Ambulatory Surgery Centers (ASC) Billing Manual

Return to Billing Manuals Web Page

Ambulatory Surgery Centers (ASCs)

The Department of Health Care Policy and Financing (the Department) periodically modifies billing information. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented.

Providers must be enrolled as a Health First Colorado provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to the Health First Colorado

Medical services provided in Ambulatory Surgery Centers (ASCs) are a benefit of the Health First Colorado.

 

Ambulatory Surgery Centers are distinct entities that provide a surgical setting for members who do not require hospitalization. If the ASC is part of a hospital, the ASC portion must be physically separated from all other health services offered at the hospital.

To receive payment, the center must be certified as an ASC by the Centers for Medicare & Medicaid Services (CMS), licensed as an ASC by the Colorado Department of Public Health and Environment (CDPHE), and enrolled in the Health First Colorado.

Providers should refer to the Code of Colorado Regulations, Program Rules (10 CCR 2505-10), for specific information when providing care in an ASC.

Back to Top

General Billing Information

Refer to the General Provider Information manual for general billing information.

Back to Top

ASC Authorized Services

Services must be reported using HCPCS surgical procedure codes. This manual contains a complete list of the Health First Colorado-approved ASC procedure codes effective January 1, 2019. The list is divided into related groups for payment. Only surgical procedure codes that are published in this manual are ASC Health First Colorado benefits.

Health First Colorado bulletins notify providers when annual coding updates are implemented.

Back to Top

Reimbursement

For payment purposes, ASC surgical procedures are grouped into ten categories. The Health First Colorado reimbursement rates are the lower of billed charges or the maximum allowable payment by group. Refer to the Provider Rates & Fee Schedule page on the Department’s website for current ASC group rates.

Back to Top

Health First Colorado Program Payment Calculation

Submitted charges must represent usual and customary charges. Do not adjust charges to correspond to the anticipated Medicaid payment.

Health First Colorado providers must agree to accept Health First Colorado reimbursement as payment in full for benefit services. Health First Colorado members may not be billed for charges that exceed the Health First Colorado allowance. The Medicaid Management Information System (interChange) calculates payment as the provider's billed charge or the established rate for the group, whichever is less.

Back to Top

Multiple Procedures

When multiple procedures are performed during the same session, payment will correspond to the procedure with the highest allowed grouper amount. Additional payment is not available for multiple or subsequent procedures performed on the same date of service.

Back to Top

Medicare Crossover Payment

Health First Colorado payment for Part B Medicare crossover claims is made as follows:

  1. The sum of reported Medicare deductible and coinsurance or
  2. The Health First Colorado allowed benefit minus the Medicare payment, whichever is less. Third Party liability payments and Health First Colorado copay amounts, as applicable, will be subtracted after the crossover allowed payment has been determined.

 

If the amount paid by Medicare equals or is greater than the Health First Colorado benefit, the Health First Colorado Program makes no additional payment. This method of determining payment is commonly referred to as "lower-of" pricing.

Note: Except for applicable Health First Colorado copayment amounts, unpaid balances cannot be billed to the Health First Colorado member or the member's family.

Back to Top

Services and Items Included at a Minimum in the ASC Reimbursement

  1. Use of the facilities where the surgical procedures are performed
  2. Nursing, technician, and related services
  3. Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances and equipment directly related to the provision of surgical procedures
  4. Diagnostic and therapeutic items and services directly related to the provision of a surgical procedure
  5. Administrative, record keeping, and housekeeping items and services
  6. All blood products (whole blood, plasma, platelets, etc.)
  7. Materials for anesthesia
  8. Intra-ocular lenses (IOLs)
  9. Supervision of the services of an anesthetist by the operating surgeon

Back to Top

Services That May Be Billed Separately

The following services/items are not included in the ASC rate and may be billed separately by the actual provider of services.

