Ambulatory Surgery Center (ASC)

There are two acceptable claim formats to submit Ambulatory Surgery Facility Charges (ASC): the 837P electronic claim transaction or the paper CMS 1500 claim form. 

The facility fee (technical component) charge needs to be billed using the CMS 1500 form. The facility charge for each coded procedure is all-inclusive of the facility-fee allowance. For exceptions, please refer to your specific contract.  

SG Modifier must be appended to all lines on the claim.

Single Procedures:

When one operative/diagnostic procedure is performed in an encounter, the billing for the facility fee (technical component) must be billed with the appropriate CPT code of the procedure performed.   

Multiple Procedures:

BCBSNE follows CMS’s policy of procedures that can be performed in an ASC.  Inquiries for any other procedures should be directed to your assigned BCBSNE Provider Executive. 

The primary procedure (procedure with the highest RVU) will be reimbursed 100% of the ASC fee-schedule amount. Additional covered surgical procedures will be reduced by 50% of the ASC fee-schedule amount. 

Nerve Block:

If the nerve block is the mode by which anesthesia and pain control are administered, it is considered part of the anesthesia and the anesthesia code should be billed.

Implants: 

Implants used during a procedure should be billed with the appropriate HCPC code. If there is not an appropriate HCPC code for the item, use code L8699 and include a description of the implanted device(s).  You may bill BCBSNE 100% of the acquisition cost (invoice amount) of the item(s); any shipping, handling or taxes will be denied as content to the implant cost. Each implant/device must be billed separately as one line item and one unit. Any implants with an acquisition cost less than $100 will be denied as content to the procedure and will not be reimbursed separately.

Cataract Surgery and Lens Insertion:

As part of the facility reimbursement fee, only the facility can bill for procedure codes related to the removal of the cataract and the insertion of an intraocular lens (IOL), which may be the standard lens or one of the new technologies IOLs.     

The ASC facility fee schedule rates for cataract surgery already factors in the cost for a standard monofocal lens. When an accommodating IOL is used, it must be billed on the ASC claim using the appropriate Level II HCPCS code.  

When covered by the member’s benefit contract, BCBSNE will calculate the reimbursement at the lesser of billed charge or 100% of the acquisition cost minus the facility fee allowance. If 100% of the acquisition cost of the lens is less than the facility fee allowance, it is not necessary for the lens to be billed separately. 

Note: Surgeons cannot bill for IOL implants. 

Fluoroscopic Guidance of Needle:

Procedures done in an ASC will be reimbursed only the technical component for these procedures. A separate professional component for each of these procedures may also be payable and should be submitted by the physician on a separate CMS 1500. 

Third-Party Providers 

BCBSNE will not separately reimburse third-party providers rendering services including, but not limited to, monitoring or equipment in an ASC setting. These services or supplies are considered “content of service.” The purpose of the denial for content of service refers to specific services and/or procedures that are an integral part of a previous or concomitant services or procedures to the extent that separate reimbursement is not recognized.

If a third-party provider is present and/or provides services or equipment based on physician’s or facility’s request, then payment to that provider will need to be coordinated between the two parties. A third-party provider must never bill BCBSNE or the member for these services.  

Reimbursement for technical-component services and equipment used during a procedure or surgery is included in the overall reimbursement to the facility. If a third-party provider is present and/or provides services or equipment on the physician’s or facility’s behalf, then payment to that provider will need to be coordinated between the two parties. A third-party provider must never bill BCBSNE or the member for these services.