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Ambulatory Surgery Centers (ASC) Billing Manual

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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 (Colorado's Medicaid program) provider in order to:

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

Medical services provided in Ambulatory Surgery Centers (ASCs) are a benefit of 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 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.

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General Billing Information

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

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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, 2023. 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. Visit the Rate and Fee Schedule web page for a list of all ASC codes with their respective groupers.

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

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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. Visit the Provider Rates and Fee Schedule web page on the Department's website for current ASC group rates.

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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.

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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.

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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.

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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

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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

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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, 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.

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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 Care Billing 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 Care Billing 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 "hard copy 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.

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ASC Group 1

ASC Group 1
1140421820264782782436466432014531750434540656228064635
1144422310264792783036482432024532050435541006228164636
1197123030265162783136483432044532150436541056228264702
1202023330266452784036555432054532750437541156232064704
1202123333269902784236556432114533150551541506232164722
1310223500269912786036568432124533250553542206232364726
1312223505270402822236569432134533350555542306232664727
1313323520270862822536580432144533450557544506361064832
1500323525271972822636584432154533550561545006366164837
1500523540272302826436589432164533750688545056366264859
1511123545272382840036590432174533850951548006366364907
1511623570272462854536640432204534050953548656366465175
1513123575272502857538220432264534150955551006368865210
1513623650272652860538221432354534250957551506441565222
1515123655273232863538222432904534650961551756441665400
1515223700273242866538300432914534750970554006441765800
1515623930273802958138505434504539850972556806442065820
1515724100273902958440818434534552050974557206442165865
1527224500275003012040819437534590050976564416443066020
1527424505275083031040831437544590550980564426445566030
1527624530275103080141005437554591051080567006447966500
1527824535275163080241006437564591551101570006448066505
1908124560275173090341007437574603051102570236448366762
1908224576275203090541008437604605051710570656448467015
1908324577275303090641009437614622051726571806449067025
1908424600275323123541010437624623051727572006449167030
1908524655275383123841015437634628551728574266449267208
1908624670275503151541016438704660851729577006446367227
1910024675275523152541017441004661051785585556449367346
1928125028275603152741018443124661151880593206449467415
1928225250275623160341116443804661252000600006449567500
1928325251275703161241500443824670652317610206451067715
1928425505276053161541510443854691753000610266452067820
1928525520276063162241512443864692253010610506453067825
1928625535276583163741530443884692453020610556455368510
1928725635277503164541800443894694653200610706456868525
1928825660277523164642180443904700053442618886457568810
1932825671277603171742300443914810253445621946458069105
1933025675277623172042310443924918053446622256458569110
2020625690277803173042320443944941853447622636459569205
2022026011277813182042600444014941953449622646460069424
2067026025277863189942700444024942153450622676460569450
2069426105277883240042720450004942253460622686461069711
2101126110278083240542804451005020053665622696461192018
2129526350278103255442900453055039053855622706462092019
2129626476278163626242960453075039554057622726463392020
21480264772781836465432004530850396540606227364634G0260
     45309  64461  
     45315     