  1. Physician services
  2. Anesthetist services
  3. Laboratory, radiology or diagnostic procedures (other than those directly related to performance of the surgical procedure)
  4. Prosthetic devices (except IOLs)
  5. Ambulance services
  6. Leg, arm, back, and neck braces
  7. Artificial limbs
  8. Durable medical equipment for use in the member’s home

 

Back to Top

Billing Procedures

Ambulatory Surgical Center facility claims are submitted as an 837 Professional (837P) electronic transaction or on the CMS 1500 paper claim form. Claim completion instructions are described in the above Billing Information. The following instructions are specific to ASC facility services claims. Ambulatory Surgical Center information does not apply to other provider types.

Ambulatory Surgical Center claims should be submitted electronically. Electronic claims submission reduces billing expense and claims processing time. Information about electronic claims submission may be obtained from Electronic Data Interchange (EDI) Support at 1-844-235-2387, Monday through Friday from 8:00 a.m. to 5:00 p.m. Mountain Time (MT).

Procedure codes: ASCs identify services using HCPCS surgical procedure codes. During claim processing, the surgical code is linked to an appropriate ASC group for payment calculation.

Back to Top

Billing Information

The ASC is responsible for obtaining required billing information from the surgeon. ASC providers are required to verify Health First Colorado eligibility before services are rendered. If eligibility is not verified, payment may be denied.

ICD-10-CM diagnosis: The diagnosis field(s) must be completed with an appropriate ICD-10-CM diagnosis code(s).

Place of service: Complete the Place Of Service (POS) field with a "24" for ASC facility charges.

Note: Electronic billers should consult the software instructions to assure that POS coding is submitted properly.

Rendering provider: Complete with the NPI number assigned to the operating surgeon.

Referring provider: If the member is enrolled in the Primary Care Physician (PCP) program and the operating surgeon is not the PCP, the PCP's NPI number must be entered in this field. PCP-enrolled members must obtain PCP referral if surgical services are performed by a physician other than the PCP. If the member does not have an assigned PCP, this field may be left blank.

Sterilization procedures: All sterilization claims must have an attached copy of a properly completed MED-178 sterilization consent form. The surgeon is responsible for providing a copy of the MED-178 to the ASC. Claims without a properly completed MED-178 are denied. Refer to the Obstetrical provider manual for complete billing requirements.

Hysterectomy procedures: Hysterectomy procedures are a benefit of Health First Colorado when performed solely for medical reasons. Hysterectomy is not a benefit if the procedure is performed solely for the purpose of sterilization, or if there was more than one purpose for the procedure and it would not have been performed but for the purpose of sterilization. Refer to the Obstetrical provider manual for complete billing requirements.

Medicare crossover claims: Health First Colorado pays the Medicare deductible and coinsurance or the Health First Colorado - allowed benefit minus the Medicare payment, whichever is less. If Medicare’s payment equals or is more than the Health First Colorado allowed benefit, crossover claims are paid at zero.

Most Medicare crossover claims are transmitted electronically from Medicare to Health First Colorado. If a Medicare claim does not cross automatically, the provider is responsible for submitting a "hardcopy crossover" claim on the CMS 1500 paper claim form. Refer to the end of the manual for an example of a completed paper crossover claim.

