01
Prior authorization and eligibility
Verified at scheduling, not the day of surgery. Authorization status tracked through date of service.
Ambulatory surgery center billing services
Ambulatory surgery center billing services
ASC billing runs on a separate payment system most billing teams were never trained on: facility fees under Ambulatory Payment Classifications, not the physician fee schedule. Implant reimbursement splits between pass-through and packaged categories. The multiple procedure reduction follows a 100/50/50 rule. And Medicare will not pay a facility fee for any procedure not on the ASC Covered Procedures List. We are an ASC billing company built for that reality, handling ASC medical billing and ASC revenue cycle management exclusively.
1,000+ Payers | 48hr Denial Turnaround | CMS + NCCI + HIPAA Compliant
APC payment system
Implant pass-through + packaged billing
100/50/50 multiple procedure reduction
ASC Covered Procedures List compliance
Why ASC billing breaks differently than physician billing
Why ASC billing breaks differently than physician billing
A
Physician billing
PFS · One claim · 10–12% denial
Physician practices bill professional fees under the Medicare Physician Fee Schedule. One claim per encounter. One payment per service. Standard CPT coding with modifier rules physicians already know.
B
ASC facility billing
APC · Two claims per case · 16–22% denial
ASCs bill facility fees under a separate payment system: Ambulatory Payment Classifications. The facility fee covers nursing, supplies, equipment, and the operating room. It is billed separately from the surgeon's professional fee, which the surgeon's practice bills on its own claim.
That split creates two claims for every case, each with its own coding rules, modifier requirements, and payer adjudication path. APC + implant + modifier + NCCI — none of it applies to physician billing.
16–22%
ASC first-pass denial rate, according to Medical Billers and Coders' 2026 ASC industry report — significantly above the physician group average of 10 to 12%. The higher rate is driven by implant pass-through billing complexity, prior authorization denials, and NCCI bundling violations that physician billing rarely encounters.
9.4%→12.8%
The average ASC claim denial rate increased from 9.4% in 2024 to an estimated 12.8% in 2026 among multi-OR facilities. That increase is not driven by coding error volume. It is driven by infrastructure gaps that general billing platforms are not built to catch.
How the ASC payment system works
How the ASC payment system works
2.6%
CY 2026 rate increase
CMS increased ASC rates by 2.6% for CY 2026. ASCs that fail ASC Quality Reporting Program requirements face a 2.0 percentage point payment reduction.
54.5%
Of the OPPS rate
Medicare ASC rates sit at approximately 54.5% of the OPPS rate for comparable procedures. A coding error that might cost a hospital $50 on a $500 procedure costs an ASC the same $50 on a $272 payment. Half the margin, same dollar loss.
573
New CPL codes in CY 2026
CMS added 573 new codes to the ASC Covered Procedures List for CY 2026. An outdated charge master either bills for procedures Medicare rejects or misses newly covered procedures.
Medicare reimburses ASCs based on the Ambulatory Payment Classification system. Each covered procedure is assigned to an APC group with a fixed facility payment. CMS updates rates annually.
Multiple procedure reduction
When multiple procedures are performed in the same session, the highest pays at 100%, each additional at 50%. Billing at full rate triggers recoupment.
⚠ Consequence: recoupment demand from payer
Pass-through versus packaged implants
Pass-through implants bill separately using HCPCS C-codes. Packaged implants are bundled into the APC rate. Billing a packaged implant separately triggers CARC 96. Missing a pass-through implant means lost revenue.
⚠ Consequence: CARC 96 denial or missed revenue
ASC Covered Procedures List
Medicare will not pay an ASC facility fee for a procedure not on the CPL. CMS added 573 new codes for CY 2026. An outdated charge master either bills for procedures Medicare rejects or misses newly covered procedures.
⚠ Consequence: zero payment on uncovered procedures
What our surgery center billing services cover
What our surgery center billing services cover
02
Charge capture from OR logs
Operative reports and supply logs reconciled against the billing record for every case. Missed charges generate no alert.
03
APC coding and claim submission
NCCI edit updates tracked on each CMS quarterly release. Modifiers 50, 51, 59, SG, LT/RT, and XE/XS/XP/XU managed per procedure.
04
Implant billing (pass-through and packaged)
Pass-through implants billed with HCPCS C-codes. Packaged items verified against APC rate. Every implant classified before submission.
05
Denial management
Root cause analysis, correction, and resubmission or appeal within 48 hours. Denial patterns tracked to prevent recurrence.
06
Coverage discovery and out-of-network
Self-pay write-offs converted to billable claims via coverage discovery. Out-of-network cases verified for benefits, medical necessity documented, and patient financial responsibility communicated before the procedure.
The cost of running ASC billing in-house
The cost of running ASC billing in-house
In-house
$46,660
Median salary BLS May 2024
$65K–$85K
Loaded cost per staff member
- Minimum 2+ staff needed for coverage
- Denial queue grows during staff turnover
- ASC-specific APC and implant expertise rare
- AR damage surfaces weeks after the problem starts
Outsourced
4–8%
Of collections
$60K–$120K
At $1.5M/yr — all-in
- Coding + denial management + credentialing + reporting
- No turnover gap — denial queue never stops
- ASC-specific billing expertise included
- Scales with case volume, no staff hiring required
The decision depends on case volume, specialty mix, and whether the current in-house team can keep denial rates below 10% and AR under 40 days. When staff turns over, the denial queue grows and nobody notices until the AR aging report surfaces the damage.
