Medical, Dental & Pharmacy
- Medical
- Ambulatory Surgical Services
- Children's Services
- Chiropractic
- Clinic Services
- Community First Services and Supports (CFSS)
- Early Intensive Development and Behavioral Intervention (EIDBI)
- Equipment and Supplies
- HCBS
- Hearing Services
- Home Care Services
- Hospice Services
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Laboratory/Pathology, Radiology, and Diagnostic Services
- Language Interpreter Services
- Long-Term Care
- Medication Reconciliation
- Mental Health Services
- Optical Services
- Personal Care Assistance (PCA) Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitation Services
- Renal Dialysis
- Restricted Recipient Program
- School-Based Community Services
- Substance Use Disorder
- Telehealth Services
- Transportation
- Tribal and Federal Indian Health Services
- Dental
- Pharmacy
Billing
Bill ASC services using the following:
- The 837I electronic claim format
- Type of bill 831 or 837 for a replacement claim
- The appropriate Current Procedural Terminology (CPT) code
- Modifiers approved for ASC hospital outpatient
- Terminated procedures must be billed with the appropriate modifier
- If more than one procedure was performed, use the appropriate modifier(s) as described in CPT or the Healthcare Common Procedure Coding System (HCPCS) manual for subsequent surgeries requiring modifiers
- Use CPT Level I and Level II (HCPCS/National) modifiers
List primary procedures first, followed by any subsequent procedures with appropriate modifiers.
Refer to Outpatient Dental Surgery Services when billing for anesthesia used during outpatient dental procedures.
Separately Billable Services
The following services and supplies are not covered as ASC services nor included in the PrimeWest Health ambulatory surgery procedure payment. These services and supplies may be billed separately.
- Professional services: physician, anesthesiologist (administration or supervision of administration of anesthesia), and certified registered nurse anesthetists (CRNA) services
- Laboratory, X-rays, or diagnostic procedures other than those directly related to the performance of the surgical procedure
- Prosthetic devices (except intraocular lenses [IOLs]); leg, arm, back, and neck braces; and artificial limbs.
- For members on a Medicare Advantage Plan (PrimeWest Senior Health Complete [HMO SNP]1 or Prime Health Complete [HMO SNP]2), PrimeWest Health follows Medicare guidelines, and IOLs are billable as a separate service. A listing of the Centers for Medicare & Medicaid Services (CMS)-approved category 3 new technology intraocular lenses (NTIOLs), anterior chamber intraocular lenses (A-C IOLs), and posterior chamber intraocular lenses (P-C IOLs) are available on the CMS website.
- Ambulance services
- Durable medical equipment (DME) for use in the patient’s home
- Take home supplies and medications not furnished at the time of surgery with a written physician’s order from a supplier
- Pathology services
- Secondary dressings applied over a primary dressing. Examples of secondary dressings are: Ace™ bandages, elastic stockings, support hose, spence boots and other foot coverings, leotards, knee supports, surgical leggings, gauntlets, pressure garments for arms and hands, etc.
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