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ASC Group 2

ASC Group 2
101211515021930256242750228405316314182645020523275715664858
101801515521931256762756628406316344182745108523305721064872
110101520121932256802760328435316354200045150523325740064885
110111522021933256952760428436316364210745160526305741064886
110121522122315260202760728456316384214045171526405741564890
110421526022505260302761028476316404218245172527005751364891
110431526123000260342761428496316414230545378530405752064892
110441527123020260552761828546316434234045379532205752264893
114061527323066260602763228555317554240545380532305812064901
114241527523071260702764028606318254245045381532405834664902
114261527723073261002764128810318304272545382532505855964905
114461574023075261112765628820325554280645383532606020064912
114501575023076261132765928825332224280845384532656188564913
114511576023100261152766430115332234295045385532706223065135
114621577723170261162766530125332334295545386532756235065150
114631602523172261402767530140362614296245391534056235565235
114701603023174262002768130320365224322745392534106236065270
114711902023405262102769530560365574323145500534256236165272
116041910123406262622769630915365584323245505534306236265410
116241911023605263202769831020365754323645560534316236565420
116261934023625264712770431050365764323745990534406360065815
116442000523665264742770531070365784323846045534446365066160
116462020023675264852770731200365814323946060535026368566174
119602022523931265502770931233368604324046200535056374666175
120052024023935265602773031237376094324146615535106444666185
120062069024066265962773231240376504324246707535156444866250
120072097524071266002773431253377004324346754535206444966682
120162101024073266052774031257383054324446760536056451766700
120172101224075266072774231259383084324547552540006456966710
120182101324076266502782531400385004324649082540016457066711
120342101424110266752782931420385104324749083541106459066720
120352102524134266762783231510385204324849084541116463066740
120362102624136267052802031511385254324949402541126468066821
120372102924138267062802231512385304325049411541206468167031
120442104024147267422802431513385424325149426541606470867115
120452104424160267562803931526387404325549540541616471267120
120462104624201267762804331528387604326052001541626471367121
120472104724345267852805031529405004326152005541636471467141
120542106024495268612805231530405104326252007541646471867560
120552110024538269512805431535405204326352010545126471967808
120562131024565270002806031570405254326452204546606472167830
120572131524566270412808631571405274326552214547006473267835
131002132024582270432808831572405304326952224551106473467935
131202133724605270472810031573408144327352234551206473667950
131312140024620270802810431574408144436052260551806473868115
131602145225031271982810831576408164436152270552006474068130
140002148525035272022819231577408404436352275552506474268360
140402149725066272522823431578411124436452277557006474468362
150022150125071272662824031595411134436552281557056474668700
150042150225075272752828031613411144436652283557066477168811
150402155225100273052829131614412504436952285557256477268815
150502155425118273252829231623412514437252287564406477469120
151002155525145273262829531624412524437352290570106477869140
151102155625150273272830031625415204437652300570206478369145
151152160025151273372830231628 4437752305571056478769620
151202161025248273912830431629 44378523105713064795C9738
151302170025263273932830831630 44384523155713564802G0105
1513521925255652750128313  45005523185715564834G0121
          64840 
          64856 
          64857 

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ASC Group 3

ASC Group 3
117701583321401244302539026437270972768528126298213125440652523435651565091
117711583421450244702539226440270982768628130298223125640654523445674065093
117721583521453244982540026442272572768728140298233126740761523455680065101
119701583621490245752541526445273012769228150298253127640842523465722065103
131011583921557245792542526449273062774528153298263128740843523515723065130
131211584721558246152545026450273072775628160298303128842408524005726865140
131321587621720246352545526455273282776628171298343129542409524025730065155
131511587721725246852549026460273392778428173298353129642410524505753065260
131521587821935249252549126480273402779228175298363129742440525005755065290
131531587921936250002549226483273552781428200298373129842500530805755865810
140011592023031250202551526489273812782228202298383153142507532355772066220
140201593123035250232554526490273852782328208298403153642810534005835066600
140211593323040250242557426492273862782628210298433154042820534205855866605
140411593423077250252557526494273922782728238298443161142860543005856066625
140601594023078250732560526496273942784628250298453321242870543045856166630
140611594123490250762560626497273952784828260298463321342972543085856266635
143501594423491250772562826499273962788428261298473390043257543125867066680
151011595023515250782564526508273972788928270298703390143259543165867167250
151211595223530250852567026510274002789228285298713390244340543185880067255
152001595623550251012568526517274182789328288298733390345388543225882067311
152401911223585251072590726518274202789428289298743626045393543245890067400
152411912023660251102592226520274242800228296298823656046020543265916067880
155701912523670251112592926525274272800328297298833656146040543286121567882
155721912623680251192604526530274972800528298298843656346080543406179067911
155741930123921251202611726555274982800828305298853656546250543446179167912
155761934224077251252611826561274992801128310298863656646255543486188667914
156002020524079251262613026568275032804128312298873657046257543526229467921
156102024524105251302614526591275092804528415298893657146258543606374467961
156302025024115251352616026593275942804628445298913658246260543806471667966
157302025124116251362617026685276002804728465298923658346270543856477667971
157312052524120252102618026686276012806228505298943658546275544006478267973
157332065024125252652620526843276022807028525298953680046700544016478467974
157342068024126252722621526844276122807228531298973681046750544056478667975
157362069324130252902623526860276152808028576298983681546753544066478868500
157382069624140252952623626863276162809028585298993681846761544086479068505
157702069724145253002625026910276192809228615299003681947553544106479268540
158202090024152253012626027001276302810228636299013682047554544156483568550
158212091024155253102637327003276342810328645299023682147555544166483669150
158222091224164253152639227033276352810628666301173683649320545206486169300
158242092224310253162641027045276372810728675301183683750205545226486269310
158252093924320253202641227048276382811029800301303686151715546206486469421
158262101624330253352641627049276472811129804301503750052235546706487469436
158282103424331253502642627050276502811229805302203760752240546806487669440
158302105024340253552642827052276522811329806304303771852276548306489569670
158322107024341253602643227059276542811429807304693772252301548606489669676
 2135524342253652643327087276762811629819309203773552334550406489769700
 21356244202537026434270962768028122298203103031030377605234164898A4300
          312053776152342  
           37780   
           37785   
           37790   
           38550   
           40650   