Built for every ASC specialty
Built for every ASC specialty
Orthopedics
Joint replacements, arthroscopy, spine procedures. Total joints have expanded on the ASC CPL. We manage implant pass-through billing, device offset calculations, and bilateral/staged modifier logic.
Pain management
Epidural steroid injections, nerve blocks, radiofrequency ablation, spinal cord stimulator trials. Prior authorization requirements vary by payer and procedure. We verify before every scheduled case.
Gastroenterology
EGD and colonoscopy at high volume with tight APC margins. We reconcile biopsy and polypectomy findings against the operative report to bill the correct procedure code, not the screening code.
Ophthalmology
Cataract surgery (CPT 66984), glaucoma, retinal surgery. Modifiers LT/RT and 50 for laterality and bilateral. IOL implant charges captured separately when applicable.
ENT and general surgery
Tonsillectomy, septoplasty, hernia repair, cholecystectomy. NCCI edit compliance and multiple procedure reduction on most multi-procedure sessions.
Multi-specialty ASCs
Billing workflows configured per specialty. APC groups, modifier rules, and payer requirements managed separately rather than one generic rule set across the center.
Works with your existing ASC systems
Works with your existing ASC systems
No system replacement. No workflow disruption. Billing connects to your existing credentialing and AR recovery workflows from a single team.
HST PathwaysSIS (Surgical Information Systems)AmkaiSolutionsAdvancedMD30+ others
ASC billing questions we get asked
ASC billing questions we get asked
Direct answers for surgery center administrators and billing teams evaluating ASC billing services.
What is ASC in billing?
ASC stands for Ambulatory Surgery Center. In billing, an ASC is a facility that performs outpatient surgical procedures and bills a facility fee separately from the surgeon's professional fee. The facility fee covers the operating room, nursing, equipment, and supplies. ASCs are reimbursed under the Ambulatory Payment Classification system for Medicare and under individual contracts for commercial payers.
What is the difference between ASC billing and hospital outpatient billing?
Both handle outpatient surgical procedures, but the payment systems differ. Hospital outpatient departments bill under the Outpatient Prospective Payment System (OPPS) at higher rates. ASCs bill under the ASC payment system, where rates are set at approximately 54.5% of OPPS. ASCs use the CMS-1500 form with Place of Service 24, while hospital outpatient uses the UB-04 with POS 22. Modifier rules, covered procedure lists, and implant billing also differ between the two settings.
How is ASC billing different from physician billing?
ASCs bill facility fees under the APC system, separate from the surgeon's professional fee. The facility claim covers the operating room, nursing, supplies, and equipment. Physician billing covers the surgeon's work. ASCs also deal with implant pass-through billing, the ASC Covered Procedures List, and the multiple procedure reduction rule, none of which apply to physician billing.
Can an ASC bill on a UB-04 form?
Most freestanding ASCs bill on the CMS-1500 (837P) form using Place of Service code 24. Some state Medicaid programs and certain commercial contracts require the UB-04 (837I) format. Hospital-based ASCs typically use the UB-04. We configure claim format rules per payer to prevent form-related rejections.
What is the ASC Covered Procedures List?
The ASC Covered Procedures List is the CMS list of surgical procedures eligible for Medicare facility fee payment in an ASC. If a procedure is not on the CPL, Medicare will not pay a facility fee for it. CMS updates the CPL annually. For CY 2026, 573 new procedure codes were added. Charge masters must be updated each year.
How do you handle implant and supply billing?
We reconcile operative reports and supply logs against the billing record for every case. Pass-through implants are billed separately using HCPCS C-codes. Packaged implants are included in the APC rate and cannot be billed as separate line items. We verify every implant classification to prevent missed revenue and CARC 96 denials.
What causes the most ASC claim denials?
Missing or expired prior authorizations, CPT coding errors, modifier misuse, NCCI bundling violations, documentation gaps, and eligibility issues. ASCs experience first-pass denial rates of 16 to 22%, driven by billing complexity that general platforms do not handle well.
How do I get started?
Request a free revenue assessment. We review your denial rate by root cause, implant charge capture accuracy, APC coding patterns, and payer contract performance. You receive a written report with findings and recommendations. No obligation, no upfront cost, and you keep the report whether or not you work with us.
Ready when you are
Your center runs the cases. We collect the revenue.
The free revenue assessment covers your denial rate by root cause, implant charge capture accuracy against OR logs, APC coding patterns, and estimated recoverable revenue. You keep the findings whether or not you work with us.
- Denial rate by root cause from your ASC claim volume
- Implant charge capture accuracy against OR logs
- APC coding pattern review
- Estimated recoverable revenue
- HIPAA-compliant — BAA signed before data moves
- No setup fee. No long-term contract.