Ambulatory Surgery Centers (ASC) Billing Manual

• Ambulatory Surgery Centers (ASCs)
• General Billing Information
• ASC Authorized Services
• Reimbursement
  • Health First Colorado Program Payment Calculation
  • Multiple Procedures
  • Medicare Crossover Payment
  • Services and Items Included at a Minimum in the ASC Reimbursement
  • Services That May Be Billed Separately
  • Billing Procedures
  • Billing Information
  • ASC Group 1
  • ASC Group 2
  • ASC Group 3
  • ASC Group 4
  • ASC Group 5
  • ASC Group 6
  • ASC Group 7
  • ASC Group 8
  • ASC Group 9
  • ASC Group 10
  • ASC Group 11
• Paper Claim Reference Table
  • CMS 1500 ASC Claim Example
  • CMS 1500 ASC Crossover Claim Example
• Sterilizations, Hysterectomies and Abortions
• Timely Filing
• ASC Revisions Log

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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 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. See 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
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	43290	45346	50961	55175	64416	65400
15152	23700	27324	28665	38300	43291	45347	50970	55400	64417	65800
15156	23930	27380	29581	38505	43450	45398	50972	55680	64420	65820
15157	24100	27390	29584	40818	43453	45520	50974	55720	64421	65865
15272	24500	27500	30120	40819	43753	45900	50976	56441	64430	66020
15274	24505	27508	30310	40831	43754	45905	50980	56442	64455	66030
15276	24530	27510	30801	41005	43755	45910	51080	56700	64479	66500
15278	24535	27516	30802	41006	43756	45915	51101	57000	64480	66505
19081	24560	27517	30903	41007	43757	46030	51102	57023	64483	66762
19082	24576	27520	30905	41008	43760	46050	51710	57065	64484	67015
19083	24577	27530	30906	41009	43761	46220	51726	57180	64490	67025
19084	24600	27532	31235	41010	43762	46230	51727	57200	64491	67030
19085	24655	27538	31238	41015	43763	46285	51728	57426	64492	67208
19086	24670	27550	31515	41016	43870	46608	51729	57700	64463	67227
19100	24675	27552	31525	41017	44100	46610	51785	58555	64493	67346
19281	25028	27560	31527	41018	44312	46611	51880	59320	64494	67415
19282	25250	27562	31603	41116	44380	46612	52000	60000	64495	67500
19283	25251	27570	31612	41500	44382	46706	52317	61020	64510	67715
19284	25505	27605	31615	41510	44385	46917	53000	61026	64520	67820
19285	25520	27606	31622	41512	44386	46922	53010	61050	64530	67825
19286	25535	27658	31637	41530	44388	46924	53020	61055	64553	68510
19287	25635	27750	31645	41800	44389	46946	53200	61070	64568	68525
19288	25660	27752	31646	42180	44390	47000	53442	61888	64575	68810
19328	25671	27760	31717	42300	44391	48102	53445	62194	64580	69105
19330	25675	27762	31720	42310	44392	49180	53446	62225	64585	69110
20206	25690	27780	31730	42320	44394	49418	53447	62263	64595	69205
20220	26011	27781	31820	42600	44401	49419	53449	62264	64600	69424
20670	26025	27786	31899	42700	44402	49421	53450	62267	64605	69450
20694	26105	27788	32400	42720	45000	49422	53460	62268	64610	69711
21011	26110	27808	32405	42804	45100	50200	53665	62269	64611	92018
21295	26350	27810	32554	42900	45305	50390	53855	62270	64620	92019
21296	26476	27816	36262	42960	45307	50395	54057	62272	64633	92020
21480	26477	27818	36465	43200	45308	50396	54060	62273	64634	G0260
					45309			64461
					45315

