What do ASC billing services include?

The facility side of the case from scheduling through payment: eligibility and authorization, facility coding, implant and supply billing, payment posting against your contracts, denials and appeals, AR follow-up, and patient balances. Some surgery centers outsource all of it, and some keep part of it in house.

How is ASC facility billing different from professional billing?

The professional claim pays the surgeon for performing the procedure. The facility claim pays the surgery center for the room, the staff, the supplies, and in most cases the implants. They use mostly the same procedure codes but different payment rules. Medicare pays ASCs from its own fee schedule, packages many services into the primary procedure, and does not pay for procedures outside the ASC Covered Procedures List.

How are implants billed in an ASC?

For Medicare, most implants are packaged into the procedure payment, and only pass-through devices pay separately. Commercial contracts often pay implants separately through a carve-out.

What is the SG modifier?

SG is a modifier Medicare once required on ASC facility claims. Medicare dropped the requirement in 2008, but some commercial payers still ask for it.

Can you bill both our surgeons and our ASC?

Yes. We bill both sides for physician-owned surgery centers and orthopedic groups with their own ASC, and we reconcile the professional and facility claims for each case. We also bill the facility side alone for surgery centers whose surgeons bill elsewhere.

What does switching billing companies involve?

We connect to your systems, load your payer contracts, and take over new claims while your current team or vendor finishes what they have open. We can take over the old AR as well. For surgery centers we work along with the major practice management systems, and we have taken data in every format a client has handed us.

ASC Billing Services for Orthopedic Surgery Centers

Orthos handles billing and coding for orthopedic ambulatory surgery centers (ASCs). Our team is U.S.-based and works only in orthopedics. We bill the facility side on its own, or the facility and the surgeons together.

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Where orthopedic ASCs lose money

The facility side of an orthopedic case has more places to lose money than the professional side, and most of them never show up as a denial.

Commercial contracts often carve implants out and pay them at invoice cost or cost plus a percentage, but only if the invoice is on file and the device is on the claim. When the implant log, the operative note, and the claim disagree, the carve-out often pays nothing, and nobody goes back for it.

On a case with several procedures, Medicare pays the highest-paying one in full and most of the others at half, and each commercial contract has its own version. A reduced payment is expected, so an underpayment inside one looks normal unless every line is posted against the contract.

Coverage and authorization problems start before the case. Medicare does not pay the facility for a procedure that is not on the ASC Covered Procedures List, and commercial and Medicare Advantage plans want authorization for most orthopedic surgery. A missing authorization found after the case is very hard to fix.

The surgeon's claim and the facility's claim for the same case should agree on procedure, laterality, and diagnosis. When they do not, one of them can get denied, and if two different companies bill them, neither one can see why.

How we work a case

Before the case. We verify eligibility and benefits, confirm the procedure is covered in the ASC setting for that payer, and secure the authorization. If the payer's requirements and the scheduled procedure do not match, your team hears about it while it can still be fixed.

Coding. Our certified coders work from the operative note, not the schedule or a charge sheet. Implants and supplies are matched to their invoices and coded before the claim goes out.

Payment. Every remittance is posted against your contract. Short payments get flagged and appealed, and denials get worked until they pay or recovery becomes unlikely.

ASC coding

Facility coding uses mostly the same procedure codes as professional coding, but Medicare pays them differently. Every procedure Medicare covers in an ASC carries a payment indicator. Some procedures pay on their own, others are packaged into the primary procedure and pay nothing separately, and device-intensive procedures are paid at a rate adjusted for the cost of the device.

Operative note coding. Claims are built from what the surgeon documented. When the note does not support what was scheduled, or it is unclear what was done, we query the surgeon.

Implants and devices. HCPCS C-codes and L-codes, pass-through devices, and invoices attached where the payer requires them.

Modifiers. Laterality, distinct procedures, and discontinued procedures, applied to each payer's rules. Medicare and commercial plans handle these differently, and the same case can need different modifiers on the two claims.

Coding is also available as an on demand service, for surgery centers that have billing covered and need coding capacity.

ASC billing and AR management

Contract loading. Your payer contracts go into our system, including case rates, implant carve-outs, and multiple-procedure terms, so every payment is checked against what the contract says.

Underpayment recovery. Comparing what payers paid against what your contracts say they owe. Underpayments do not generate a denial, so they can go unnoticed for years.

Denials and appeals. Surgical appeals go out with the operative note and the authorization, which is what payers respond to.

AR follow-up. Ongoing follow-up, plus one-time cleanup of aged receivables, including backlogs left by a prior vendor.

Patient balances. Statements, patient calls, and payment posting.

One case, two claims

Most orthopedic ASC cases produce two claims, the surgeon's professional claim and the surgery center's facility claim. They follow different rules on implants, site of service, and authorization, but they describe the same surgery, and payers can compare them.

When the surgeon and the surgery center are both clients, we reconcile the two claims for every case, so a missing modifier or a mismatched code on one side gets caught before it becomes a denial on the other. This is common for physician-owned surgery centers and for orthopedic groups that run their own ASC.

If your surgeons bill elsewhere, we handle the facility side on its own.

Orthopedic cases we bill

We bill the full range of orthopedic surgery done in ASCs, including hand, foot and ankle, and fracture cases.

Total joints. Primary and revision knee and hip replacement. Medicare keeps adding joint procedures to the ASC list, and joint cases carry large implant carve-outs.

Sports medicine. Shoulder, knee, and hip arthroscopy, often with several procedures in one session, so multiple-procedure and bundling rules come up on most cases.

Spine. Fusions and decompressions. Levels, approaches, and instrumentation all change the claim, and authorization requirements are stricter than for most other procedures.

Pain management. Epidural and facet injections, nerve blocks, and spinal cord stimulators. Authorization and frequency limits decide whether these pay.

Keeping up with Medicare and payer changes

Medicare updates the ASC payment rule and the Covered Procedures List every year, and orthopedic procedures moving into the ASC setting come with new rates and rules. Traditional Medicare has also started requiring prior authorization for some procedures in some states through programs like WISeR. Commercial plans change their policies on their own schedules, usually with little notice.

Frequently Asked Questions

The facility side of the case from scheduling through payment: eligibility and authorization, facility coding, implant and supply billing, payment posting against your contracts, denials and appeals, AR follow-up, and patient balances. Some surgery centers outsource all of it, and some keep part of it in house.
The professional claim pays the surgeon for performing the procedure. The facility claim pays the surgery center for the room, the staff, the supplies, and in most cases the implants. They use mostly the same procedure codes but different payment rules. Medicare pays ASCs from its own fee schedule, packages many services into the primary procedure, and does not pay for procedures outside the ASC Covered Procedures List.
For Medicare, most implants are packaged into the procedure payment, and only pass-through devices pay separately. Commercial contracts often pay implants separately through a carve-out.
SG is a modifier Medicare once required on ASC facility claims. Medicare dropped the requirement in 2008, but some commercial payers still ask for it.
Yes. We bill both sides for physician-owned surgery centers and orthopedic groups with their own ASC, and we reconcile the professional and facility claims for each case. We also bill the facility side alone for surgery centers whose surgeons bill elsewhere.
We connect to your systems, load your payer contracts, and take over new claims while your current team or vendor finishes what they have open. We can take over the old AR as well. For surgery centers we work along with the major practice management systems, and we have taken data in every format a client has handed us.