Medicare Payment Resources

The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called Medicare Administrative Contractors (MACs) to process Medicare claims, enroll healthcare providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. Find your MAC.

Medicare pays ASCs a prospectively determined rate for covered procedures. These rates are updated annually via a regular process. Each summer, Medicare proposes rates for the next year and then finalizes the rates in the fall.

Medicare Payment Rule

CMS releases a proposed payment rule for ASCs and hospital outpatient departments (HOPD) each July and a final payment rule each November. Click through to find current and past year rules, comment letters, payment resources, and more.

Medicare Rate Calculator

ASCA provides the Medicare Rate Calculator, a members-only resource that shows your local Medicare payment rates for ASC-payable procedures. By selecting your state and county from the drop-down menus, the calculator automatically finds your local wage index and calculates the total payment, Medicare payment and beneficiary copayment for each procedure.

Medicare Claims Processing Manual

The Medicare Claims Processing Manual is a comprehensive resource document published by CMS that contains definitions, policies, and processes relating to submitting a claim for procedures performed in an ASC.

ICD-10 Resources

Since October 1, 2015, Medicare has been using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10). According to the American Academy of Professional Coders (AAPC), ICD-10 is a standardized classification system of diagnosis codes that represent conditions and diseases, related health problems, signs and symptoms, external causes of injuries and diseases, and more. These codes are generally required by payers to justify procedures as medically necessary.

Facility Fee

Payors, including Medicare, reimburse facilities such as ASCs separately from physicians. The facility reimbursement is called the “technical component,” whereas physicians are reimbursed via a payment called the “professional component.” The technical component is also called the facility fee and pays for services such as nursing, technicians, administrative services, etc.