Last Modified: 4/4/2024
Location: FL, PR, USVI
Business: Part A, Part B
ASC services are paid by Medicare under the ASC payment system; therefore, different payment situations may occur when modifiers are used. To understand if modifiers may apply, it's important to know which services are covered in an ASC setting.
Services included and not included for ASCs
Facility services are items and services furnished in connection with listed covered procedures, if furnished in a hospital operating suite, hospital outpatient department, or in ASC setting. These do not include physicians' services, or medical and other health services for which payment may be made under other Medicare provisions (e.g., services of an independent laboratory located on the same site as the ASC, anesthetist professional services, non-implantable durable medical equipment [DME]).
Examples of covered ASC facility services include:
• Nursing services, services of technical personnel, and other related services
• Use by the patient of the ASC's facilities
• Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment
• Diagnostic or therapeutic items and services
• Administrative, recordkeeping, and housekeeping items and services
• Blood, blood plasma, platelets, etc., except those to which blood deductible applies
• Materials for anesthesia
• Intraocular lenses (IOLs)
Services not considered ASC services:
• Physicians' services
• Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS)
• Including non-implantable DME, prosthetic devices, non-implantable prosthetic devices
• Leg, arm, back, and neck braces
• Artificial legs, arms, and eyes
• Ambulance services
• Services of independent laboratory
Coverage of ASC services under Part B is tied to specified surgical procedures contained in a list revised and published periodically by CMS, which can be found along with additional information on the
ASC Payment webpage 
.
For services not considered ASC services, CMS uses alternate payment methods for office-based surgical procedures, device-intensive procedures, covered ancillary radiology services, and drugs and biologicals.
Since ASC payment does not include the professional services of the physician, these are billed separately by the physician. Physicians' services include the services of anesthesiologists administering or supervising the administration of anesthesia to ASC patients and the patients' recovery from the anesthesia. The term physicians' services also include any routine pre- or postoperative services, such as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other services which the individual physician usually performs.
As such, modifiers which are applicable to physicians' services, like evaluation and management (E/M) services would not be billed by ASCs. For instance, modifiers 24 and 25 are exclusive to E/M services and are not billed by ASCs.
Modifiers applicable exclusively to services not considered ASC services would not apply to ASC services. For example: Modifier 91 is exclusively applicable to laboratories.
Per the National Correct Coding Initiative (NCCI) editing, anatomic modifiers which may apply to surgical procedures should be included as necessary when billing these procedures: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, and RI.
The
CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 14 -- Ambulatory Surgical Centers 
, Section 40.5 - Payment for Multiple Procedures, states a procedure performed bilaterally in one operative session is reported as two procedures, either as a single unit on two separate lines (appending modifiers -RT and -LT) or with "2" in the 'units' field on one line. ASCs would not use modifier -50. Claims by ASCs inappropriately billed with a modifier -50 will be rejected.
In general, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. Most edits involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have NCCI modifier indicators of "1" because the two codes of the code pair edit may be reported if performed on the contralateral organs or structures.
Where services are performed in an ASC, the physician and others who perform covered services may also be paid for his or her professional services; however, the "professional" rate is then adjusted since the ASC incurs the facility costs.
ASCs bill modifier -TC to indicate their technical (facility) component for services with a separate technical and professional component, while physicians bill professional services with modifier -26. ASCs also bill covered ancillary services with modifier -TC.
Covered ancillary items and services integral to a covered surgical procedure for which separate payment to the ASC is allowed include:
• Brachytherapy sources
• Certain implantable items that have pass-through status under the outpatient prospective payment system (OPPS)
• Certain items and services that CMS designates as contractor-priced, including, but not limited to, the procurement of corneal tissue
• Certain drugs and biologicals for which separate payment is allowed under the OPPS
• Certain radiology services for which separate payment is allowed under the OPPS
ASCs use modifier -73 to indicate a surgical procedure was terminated prior to induction of anesthesia or initiation of the procedure.
Contractors pay 50 percent of the rate if a surgical procedure is terminated due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating room but before anesthesia has been induced or the procedure initiated.
For example, 50 percent is paid if the patient develops an allergic reaction to a drug administered by the ASC prior to surgery or if, upon injection of a retrobulbar block, the patient experiences a retrobulbar hemorrhage which prevents continuation of the procedure. Although some supplies and resources are expended, they are not consumed to the same extent had anesthesia been fully induced and the surgery completed.
ASC surgical services billed with modifier -73 modifier are not subject to the multiple procedure reduction.
ASCs use modifier -74 for surgical procedures terminated after administration of anesthesia or initiation of the procedure.
Contractors make full payment for the surgical procedure if a medical complication arises causing the procedure to be terminated after anesthesia has been induced or the procedure initiated.
For example, full payment is made if, after anesthesia has been accomplished and the surgeon has made a preliminary incision, the patient's blood pressure increases suddenly and the surgery is terminated to avoid increasing surgical risk to the patient.
ASC surgical procedures billed with modifier -74 may be subject to multiple procedure reduction if the surgical procedure itself is subject to the multiple procedure reduction.
ASCs use modifier -52 to indicate the discontinuance of a procedure not requiring anesthesia.
Contractors apply a 50 percent payment reduction for discontinued radiology and other procedures not requiring anesthesia.
ASC services billed with modifier -52 modifier are not subject to the multiple procedure reduction.
Device furnished with no cost or with full or partial credit
Contractors pay ASCs a reduced amount for certain specified procedures when a specified device is furnished without cost or for which either a partial or full credit is received (e.g., device recall). For specified procedure codes including payment for a device, ASCs are required to include modifier -FB on the procedure code when a specified device is furnished without cost or for which full credit is received. If the ASC receives a partial credit of 50 percent or more of the cost of a specified device, the ASC is required to include modifier -FC on the procedure code if the procedure is on the list of specified procedures to which the -FC reduction applies. A single procedure code should not be submitted with both modifiers -FB and -FC. Tables listing the procedures and devices to which the payment adjustments apply, and the full and partial adjustment amounts, are available on the CMS website.
Although the modifiers discussed in this article are relative to ASCs, this is not an exhaustive list. Please refer to the CPT manual and CMS resources for additional modifiers which may apply to specific ASC services and situations.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