Back to Top

ASC Group 1

ASC Group 1
11404 21820 26478 27824 36466 43201 45317 50434 54065 62280 64635
11444 22310 26479 27830 36482 43202 45320 50435 54100 62281 64636
11971 23030 26516 27831 36483 43204 45321 50436 54105 62282 64702
12020 23330 26645 27840 36555 43205 45327 50437 54115 62320 64704
12021 23333 26990 27842 36556 43211 45331 50551 54150 62321 64722
13102 23500 26991 27860 36568 43212 45332 50553 54220 62323 64726
13122 23505 27040 28222 36569 43213 45333 50555 54230 62326 64727
13133 23520 27086 28225 36580 43214 45334 50557 54450 63610 64832
15003 23525 27197 28226 36584 43215 45335 50561 54500 63661 64837
15005 23540 27230 28264 36589 43216 45337 50688 54505 63662 64859
15111 23545 27238 28400 36590 43217 45338 50951 54800 63663 64907
15116 23570 27246 28545 36640 43220 45340 50953 54865 63664 65175
15131 23575 27250 28575 38220 43226 45341 50955 55100 63688 65210
15136 23650 27265 28605 38221 43235 45342 50957 55150 64415 65222
15151 23655 27323 28635 38222 43450 45346 50961 55175 64416 65400
15152 23700 27324 28665 38300 43453 45347 50970 55400 64417 65800
15156 23930 27380 29581 38505 43753 45398 50972 55680 64420 65820
15157 24100 27390 29584 40818 43754 45520 50974 55720 64421 65865
15272 24500 27500 30120 40819 43755 45900 50976 56441 64430 66020
15274 24505 27508 30310 40831 43756 45905 50980 56442 64455 66030
15276 24530 27510 30801 41005 43757 45910 51080 56700 64479 66500
15278 24535 27516 30802 41006 43760 45915 51101 57000 64480 66505
19081 24560 27517 30903 41007 43761 46030 51102 57023 64483 66762
19082 24576 27520 30905 41008 43762 46050 51710 57065 64484 67015
19083 24577 27530 30906 41009 43763 46220 51726 57180 64490 67025
19084 24600 27532 31235 41010 43870 46230 51727 57200 64491 67030
19085 24655 27538 31238 41015 44100 46285 51728 57426 64492 67208
19086 24670 27550 31515 41016 44312 46608 51729 57700 64493 67227
19100 24675 27552 31525 41017 44380 46610 51785 58555 64494 67346
19281 25028 27560 31527 41018 44382 46611 51880 59320 64495 67415
19282 25250 27562 31603 41116 44385 46612 52000 60000 64510 67500
19283 25251 27570 31612 41500 44386 46706 52317 61020 64520 67715
19284 25505 27605 31615 41510 44388 46917 53000 61026 64530 67820
19285 25520 27606 31622 41512 44389 46922 53010 61050 64553 67825
19286 25535 27658 31637 41530 44390 46924 53020 61055 64568 68510
19287 25635 27750 31645 41800 44391 46946 53200 61070 64575 68525
19288 25660 27752 31646 42180 44392 47000 53442 61888 64580 68810
19328 25671 27760 31717 42300 44394 48102 53445 62194 64585 69105
19330 25675 27762 31720 42310 44401 49180 53446 62225 64595 69110
20206 25690 27780 31730 42320 44402 49418 53447 62263 64600 69205
20220 26011 27781 31820 42600 45000 49419 53449 62264 64605 69424
20670 26025 27786 31899 42700 45100 49421 53450 62267 64610 69450
20694 26105 27788 32400 42720 45305 49422 53460 62268 64611 69711
21011 26110 27808 32405 42804 45307 50200 53665 62269 64620 92018
21295 26350 27810 32554 42900 45308 50390 53855 62270 64633 92019
21296 26476 27816 36262 42960 45309 50395 54057 62272 64634 92020
21480 26477 27818 36465 43200 45315 50396 54060 62273   G0260