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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	32555	42806	45383	53260	60200	64912
11450	15750	23076	26113	27659	28825	33222	42808	45384	53265	61885	64913
11451	15760	23100	26115	27664	30115	33223	42950	45385	53270	62230	65135
11462	15777	23170	26116	27665	30125	33233	42955	45386	53275	62350	65150
11463	16025	23172	26140	27675	30140	36261	42962	45391	53405	62355	65235
11470	16030	23174	26200	27681	30320	36522	43227	45392	53410	62360	65270
11471	19020	23405	26210	27695	30560	36557	43231	45500	53425	62361	65272
11604	19101	23406	26262	27696	30915	36558	43232	45505	53430	62362	65410
11624	19110	23605	26320	27698	31020	36575	43236	45560	53431	62365	65420
11626	19340	23625	26471	27704	31050	36576	43237	45990	53440	63600	65815
11644	20005	23665	26474	27705	31070	36578	43238	46045	53444	63650	66160
11646	20200	23675	26485	27707	31200	36581	43239	46060	53502	63685	66174
11960	20225	23931	26550	27709	31233	36860	43240	46200	53505	63746	66175
12005	20240	23935	26560	27730	31237	37609	43241	46615	53510	64446	66185
12006	20690	24066	26596	27732	31240	37650	43242	46707	53515	64448	66250
12007	20975	24071	26600	27734	31253	37700	43243	46754	53520	64449	66682
12016	21010	24073	26605	27740	31257	38305	43244	46760	53605	64517	66700
12017	21012	24075	26607	27742	31259	38308	43245	47552	54000	64569	66710
12018	21013	24076	26650	27825	31400	38500	43246	49082	54001	64570	66711
12034	21014	24110	26675	27829	31420	38510	43247	49083	54110	64590	66720
12035	21025	24134	26676	27832	31510	38520	43248	49084	54111	64630	66740
12036	21026	24136	26705	28020	31511	38525	43249	49402	54112	64680	66821
12037	21029	24138	26706	28022	31512	38530	43250	49411	54120	64681	67031
12044	21040	24147	26742	28024	31513	38542	43251	49426	54160	64708	67115
12045	21044	24160	26756	28039	31526	38740	43255	49540	54161	64712	67120
12046	21046	24201	26776	28043	31528	38760	43260	52001	54162	64713	67121
12047	21047	24345	26785	28050	31529	40500	43261	52005	54163	64714	67141
12054	21060	24495	26861	28052	31530	40510	43262	52007	54164	64718	67560
12055	21100	24538	26951	28054	31535	40520	43263	52010	54512	64719	67808
12056	21310	24565	27000	28060	31570	40525	43264	52204	54660	64721	67830
12057	21315	24566	27041	28086	31571	40527	43265	52214	54700	64732	67835
13100	21320	24582	27043	28088	31572	40530	43269	52224	55110	64734	67935
13120	21337	24605	27047	28100	31573	40814	43273	52234	55120	64736	67950
13131	21400	24620	27080	28104	31574	40814	44360	52260	55180	64738	68115
13160	21452	25031	27198	28108	31576	40816	44361	52270	55200	64740	68130
14000	21485	25035	27202	28192	31577	40840	44363	52275	55250	64742	68360
14040	21497	25066	27252	28234	31578	41112	44364	52277	55700	64744	68362
15002	21501	25071	27266	28240	31595	41113	44365	52281	55705	64746	68700
15004	21502	25075	27275	28280	31613	41114	44366	52283	55706	64771	68811
15040	21552	25100	27305	28291	31614	41250	44369	52285	55725	64772	68815
15050	21554	25118	27325	28292	31623	41251	44372	52287	56440	64774	69120
15100	21555	25145	27326	28295	31624	41252	44373	52290	57010	64778	69140
15110	21556	25150	27327	28300	31625	41520	44376	52300	57020	64783	69145
15115	21600	25151	27337	28302	31628		44377	52305	57105	64787	69620
15120	21610	25248	27391	28304	31629		44378	52310	57130	64795	C9738
15130	21700	25263	27393	28308	31630		44384	52315	57135	64802	G0105
15135	21925	25565	27501	28313			45005	52318	57155	64834	G0121
										64840
										64856
										64857

