Three Claims for Every ASC Surgery
One cataract case can create three separate claims from three billing entities. Each must describe the same eye, date and procedure. The table shows how they differ.
| Claim | Who bills | What it covers | Example codes |
|---|---|---|---|
| Facility | ASC | Room, staff, supplies, standard implants | 66984 with RT or LT on the ASC claim |
| Professional | Surgeon | The surgeon's work and global care | 66984 with RT or LT, and 54 when co-managed |
| Anesthesia | Anesthesia provider | Monitored anesthesia care | 00142 for lens surgery with time units |
A mismatch between these claims, such as a different eye or date, invites denials and payer questions. We check facility claims against surgeon claims before submission when we bill both.
ASC Covered Procedures and Payer Contracts
Medicare pays an ASC only for procedures on the ASC covered procedures list. CMS updates the list each January through the OPPS and ASC final rule. A procedure not on the list produces no Medicare facility payment and cannot be appealed. We check every scheduled case against the current list and against each commercial contract, since commercial payers set their own lists and carve-outs.
How Does ASC Payment Work?
Medicare pays ASCs using relative weights from the outpatient payment system multiplied by the ASC conversion factor. Four rules shape the payment on each ophthalmic case.
- Multiple procedure discounting pays the second and later eligible procedures at 50%
- Standard IOLs and most supplies are packaged into the procedure payment
- Some drugs and devices qualify for separate pass-through payment for a limited time
- Premium lens costs are billed to the patient, not to Medicare
Modifiers 73 and 74 for Discontinued ASC Cases
Eye cases are sometimes stopped after the patient is prepared, for example because of a blood pressure spike or a problem found on the table. Modifier 73 reports a case stopped after preparation but before anesthesia, and Medicare pays it at a reduced rate. Modifier 74 reports a case stopped after anesthesia began and is generally paid in full. The operative or nursing note must state when and why the case stopped. Discontinued cases are excluded from further multiple procedure reductions.
ASC Billing by Subspecialty for USA Surgery Centers
In the USA, most ophthalmic ASC volume is cataract surgery, but centers also run glaucoma, retina and oculoplastic cases. Each brings its own facility billing rules, such as MIGS device coding, vitrectomy supply use and functional documentation for eyelid surgery. See cataract surgery billing, glaucoma billing and retina billing for the professional side of each.
Monthly ASC Billing Reports
Each month you receive facility revenue per case by procedure and payer, cases on hold for authorization, discontinued-case counts and denials by cause. We also flag payers whose ASC rates fall below Medicare for the same procedures. Prior authorization for surgical cases runs through our prior authorization team. A free billing audit can include your center's last 90 days of facility claims.