Back to Top

ASC Group 2

ASC Group 2
10121 15150 21930 25624 27502 28405 31631 41826 45020 52327 57156 64858
10180 15155 21931 25676 27566 28406 31634 41827 45108 52330 57210 64872
11010 15201 21932 25680 27603 28435 31635 42000 45150 52332 57400 64885
11011 15220 21933 25695 27604 28436 31636 42107 45160 52630 57410 64886
11012 15221 22315 26020 27607 28456 31638 42140 45171 52640 57415 64890
11042 15260 22505 26030 27610 28476 31640 42182 45172 52700 57513 64891
11043 15261 23000 26034 27614 28496 31641 42305 45378 53040 57520 64892
11044 15271 23020 26055 27618 28546 31643 42340 45379 53220 57522 64893
11406 15273 23066 26060 27632 28555 31755 42405 45380 53230 58120 64901
11424 15275 23071 26070 27640 28606 31825 42450 45381 53240 58346 64902
11426 15277 23073 26100 27641 28810 31830 42725 45382 53250 58559 64905
11446 15740 23075 26111 27656 28820 32551 42806 45383 53260 60200 64912
11450 15750 23076 26113 27659 28825 32555 42808 45384 53265 61885 64913
11451 15760 23100 26115 27664 30115 32560 42950 45385 53270 62230 65135
11462 15777 23170 26116 27665 30125 33222 42955 45386 53275 62350 65150
11463 16025 23172 26140 27675 30140 33223 42962 45391 53405 62355 65235
11470 16030 23174 26200 27681 30320 33233 43227 45392 53410 62360 65270
11471 19020 23405 26210 27695 30560 36261 43231 45500 53425 62361 65272
11604 19101 23406 26262 27696 30915 36522 43232 45505 53430 62362 65410
11624 19110 23605 26320 27698 31020 36557 43236 45560 53431 62365 65420
11626 19340 23625 26471 27704 31050 36558 43237 45990 53440 63600 65815
11644 20005 23665 26474 27705 31070 36575 43238 46045 53444 63650 66160
11646 20200 23675 26485 27707 31200 36576 43239 46060 53502 63685 66174
11960 20225 23931 26550 27709 31233 36578 43240 46200 53505 63746 66175
12005 20240 23935 26560 27730 31237 36581 43241 46615 53510 64517 66185
12006 20690 24066 26596 27732 31240 36860 43242 46707 53515 64569 66250
12007 20975 24071 26600 27734 31241 37609 43243 46754 53520 64570 66682
12016 21010 24073 26605 27740 31253 37650 43244 46760 53605 64590 66700
12017 21012 24075 26607 27742 31257 37700 43245 47552 54000 64630 66710
12018 21013 24076 26650 27825 31259 38305 43246 49082 54001 64680 66711
12034 21014 24110 26675 27829 31400 38308 43247 49083 54110 64681 66720
12035 21025 24134 26676 27832 31420 38500 43248 49084 54111 64708 66740
12036 21026 24136 26705 28020 31510 38510 43249 49402 54112 64712 66821
12037 21029 24138 26706 28022 31511 38520 43250 49411 54120 64713 67031
12044 21040 24147 26742 28024 31512 38525 43251 49426 54160 64714 67115
12045 21044 24160 26756 28039 31513 38530 43255 49540 54161 64718 67120
12046 21046 24201 26776 28043 31526 38542 43260 52001 54162 64719 67121
12047 21047 24345 26785 28050 31528 38740 43261 52005 54163 64721 67141
12054 21060 24495 26861 28052 31529 38760 43262 52007 54164 64732 67560
12055 21100 24538 26951 28054 31530 40500 43263 52010 54512 64734 67808
12056 21310 24565 27000 28060 31535 40510 43264 52204 54660 64736 67830
12057 21315 24566 27041 28086 31570 40520 43265 52214 54700 64738 67835
13100 21320 24582 27043 28088 31571 40525 43269 52224 55110 64740 67935
13120 21337 24605 27047 28100 31572 40527 43273 52234 55120 64742 67950
13131 21400 24620 27080 28104 31573 40530 44360 52260 55180 64744 68115
13160 21452 25031 27198 28108 31574 40814 44361 52270 55200 64746 68130
14000 21485 25035 27202 28192 31576 40814 44363 52275 55250 64771 68360
14040 21497 25066 27252 28234 31577 40816 44364 52277 55700 64772 68362
15002 21501 25071 27266 28240 31578 40840 44365 52281 55705 64774 68700
15004 21502 25075 27275 28280 31595 41112 44366 52283 55706 64778 68811
15040 21552 25100 27305 28291 31613 41113 44369 52285 55725 64783 68815
15050 21554 25118 27325 28292 31614 41114 44372 52287 56440 64787 69120
15100 21555 25145 27326 28295 31623 41250 44373 52290 57010 64795 69140
15110 21556 25150 27327 28300 31624 41251 44376 52300 57020 64802 69145
15115 21600 25151 27337 28302 31625 41252 44377 52305 57105 64834 69620
15120 21610 25248 27391 28304 31628 41520 44378 52310 57130 64840 C9738
15130 21700 25263 27393 28308 31629   44384 52315 57135 64856 G0105
15135 21925 25565 27501 28313 31630   45005 52318 57155 64857 G0121

