Procedure not covered in ASC
Claims deny when a code is not on Medicare's ASC list or the commercial contract excludes it. We verify setting coverage at scheduling and flag cases that need a different site or an exception request.
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Ambulatory surgery center billing services
ASC billing is a facility claim coded from the operative report, paid under rules that differ from both the surgeon's claim and the hospital outpatient department. Payment depends on whether the procedure is on the payer's covered list, how multiple and discontinued procedures are reported and whether implants and device-intensive codes are handled correctly.
What makes ASC billing different
The surgeon and the center bill the same case under different rules, and the facility side has its own traps.
- Medicare pays only procedures on the ASC covered procedures list, billed on a CMS-1500 with place of service 24, while most commercial payers want a UB-04 with revenue codes such as 0360 and 0278 under a contracted grouper.
- Discontinued cases use modifier 73 when the procedure stops before anesthesia and 74 when it stops after, and the facility is paid differently for each, so the operative and anesthesia records must show the timing.
- Multiple procedures in one session are subject to the multiple procedure reduction, with bilateral procedures reported per payer preference using 50 or RT and LT, and NCCI edits apply to the facility claim just as they do to the surgeon.
- Device-intensive procedures and implants require the invoice, the HCPCS or C-code where the payer uses one, and the contract language on pass-through or carve-out payment, which varies by payer.
Denials we see most in ASC
Every denial gets a root cause, a fix and a feedback loop, so the same denial stops coming back.
Implant and device reimbursement
Implants are denied or paid at a fraction when the invoice, code or carve-out language is missing. We bill implants per contract terms with invoices attached and appeal underpayments against the fee schedule.
Authorization and site mismatch
Authorizations issued to the surgeon or for an outpatient hospital setting do not cover the center. We confirm the facility authorization, the CPT and the date before the case is performed.
How Core MB bills for ASC
Core MB codes ASC claims from the operative report, applies each payer's claim format and grouper logic, and reconciles facility payments against the contracted rate. Credentialing for the center and its surgeons, including payer enrollment of the facility itself, runs in the same client portal. Credentialing for new providers runs in the same system, tracked live in your client portal.
- Operative report coding by certified coders, with NCCI, multiple procedure reduction and modifier 73 and 74 review on every case.
- Payer-specific claim formats, CMS-1500 for Medicare and UB-04 with revenue codes for contracted commercial plans.
- Implant invoice tracking per case and contract-based underpayment appeals for device-intensive procedures and carve-outs.
Everything in the service
Centers get the full facility revenue cycle from Core MB, from scheduling verification and authorization through coding, claim submission, implant tracking, appeals and reporting by surgeon and payer.
- Insurance verification and eligibility checks
- Charge entry and specialty-specific coding review
- Claim scrubbing and electronic submission
- Payer follow-up on every open claim
- Denial management and appeals
- Payment posting and reconciliation
- Accounts receivable recovery
- Patient statements and balance support
- Monthly reporting you can read in five minutes
- Provider credentialing and payer enrollment
ASC billing questions
When do we use modifier 73 versus 74?
Modifier 73 applies when the patient has been prepared and taken to the room but the procedure is discontinued before anesthesia is administered. Modifier 74 applies when the procedure is discontinued after anesthesia begins. The facility is paid differently under each, so we confirm the timing in the record before coding.
Why do commercial payers reject the claim format Medicare accepts?
Medicare requires ASCs to bill professional-format claims, but many commercial contracts specify UB-04 claims with revenue codes and a grouper or percentage-of-charge methodology. We maintain the format, revenue code set and implant rules for each contract so claims are not rejected at the front end.
How do you handle a case where the surgeon and center bill different codes?
Mismatched codes between the professional and facility claims invite audits and denials on both sides. We code the facility claim from the same operative report, compare it to the surgeon's claim when available and resolve discrepancies before submission rather than after a denial.
How do we get started with Core MB for ASC billing?
Tell us your specialties, case volume and payer contracts through the quote form and we will reply with a written proposal. Transitions run alongside your current billing so cases keep flowing, and credentialing for the center and its surgeons can start at the same time.
More in facilities and ancillary care
Facility claims coded right from the operative report
Tell us about your case mix and we will show how Core MB handles ASC coverage lists, claim formats and implant payment so the center is paid per contract.