2 Non-office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight.

Status Code: A - Active Code

Global Days: 000 - Endoscopic or Minor Procedure

PC/TC Indicator (26): 0 - Physician Service Code

Multiple Procedures (51): 2 - Standard payment adjustment rules for multiple procedures apply.

Bilateral Surgery (50): 0 - 150% payment adjustment for bilateral procedures does NOT apply.

Physician Supervisions: 09 - Concept does not apply.

Assistant Surgeon (80, 82): 1 - Statutory payment restriction for assistants at surgery applies to this procedure...

Co-Surgeons (62): 0 - Co-surgeons not permitted for this procedure.

Team Surgery (66): 0 - Team surgeons not permitted for this procedure.

Type of Service (TOS): 2 - Surgery

Berenson-Eggers TOS (BETOS): P5A - Ambulatory procedures - skin

Diagnostic Imaging Family: 99 - Concept Does Not Apply

Non-Facility MUEs: 1

Facility MUEs: 1

CCS Clinical Classification: 172 - Skin graft

List-A-Code

TOOLS>List-A-Code

For a list of codes specific to a group of criteria use the List-A-Code tool, great for a complete list of codes when looking for certain code types or specific criteria assigned to a code. Create a list from key words or from the Medicare Physician Fee Schedule Indicators (MFPS). For example, if you want to view a list of APC or ASC’s with certain status or payment indicators, create a CSV or spreadsheet with only the criteria you specify. Create a list or view a list of codes based on payment adjustments for bilateral procedures or any other indicators assigned to the codes for pricing.

Be aware there are Inpatient only codes, these procedures can only be done in a hospital setting just as specific ASC procedures must be approved for the ASC setting. Using the indicator flags at the bottom of List-A-Code to get a complete list.

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