Back to Top

ASC Group 3

ASC Group 3
11770 15833 21401 24430 25390 26437 27097 27685 28126 29821 31254 40652 52343 56515 65091
11771 15834 21450 24470 25392 26440 27098 27686 28130 29822 31256 40654 52344 56740 65093
11772 15835 21453 24498 25400 26442 27257 27687 28140 29823 31267 40761 52345 56800 65101
11970 15836 21490 24575 25415 26445 27301 27692 28150 29825 31276 40842 52346 57220 65103
13101 15839 21557 24579 25425 26449 27306 27745 28153 29826 31287 40843 52351 57230 65130
13121 15847 21558 24615 25450 26450 27307 27756 28160 29830 31288 42408 52400 57268 65140
13132 15876 21720 24635 25455 26455 27328 27766 28171 29834 31295 42409 52402 57300 65155
13151 15877 21725 24685 25490 26460 27339 27784 28173 29835 31296 42410 52450 57530 65260
13152 15878 21935 24925 25491 26480 27340 27792 28175 29836 31297 42440 52500 57550 65290
13153 15879 21936 25000 25492 26483 27355 27814 28200 29837 31298 42500 53080 57558 65810
14001 15920 23031 25020 25515 26489 27381 27822 28202 29838 31531 42507 53235 57720 66220
14020 15931 23035 25023 25545 26490 27385 27823 28208 29840 31536 42810 53400 58350 66600
14021 15933 23040 25024 25574 26492 27386 27826 28210 29843 31540 42820 53420 58558 66605
14041 15934 23077 25025 25575 26494 27392 27827 28238 29844 31611 42860 54300 58560 66625
14060 15940 23078 25073 25605 26496 27394 27846 28250 29845 33212 42870 54304 58561 66630
14061 15941 23490 25076 25606 26497 27395 27848 28260 29846 33213 42972 54308 58562 66635
14350 15944 23491 25077 25628 26499 27396 27884 28261 29847 36260 43257 54312 58670 66680
15101 15950 23515 25078 25645 26508 27397 27889 28270 29870 36560 43259 54316 58671 67250
15121 15952 23530 25085 25670 26510 27400 27892 28285 29871 36561 44340 54318 58800 67255
15200 15956 23550 25101 25685 26517 27418 27893 28288 29873 36563 46020 54322 58820 67311
15240 19112 23585 25107 25907 26518 27420 27894 28289 29874 36565 46040 54324 58900 67400
15241 19120 23660 25110 25922 26520 27424 28002 28296 29882 36566 46080 54326 59160 67880
15570 19125 23670 25111 25929 26525 27427 28003 28297 29883 36570 46250 54328 61215 67882
15572 19126 23680 25119 26045 26530 27497 28005 28298 29884 36571 46255 54340 61790 67911
15574 19301 23921 25120 26117 26555 27498 28008 28305 29885 36582 46257 54344 61791 67912
15576 19342 24077 25125 26118 26561 27499 28011 28310 29886 36583 46258 54348 61886 67914
15600 20205 24079 25126 26130 26568 27503 28041 28312 29887 36585 46260 54352 62294 67921
15610 20245 24105 25130 26145 26591 27509 28045 28415 29889 36800 46270 54360 63744 67961
15630 20250 24115 25135 26160 26593 27594 28046 28445 29891 36810 46275 54380 64716 67966
15730 20251 24116 25136 26170 26685 27600 28047 28465 29892 36815 46700 54385 64776 67971
15731 20525 24120 25210 26180 26686 27601 28062 28505 29894 36818 46750 54400 64782 67973
15733 20650 24125 25265 26205 26843 27602 28070 28525 29895 36819 46753 54401 64784 67974
15734 20680 24126 25272 26215 26844 27612 28072 28531 29897 36820 46761 54405 64786 67975
15736 20693 24130 25290 26235 26860 27615 28080 28576 29898 36821 47553 54406 64788 68500
15738 20696 24140 25295 26236 26863 27616 28090 28585 29899 36861 47554 54408 64790 68505
15770 20697 24145 25300 26250 26910 27619 28092 28615 29900 37500 47555 54410 64792 68540
15775 20900 24152 25301 26260 27001 27630 28102 28636 29901 37607 49320 54415 64835 68550
15776 20910 24155 25310 26373 27003 27634 28103 28645 29902 37718 49590 54416 64836 69150
15820 20912 24164 25315 26392 27033 27635 28106 28666 30117 37722 50205 54520 64861 69300
15821 20922 24310 25316 26410 27045 27637 28107 28675 30118 37735 51715 54522 64862 69310
15822 20939 24320 25320 26412 27048 27638 28110 29800 30130 37760 52235 54620 64864 69421
15824 21016 24330 25335 26416 27049 27647 28111 29804 30150 37761 52240 54670 64874 69436
15825 21034 24331 25350 26426 27050 27650 28112 29805 30220 37780 52276 54680 64876 69440
15826 21050 24340 25355 26428 27052 27652 28113 29806 30430 37785 52301 54830 64895 69670
15828 21070 24341 25360 26432 27059 27654 28114 29807 30920 37790 52334 54860 64896 69676
15830 21355 24342 25365 26433 27087 27676 28116 29819 31030 38550 52341 55040 64897 69700
15832 21356 24420 25370 26434 27096 27680 28122 29820 31205 40650 52342 55500 64898 A4300

