Implant billing is where ASC revenue is most often quietly lost. Bill a packaged device separately and the line denies. Fail to report the device on a device-intensive procedure and you are paid as though no device was used. The categories are not intuitive, so here they are.
Most implantable device costs in an ASC are packaged into the facility fee and cannot be billed separately. The exceptions are device-intensive procedures, where the device offset exceeds 30 percent of the procedure cost, and pass-through devices with temporary HCPCS C-codes, which are separately payable for a limited period.
Under the ASC payment system, the facility fee for a covered surgical procedure is understood to already include the implantable devices, supplies and drugs used in it. CMS is explicit that an ASC should not report separate line items or HCPCS codes for items packaged into the payment allowance.
So the starting assumption for any device is: it is already paid for. Billing it as its own line produces a denial, commonly with a remark indicating the service is included in the allowance for another service already adjudicated.
Two categories escape that default. Both are worth knowing precisely, because the money involved per claim in an ASC is large.
Some procedures are so dominated by the cost of the device that packaging them at the ordinary rate would underpay the facility badly. CMS designates these device-intensive and builds the device cost into a higher payment rate for the procedure itself.
The current definition, in force since 1 January 2019: a procedure involving the surgical implantation or insertion of an implantable device assigned a CPT or HCPCS code — including single-use devices — with a device offset exceeding 30 percent of the procedure's mean cost.
Two things changed on that date and both still trip people up. The threshold came down from more than 40 percent to more than 30 percent, and single-use devices became eligible regardless of whether they remain in the body after the procedure. New procedure codes requiring an implantable device are now assigned a default device offset of at least 31 percent until claims data exists, which means they carry device-intensive status from the start.
The payment is in the procedure rate, not a separate device line — but the device HCPCS code still belongs on the claim. Omitting it is the error that costs money here, and it is invisible: the claim pays, just not at the device-intensive rate.
New device technology would otherwise be stranded outside the payment system until claims data accumulated. Transitional pass-through status closes that gap: a qualifying device receives a temporary HCPCS C-code and is separately payable above the bundled rate for a limited period, generally around three years.
The catch is that pass-through status expires. A C-code that was separately payable last year may have been absorbed into the packaged rate this year, and nobody sends you a letter about it. The denials simply start.
Take the device C-codes your centre bills most and confirm each is still on the current pass-through list. This is a short exercise and it catches a failure mode that otherwise presents as an unexplained rise in denials on your highest-value claims.
When multiple procedures are performed in the same session, the ASC payment system reduces payment for the second and subsequent procedures — commonly 50 percent of the rate that would otherwise apply, with the highest-paying procedure ranked first.
This is expected and correct. The reason to know it precisely is the opposite error: if your posting shows the reduction applied to the wrong procedure — the full rate given to the lesser procedure and the reduction to the greater — the claim underpays, and it looks exactly like a correctly adjudicated claim.
Device-intensive procedures are treated differently in this calculation, because the device portion of the payment is not what the reduction is aimed at. Where a device-intensive procedure is involved in a multiple-procedure claim, check the remittance against your contracted rate line by line rather than assuming.
Send a month of ASC remittances and we will run all four and send back what we find, including the ones you pass. No charge, no obligation.
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