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ASC Group 4

ASC Group 4
14301212402361525275264182733028035298513154649495544206585067405
14302213252361625280264202733128055298553155149496544356587067550
15620213362380025312264982733228118298563155249525544406587567570
15840213382400025375265002733328119298603155349591545306588067900
15841213402400625391265022733428193298613155449593545506615067903
15845214212410125393265402733528262298633518849600546006615567904
15922214452410225405265422734528286298753520749613546406617067908
15935214512430125420265452734728306298763682549614548406617267909
15936214612430525426265462735028307299143683049615548616622567916
15937214652440025440265482735628309299153683251020549006682567917
15945229002441025525265622740328315299163683351030549016683067923
15946229012443525800266082740528320301603683551040550606684067924
15951229022451525820266152740728322304003855551045555206685268320
15953229032451626040266652740928340305203874551050555306692068325
15958230442454526075267152742828341305804212051065555356700568326
19300231052458626080267352742928344306004226051500602806701068328
19303231062466526121267652743028345309304250551520602816702768330
19316231072466626123268412743528420310324250952250648216703668335
19318231402480026125268422743728485310514251052325648316710168340
19324231502510526135268502762028705310754322952352648656731268720
19350231802511226185268522762528715310804323352353651056731468745
19355231822511526352268622762628725310814326652354652656731668750
19370231842511626356269522769028730310844626152355652756731868770
19371231902521526357270352769128735310854626252356652806732069666
20902234302523026358271002775828740310864628052601652856733169667
209202344025240263702710527759287503108746288540156577267332 
209242348025260263722711027828287553123949250542056577567334 
 2353225270263902711127870287603154149321 6577867335 
 2355225274264152731027871298503154549322 6577967340 

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ASC Group 5

ASC Group 5
1565022905243622552627062298274084549555575566593067902
1582323120243652560727065304104112050432581456618067906
1582923125243662560827066304204214550433586606693069550
1935723130243702560927067304354220051992586616694069631
1936623145243712580527329305404220552320586626704169632
1938023146245462581027357305454221053210586726704269633
2120623155245872582527358310904222053215586736704369660
2120923156248022583027360312014222654692586746710569661
2124223195250402653527364312554223555041598126710769662
2124323395253322653627438313004281555540598206721869720
2127023410253372656527441315604282156620598216741269728
2128023415254412656727442315614282556810598406741369729
2128223450254422658027443315804282657240598416742069730
2133023460254432658727496315904283057250598706743069740
2133923465254442659027700315914283157260598716744069745
2145423630254452674627768315924283557288651106744569801
21462243602544726820282993175042836572896542667450 
22904243612544927060287373823049550572916590067901 
    2982440844     

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ASC Group 6

ASC Group 6
2987729879298802988129888544376698566986

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ASC Group 7

ASC Group 7
193022124523420274224242550693657566951169643
211202124623455274254266550694657706953069644
211212124823462281204289050695659206955269645
211222124923466304504289256625661306960169646
211232126723485304604676257265668506960269650
211252127523802306204694757267670396960369805
211812133524363306304753358353670406960469806
212082134525446407004753465112671086960569905
212102310126230407014753565114673436963569910
212152333426531407204753665710693206963669915
212302339726541422154754165730695016963769930
2123523400267274241549520657506950269641 
21244234122737242420 657556950569642 

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ASC Group 8

ASC Group 8
316523165331654669826698366984

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ASC Group 9

ASC Group 9
116062251030462364753857144370495054959250590526475587558575
191052251130465364763857244379495074959450947526485854562287
192962251235875364783857345190495214959550948546905854669714
19297298483587636479418994539049553 52282555505855069715
19298298623647336831432104554149557  558735856369717
19325298933647438570436534755649500  558745856569718
21127     49501     

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ASC Group 10

ASC Group 10
21406274464753747539475624756449651582625915160500
214073162647538475404756349650582605915060240 