Back to Top

ASC Group 4

ASC Group 4
14301 21240 23615 25275 26418 27330 28035 29851 31546 49495 54420 65850 67405
14302 21325 23616 25280 26420 27331 28055 29855 31551 49496 54435 65870 67550
15620 21336 23800 25312 26498 27332 28118 29856 31552 49525 54440 65875 67570
15840 21338 24000 25375 26500 27333 28119 29860 31553 49560 54530 65880 67900
15841 21340 24006 25391 26502 27334 28193 29861 31554 49565 54550 66150 67903
15845 21421 24101 25393 26540 27335 28262 29863 35188 49570 54600 66155 679040
15922 21445 24102 25405 26542 27345 28286 29875 35207 49580 54640 66170 67908
15935 21451 24301 25420 26545 27347 28306 29876 36825 49600 54840 66172 67909
15936 21461 24305 25426 26546 27350 28307 29914 36830 49652 54861 66225 67916
15937 21465 24400 25440 26548 27356 28309 29915 36832 49654 54900 66825 67917
15945 22900 24410 25525 26562 27403 28315 29916 36833 49656 54901 66830 67923
15946 22901 24435 25800 26608 27405 28320 30160 36835 51020 55060 66840 67924
15951 22902 24515 25820 26615 27407 28322 30400 38555 51030 55520 66852 68320
15953 22903 24516 26040 26665 27409 28340 30520 38745 51040 55530 66920 68325
15958 23044 24545 26075 26715 27428 28341 30580 42120 51045 55535 67005 68326
19300 23105 24586 26080 26735 27429 28344 30600 42260 51050 60280 67010 68328
19303 23106 24665 26121 26765 27430 28345 30930 42505 51065 60281 67027 68330
19316 23107 24666 26123 26841 27435 28420 31032 42509 51500 64821 67036 68335
19318 23140 24800 26125 26842 27437 28485 31051 42510 51520 64831 67101 68340
19324 23150 25105 26135 26850 27620 28705 31075 43229 52250 64865 67312 68720
19350 23180 25112 26185 26852 27625 28715 31080 43233 52325 65105 67314 68745
19355 23182 25115 26352 26862 27626 28725 31081 43266 52352 65265 67316 68750
19370 23184 25116 26356 26952 27690 28730 31084 46261 52353 65275 67318 68770
19371 23190 25215 26357 27035 27691 28735 31085 46262 52354 65280 67320 69666
20902 23430 25230 26358 27100 27758 28740 31086 46280 52355 65285 67331 69667
20920 23440 25240 26370 27105 27759 28750 31087 46288 52356 65772 67332  
20924 23480 25260 26372 27110 27828 28755 31239 49250 52601 65775 67334  
  23532 25270 26390 27111 27870 28760 31541 49321 54015 65778 67335  
  23552 25274 26415 27310 27871 29850 31545 49322 54205 65779 67340  