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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	33900	43257	54312	58670	66680
15101	15950	23515	25078	25645	26508	27397	27889	28270	29870	33901	43259	54316	58671	67250
15121	15952	23530	25085	25670	26510	27400	27892	28285	29871	33902	44340	54318	58800	67255
15200	15956	23550	25101	25685	26517	27418	27893	28288	29873	33903	45388	54322	58820	67311
15240	19112	23585	25107	25907	26518	27420	27894	28289	29874	36260	45393	54324	58900	67400
15241	19120	23660	25110	25922	26520	27424	28002	28296	29882	36560	46020	54326	59160	67880
15570	19125	23670	25111	25929	26525	27427	28003	28297	29883	36561	46040	54328	61215	67882
15572	19126	23680	25119	26045	26530	27497	28005	28298	29884	36563	46080	54340	61790	67911
15574	19301	23921	25120	26117	26555	27498	28008	28305	29885	36565	46250	54344	61791	67912
15576	19342	24077	25125	26118	26561	27499	28011	28310	29886	36566	46255	54348	61886	67914
15600	20205	24079	25126	26130	26568	27503	28041	28312	29887	36570	46257	54352	62294	67921
15610	20245	24105	25130	26145	26591	27509	28045	28415	29889	36571	46258	54360	63744	67961
15630	20250	24115	25135	26160	26593	27594	28046	28445	29891	36582	46260	54380	64716	67966
15730	20251	24116	25136	26170	26685	27600	28047	28465	29892	36583	46270	54385	64776	67971
15731	20525	24120	25210	26180	26686	27601	28062	28505	29894	36585	46275	54400	64782	67973
15733	20650	24125	25265	26205	26843	27602	28070	28525	29895	36800	46700	54401	64784	67974
15734	20680	24126	25272	26215	26844	27612	28072	28531	29897	36810	46750	54405	64786	67975
15736	20693	24130	25290	26235	26860	27615	28080	28576	29898	36815	46753	54406	64788	68500
15738	20696	24140	25295	26236	26863	27616	28090	28585	29899	36818	46761	54408	64790	68505
15770	20697	24145	25300	26250	26910	27619	28092	28615	29900	36819	47553	54410	64792	68540
15820	20900	24152	25301	26260	27001	27630	28102	28636	29901	36820	47554	54415	64835	68550
15821	20910	24155	25310	26373	27003	27634	28103	28645	29902	36821	47555	54416	64836	69150
15822	20912	24164	25315	26392	27033	27635	28106	28666	30117	36836	49320	54520	64861	69300
15824	20922	24310	25316	26410	27045	27637	28107	28675	30118	36837	50205	54522	64862	69310
15825	20939	24320	25320	26412	27048	27638	28110	29800	30130	36861	51715	54620	64864	69421
15826	21016	24330	25335	26416	27049	27647	28111	29804	30150	37500	52235	54670	64874	69436
15828	21034	24331	25350	26426	27050	27650	28112	29805	30220	37607	52240	54680	64876	69440
15830	21050	24340	25355	26428	27052	27652	28113	29806	30430	37718	52276	54830	64895	69670
15832	21070	24341	25360	26432	27059	27654	28114	29807	30469	37722	52301	54860	64896	69676
	21355	24342	25365	26433	27087	27676	28116	29819	30920	37735	52334	55040	64897	69700
	21356	24420	25370	26434	27096	27680	28122	29820	31030	31030	37760	52341	64898	A4300
										31205	37761	52342
											37780
											37785
											37790
											38550
											40650