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ASC Group 11

ASC Group 11
V2785

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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 and LabelField is?Instructions
1. Insurance TypeRequiredPlace an "X" in the box marked as Medicaid.
1a. Insured's ID NumberRequiredEnter 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 NameRequiredEnter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/SexRequiredEnter 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 NameConditionalComplete 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 AddressNot Required 
6. Patient's Relationship to InsuredConditionalComplete 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 AddressNot Required 
8. Reserved for NUCC UseNot Required 
9. Other Insured's NameConditionalIf field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group NumberConditionalIf 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 NameConditionalIf field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to?ConditionalWhen 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 NumberConditionalComplete 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, SexConditionalComplete 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 IDNot Required 
11c. Insurance Plan Name or Program NameNot Required 
11d. Is there another Health Benefit Plan?ConditionalWhen appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signatureRequiredEnter "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 SignatureNot Required 
14. Date of Current Illness Injury or PregnancyConditionalComplete 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 NotNot Required 
16. Date Patient Unable to Work in Current OccupationNot Required 
17. Name of Referring PhysicianConditional 
17b. NPI of Referring PhysicianRequiredRequired in accordance with Program Rule 8.125.8.A
18. Hospitalization Dates Related to Current ServiceNot required 
19. Additional Claim InformationConditional 
20. Outside Lab?
$ Charges		ConditionalComplete 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 InjuryRequiredEnter 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 CodeConditionalList 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 AuthorizationNot Required 
24. Claim Line DetailInformationThe 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 ServiceRequired

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.

FromTo
010119   

or

FromTo
010119010119

Span dates of service

FromTo
010119013119

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 and Areas of Oral Cavity

24B. Place of ServiceRequiredEnter 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. EMGConditionalEnter 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 SuppliesRequiredEnter the procedure code that specifically describes the service for which payment is requested.
24D.RequiredEnter 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. ModifierNot Required 
24E. Diagnosis PointerRequiredEnter 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. $ ChargesRequiredEnter 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-pay or commercial insurance payments from the usual and customary charges.
24G. Days or UnitsRequiredEnter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.
24H. EPSDT/Family PlanConditionalEPSDT (shaded area)
For Early and 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 QualifierNot Required 
24J. Rendering Provider ID #Not Required 
25. Federal Tax ID NumberNot Required 
26. Patient's Account NumberOptionalEnter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment?RequiredThe accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total ChargeRequiredEnter 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 PaidConditionalEnter 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 CredentialsRequiredEach 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 #		RequiredEnter 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 #		RequiredEnter 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 NumberRequired 
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.

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CMS 1500 ASC Claim Example

CMS 1500 ASC Claim Example

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CMS 1500 ASC Crossover Claim Example

CMS 1500 ASC crossover Claim Example

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Sterilizations, Hysterectomies and Abortions

Refer to the Obstetrical Care Billing Manual located on the Billing Manuals web page under the CMS 1500 drop-down for more information on sterilization, hysterectomies and abortions.

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Timely Filing

Refer to the General Provider Information Manual located on the Billing Manuals web page under the General Provider Information drop-down for more information on timely filing policy, including the resubmission rules for denied claims.

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ASC Revisions Log

Revision DateAddition/ChangesMade by
12/1/2016Manual revised for interChange implementation. For manual revisions prior to 12/1/2016, please refer to Archive.HPE (now DXC)
12/27/2016Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx.HPE (now DXC)
1/10/2017Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_3.xlsx.HPE (now DXC)
1/19/2017Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_4.xlsxHPE (now DXC)
1/26/2017Updates based on Department 1/20/2017 approval email.HPE (now DXC)
5/22/2017Updates based on Fiscal Agent name change from HPE to DXCDXC
2/9/2018Removed NDC supplemental qualifier - not relevant for ASC providersDXC
6/25/2018Updated billing and timely to point to general manualHCPF
12/21/2018Clarification to signature requirementsHCPF
5/24/2019Updated procedure groups, removed pilot program and rate table sectionsHCPF
1/7/2020Converted to web pageHCPF
4/21/2020Added ASC Group 11HCPF
6/17/2020Updated procedure groupsHCPF
9/10/2020Added Line to Box 32 under the CMS 1500 Paper Claim Reference TableHCPF
12/1/2021Updated allowed proceduresHCPF
5/10/2022Added approved procedures, removed outdated anesthesia languageHCPF
5/31/2022Removed extra zero from group 4 code 67904HCPF
7/20/2022Added link to Rates page for list of ASC codes and groupersHCPF
10/14/2022Removed Phone Number to EDI. Linked verbiage to Provider Help web page.HCPF
3/1/2023Updated procedures based on 2023 HCPCSHCPF
5/18/23Corrected typo in table 3HCPF

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