Back to Top

ASC Group 5

ASC Group 5
15650 22905 24362 25526 27062 29827 40845 49555 57556 65930 67902
15823 23120 24365 25607 27065 30410 41120 50432 58145 66180 67906
15829 23125 24366 25608 27066 30420 42145 50433 58660 66930 69550
19357 23130 24370 25609 27067 30435 42200 51992 58661 66940 69631
19366 23145 24371 25805 27329 30540 42205 52320 58662 67041 69632
19380 23146 24546 25810 27357 30545 42210 53210 58672 67042 69633
21206 23155 24587 25825 27358 31090 42220 53215 58673 67043 69660
21209 23156 24802 25830 27360 31201 42226 54692 58674 67105 69661
21242 23195 25040 26535 27364 31255 42235 55041 59812 67107 69662
21243 23395 25332 26536 27438 31300 42815 55540 59820 67218 69720
21270 23410 25337 26565 27441 31560 42821 56620 59821 67412 69740
21280 23415 25441 26567 27442 31561 42825 56810 59840 67413 69745
21282 23450 25442 26580 27443 31580 42826 57240 59841 67420 69801
21330 23460 25443 26587 27496 31590 42830 57250 59870 67430  
21339 23465 25444 26590 27700 31591 42831 57260 59871 67440  
21454 23630 25445 26746 28299 31592 42835 57288 65110 67445  
21462 24360 25447 26820 28737 31750 42836 57289 65426 67450  
22904 24361 25449 27060 29824 40844 49550 57291 65900 67901  

Back to Top

ASC Group 6

ASC Group 6
29877 29879 29880 29881 29888 54437 66985 66986

Back to Top

ASC Group 7

ASC Group 7
19302 21245 23420 27422 42425 50693 65756 69511 69643
21120 21246 23455 27425 42665 50694 65770 69530 69644
21121 21248 23462 28120 42890 50695 65920 69552 69645
21122 21249 23466 30450 42892 56625 66130 69601 69646
21123 21267 23485 30460 46762 57265 66850 69602 69650
21125 21275 23802 30620 46947 57267 67039 69603 69805
21181 21335 24363 30630 47533 58353 67040 69604 69806
21208 21345 25446 40700 47534 65112 67108 69605 69905
21210 23101 26230 40701 47535 65114 67343 69635 69910
21215 23334 26531 40720 47536 65710 69320 69636 69915
21230 23397 26541 42215 47541 65730 69501 69637 69930
21235 23400 26727 42415 49520 65750 69502 69641  
21244 23412 27372 42420 49568 65755 69505 69642  

