ASC Coding and Billing: Complexity Codes for Interventional Radiology and Cardiac Catheterization Procedures
The following outline highlights the key aspects of Medicare coding and billing for procedures performed in ASCs, particularly focusing on the new complexity codes introduced in 2023 and their impact on 2024 billing. ASCs offer a unique reimbursement structure that blends elements of both hospital outpatient and physician office billing, making it critical for providers to fully understand how procedures, devices, and bundled components are coded and reimbursed.
Effective January 1, 2023, CMS introduced Complexity HCPC C codes for select procedures, including Interventional Radiology and Cardiac Catheterization, performed in an Ambulatory Surgery Center (ASC) (POS 24). Previously, these C codes applied primarily to billing for devices (e.g., catheters, stents) under “pass-through status” and other hospital-based services (e.g., C8933: MRI with and without contrast for upper extremity joints). These Medicare complexity codes for ASCs closely align with hospital billing and reimbursement rules, packaging services that are commonly performed during procedures. Some devices, however, remain separately payable.
Packaged Services in ASC Reimbursement
In the ASC setting, many components are packaged into Medicare reimbursement payments. It’s essential to verify billing and reimbursement policies with other payers, as they may differ from Medicare. Examples of common packaged services include:
- Moderate Sedation: CPT codes 99152 and 99153
- Add-on Codes: (indicated by a “+”) such as IVUS (+37252, +37253), additional selective catheter placement (+36248, +36218), and vascular ultrasound access guidance (+76937)
- Imaging services, including radiologic supervision and interpretation, are packaged into the payment. Bilateral extremity angiography, 75716 is not listed on the ASC fee schedule as not separately reimbursable.
Status and Payment Indicators
CMS created Status and Payment Indicators (PIs) to guide Medicare claims. For ASC reimbursement, some CPT codes are assigned a Status Payment Indicator of N1, meaning the service is packaged and not separately payable.
MedLearn Matters 13481 states: “ASCs should not separately bill for packaged codes (ASC PI=N1) as they are not reportable under the ASC payment system.”
These codes do not appear on the ASC fee schedule due to packaging.
Non-Medicare carriers may have different policies, so verify and adjust billing accordingly.
Device Reimbursement
Devices are separately billable in ASCs. CMS has created “pass-through” codes for some devices, designated by the Payment Indicator H, meaning “Pass-through Device Category, separate cost-based payment; not subject to copayment.”
Action for Providers: Verify device reimbursement policies with non-Medicare carriers, as Medicare reimbursement does not guarantee reimbursement from other carriers.
Payments in ASCs vs. HOPPS
The payment rate in ASCs is approximately 60% of the Hospital Outpatient Prospective Payment System (HOPPS) reimbursement rate, which is generally higher than the Medicare Physician Fee Schedule (MPFS) used in Office-Based Labs (OBLs).
For many procedures in ASCs, a Payment Indicator of J8 indicates that the procedure is device-intensive, meaning the device cost constitutes at least 30% of the total cost. In such cases, ASC reimbursement mirrors HOPPS, bundling codes typically billed separately in OBL settings.
Complexity Codes in 2024
CMS reviewed twelve complexity codes introduced in 2023. These codes did not meet the complexity adjustment criteria for CY 2024 and are not on the 2024 ASC fee schedule. In 2024, they are billed using Category I CPT codes as applicable.
For instance, CPT 37225 (Iliac PTA and atherectomy) will be billed in both ASC and OBL settings in 2024. Although IVUS is not separately billable in the ASC due to the N1 payment indicator, the ASC reimbursement remains higher than in the OBL setting.
Multiple Procedure Discounts in ASCs
ASC billing is subject to multiple procedure discounts. The highest-valued procedure is reimbursed at 100% of the allowable rate, while additional procedures are discounted based on the Payment Indicator policy, but typically at 50% of allowable.
Comparison of ASC Versus OBL Coding and Billing
A careful analysis of your current case mix and payers comparing reimbursement in both settings can reveal strategic business decisions around Hybrid OBL/SC model to take advantage of reimbursement by case and payer.
OBL cases: CPT codes are billed individually (“à la carte”), with variations based on the specific case scenario. Multiple payment reductions (MPPR) often apply to secondary codes, reducing reimbursement for additional services.
ASC cases: Billing is packaged, meaning the reimbursement is consistent across similar case scenarios, with fewer variations compared to OBLs.
Case Analysis Comparisons
Conclusion:
This summarizes Medicare coding and billing in the ASC setting. It is important to check each payer’s policies and contracts before performing procedures, as reimbursement policies vary, and pre-authorization does not guarantee payment.
We hope you find this article informative.
Please get in touch with StreamlineMD for additional information.
References:
2024 ASC Fee Schedule: Search the Physician Fee Schedule | CMS
2024 National Medicare Physician Fee Schedule, Search the Physician Fee Schedule | CMS
2024 MedLearn Matters, https://www.cms.gov/files/document/mm13481-ambulatory-surgical-center-payment-system-january-2024-update.pdf
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