Ambulatory Surgery Centers (ASCs) are distinct settings designed for outpatient procedures that do not require an overnight hospital stay. Understanding the standardized claim forms used by these facilities is necessary for accurate financial processing and reimbursement. The specific form submitted depends on whether the claim is for the facility’s operational costs or for the individual clinician’s services.
The Definitive Answer: ASCs and Institutional Billing
Ambulatory Surgery Centers bill on the UB-04 claim form, also known as the CMS-1450. This form is used by the ASC to bill for the facility component of a surgical procedure. Because ASCs are classified as institutional providers, they must use this form designated for organizations rather than for individual practitioners.
The UB-04 captures the facility charges associated with the surgical episode. These charges cover all operational costs necessary to perform the procedure safely, including the operating room, specialized equipment, non-reusable supplies, and staff salaries. The facility charge also accounts for time spent in the pre-operative and post-operative recovery areas.
Understanding the UB-04 Claim Form
The UB-04 form is the standardized document used across the healthcare industry for institutional claims submitted to Medicare, Medicaid, and most commercial insurance carriers. It functions as the primary communication tool between the healthcare organization and the payer, capturing a comprehensive picture of the patient’s encounter.
This document requires the use of specific codes that detail the services provided, including procedure codes (CPT/HCPCS) and diagnosis codes (ICD-10). A primary element of the UB-04 is the inclusion of Revenue Codes. These three-digit codes categorize the type of service being billed, such as operating room time or supplies.
The UB-04 is officially maintained by the National Uniform Billing Committee (NUBC). Its function is to standardize the reporting of institutional claims, which expedites the processing of payments. For an ASC, accurately completing the form is vital for ensuring the facility is paid the correct amount for its operational costs.
Separating Facility Charges from Professional Fees
The use of the UB-04 for facility charges necessitates “split billing” for a complete surgical claim. A single surgical event in an ASC results in at least two distinct claims submitted to the patient’s insurance: the institutional bill on the UB-04 and the professional bill submitted on the CMS-1500 form.
The CMS-1500 is the standard claim form designated for all professional services rendered by individual clinicians. This includes the surgeon, the anesthesiologist, and any supervising radiologist or pathologist. These individuals bill for their personal expertise and time, which are charges separate from the facility’s overhead.
Consequently, a patient who undergoes a procedure at an ASC will often receive multiple Explanations of Benefits (EOBs) and potentially separate bills for the same date of service. The UB-04 covers the cost of the physical setting and its resources, while the CMS-1500 claims cover the fees of the medical professionals involved. This separation ensures that both the ASC and the practitioners are reimbursed appropriately for their respective roles in the procedure.