Back to Top

ASC Group 8

ASC Group 8
31652 31653 31654 66982 66983 66984

Back to Top

ASC Group 9

ASC Group 9
11606 22510 30462 36475 38571 44370 49505 49566 49655 52647 55875 58575
19296 22511 30465 36476 38572 44379 49507 49572 49657 52648 58545 62287
19297 22512 35875 36478 38573 45190 49521 49582 50590 54690 58546 69714
19298 29848 35876 36479 41899 47556 49553 49585 50947 55550 58550 69715
19325 29862 36473 36831 43210 49500 49557 49587 50948 55873 58563 69717
21127 29893 36474 38570 43653 49501 49561 49653 52282 55874 58565 69718

Back to Top

ASC Group 10

ASC Group 10
47537 47538 47539 47540 47562 47563 47564 49650 49651

Back to Top

ASC Group 11

ASC Group 11
V2785

Back to Top

CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Patient's Relationship to Insured Conditional Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Conditional Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional  
17b. NPI of Referring Physician Required Required in accordance with Program Rule 8.125.8.A
18. Hospitalization Dates Related to Current Service Not required  
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges
Conditional Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Not Required  
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Practitioner claims must be consecutive days.
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.
Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
N4 - National Drug Codes
  • Enter NDC qualifier N4 (left-justified), immediately followed by the 11-digit NDC numeric code.
  • Enter one space for separation.
  • Enter the appropriate qualifier for the correct dispensing NDC unit of measure (UN – Units, ML – Milliliter, GR – Gram, or F2 – International Unit), immediately followed by the quantity (number of NDC units).
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
24 - ASC
24C. EMG Conditional Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.
24D. Procedures, Services, or Supplies Required Enter the procedure code that specifically describes the service for which payment is requested.
24D. Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.

Telemedicine
For originating provider use procedure code Q3014.

For distant provider use procedure code + modifier GT.
24D. Modifier Not Required  
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.

Anesthesia Services
Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period.

Anesthesia time begins when the anesthetist begins member preparation for induction in the operating room or an equivalent area and ends when the anesthetist is no longer in constant attendance. No additional benefit or additional units are added for emergency conditions or the member’s physical status.

The fiscal agent converts reported anesthesia time into fifteen minute units. Any fractional unit of service is rounded up to the next fifteen minute increment.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV - Available- Not Used
S2 - Under Treatment
ST - New Service Requested
NU - Not Used

Family Planning (unshaded area)
If the service is Family Planning, enter "Y" for YES or "N" for NO in the bottom, unshaded area of the field.
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Not Required  
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider’s name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
"Signature on file" notation is not acceptable in place of an authorized signature.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

Back to Top

 

CMS 1500 ASC Claim Example

CMS 1500 ASC Claim Example

Back to Top

 

CMS 1500 ASC Crossover Claim Example

CMS 1500 ASC crossover Claim Example

Back to Top

 

Sterilizations, Hysterectomies, and Abortions

For more information on Sterilization, Hysterectomies, and Abortions, please see the Obstetrical Care Billing Manual on the Billing Manuals web page under CMS 1500 drop-down menu.

Back to Top

Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.

Back to Top

ASC Revisions Log

Revision Date Addition/Changes Made by
12/1/2016 Manual revised for interChange implementation. For manual revisions prior to 12/1/2016, please refer to Archive. HPE (now DXC)
12/27/2016 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx. HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsx. HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email. HPE (now DXC)
5/22/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
2/9/2018 Removed NDC supplemental qualifier - not relevant for ASC providers DXC
6/25/2018 Updated billing and timely to point to general manual HCPF
12/21/2018 Clarification to signature requirements HCPF
5/24/2019 Updated procedure groups, removed pilot program and rate table sections HCPF
1/7/2020 Converted to web page HCPF
4/21/2020 Added ASC Group 11 HCPF
6/17/2020 Updated procedure groups HCPF
9/10/2020 Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table  HCPF

Back to Top