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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	49591	54530	65880	67900
15841	21340	24006	25391	26502	27334	28193	29861	31554	49593	54550	66150	67903
15845	21421	24101	25393	26540	27335	28262	29863	35188	49600	54600	66155	67904
15922	21445	24102	25405	26542	27345	28286	29875	35207	49613	54640	66170	67908
15935	21451	24301	25420	26545	27347	28306	29876	36825	49614	54840	66172	67909
15936	21461	24305	25426	26546	27350	28307	29914	36830	49615	54861	66225	67916
15937	21465	24400	25440	26548	27356	28309	29915	36832	51020	54900	66825	67917
15945	22900	24410	25525	26562	27403	28315	29916	36833	51030	54901	66830	67923
15946	22901	24435	25800	26608	27405	28320	30160	36835	51040	55060	66840	67924
15951	22902	24515	25820	26615	27407	28322	30400	38555	51045	55520	66852	68320
15953	22903	24516	26040	26665	27409	28340	30520	38745	51050	55530	66920	68325
15958	23044	24545	26075	26715	27428	28341	30580	42120	51065	55535	67005	68326
19300	23105	24586	26080	26735	27429	28344	30600	42260	51500	60280	67010	68328
19303	23106	24665	26121	26765	27430	28345	30930	42505	51520	60281	67027	68330
19316	23107	24666	26123	26841	27435	28420	31032	42509	52250	64821	67036	68335
19318	23140	24800	26125	26842	27437	28485	31051	42510	52325	64831	67101	68340
19324	23150	25105	26135	26850	27620	28705	31075	43229	52352	64865	67312	68720
19350	23180	25112	26185	26852	27625	28715	31080	43233	52353	65105	67314	68745
19355	23182	25115	26352	26862	27626	28725	31081	43266	52354	65265	67316	68750
19370	23184	25116	26356	26952	27690	28730	31084	46261	52355	65275	67318	68770
19371	23190	25215	26357	27035	27691	28735	31085	46262	52356	65280	67320	69666
20902	23430	25230	26358	27100	27758	28740	31086	46280	52601	65285	67331	69667
20920	23440	25240	26370	27105	27759	28750	31087	46288	54015	65772	67332
20924	23480	25260	26372	27110	27828	28755	31239	49250	54205	65775	67334
	23532	25270	26390	27111	27870	28760	31541	49321		65778	67335
	23552	25274	26415	27310	27871	29850	31545	49322		65779	67340

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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	69728
21280	23415	25441	26567	27442	31561	42825	56810	59840	67413	69729
21282	23450	25442	26580	27443	31580	42826	57240	59841	67420	69730
21330	23460	25443	26587	27496	31590	42830	57250	59870	67430	69740
21339	23465	25444	26590	27700	31591	42831	57260	59871	67440	69745
21454	23630	25445	26746	27768	31592	42835	57288	65110	67445	69801
21462	24360	25447	26820	28299	31750	42836	57289	65426	67450
22904	24361	25449	27060	28737	38230	49550	57291	65900	67901
				29824	40844

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ASC Group 6

ASC Group 6
29877	29879	29880	29881	29888	54437	66985	66986

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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		65755	69505	69642

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ASC Group 8

ASC Group 8
31652	31653	31654	66982	66983	66984

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ASC Group 9

ASC Group 9
11606	22510	30462	36475	38571	44370	49505	49592	50590	52647	55875	58575
19105	22511	30465	36476	38572	44379	49507	49594	50947	52648	58545	62287
19296	22512	35875	36478	38573	45190	49521	49595	50948	54690	58546	69714
19297	29848	35876	36479	41899	45390	49553		52282	55550	58550	69715
19298	29862	36473	36831	43210	45541	49557			55873	58563	69717
19325	29893	36474	38570	43653	47556	49500			55874	58565	69718
21127						49501

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ASC Group 10

ASC Group 10
21406	27446	47537	47539	47562	47564	49651	58262	59151	60500
21407	31626	47538	47540	47563	49650	58260	59150	60240

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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 & 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-pay 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.
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.

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CMS 1500 ASC Claim Example

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CMS 1500 ASC Crossover Claim Example

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Sterilizations, Hysterectomies and Abortions

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

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Timely Filing

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

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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
12/1/2021	Updated allowed procedures	HCPF
5/10/2022	Added approved procedures, removed outdated anesthesia language	HCPF
5/31/2022	Removed extra zero from group 4 code 67904	HCPF
7/20/2022	Added link to Rates page for list of ASC codes and groupers	HCPF
10/14/2022	Removed Phone Number to EDI. Linked verbiage to Provider Help web page.	HCPF
3/1/2023	Updated procedures based on 2023 HCPCS	HCPF
5/18/23	Corrected typo in table 3	HCPF

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