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Outpatient POF/ASC Criteria

Outpatient Preferred Outpatient Facility (POF)/Ambulatory Surgery Center (ASC) criteria are as follows:

1. Blue Cross and Blue Shield of Alabama looks for one of the following revenue codes on your facility's outpatient claims:

360-369
481
490
499
700-709
720-729
750-759
790-799

2. If any of the above revenue codes are billed, a Healthcare Common Procedure Coding System (HCPCS) code is required on that line item.

3. The surgical procedure with the greatest charge will determine if the claim pays POF/ASC or POF (percent of charges). If the HCPCS code with the greatest charge is a POF/ASC procedure, the claim will process as POF/ASC. If not, the claim will process as POF.

4. If the claim processes as POF/ASC, the procedure with the highest allowance (not billed charge) will pay at 100 percent of the Payment Group Assignment (PGA). If there are multiple ASC procedures on the claim, the second procedure with the next greatest allowance will pay at 50 percent of the PGA, the third procedure with the next greatest allowance will pay at 25 percent of the PGA and the fourth procedure with the next greatest allowance will pay at 25 percent of the PGA. A maximum of four procedures may be paid on a claim.

5. You may bill multiple surgical procedures as you do Medicare, i.e., global surgical charges on one line and 0.00 charges on subsequent lines with surgical HCPCS codes. Don't forget about item 3 above. If you bill global surgical charges, you must bill with revenue code 36X.

6. Your facility's outpatient observation will either process as POF/ASC or POF depending on the criteria listed above. You should continue to bill claims as inpatient if they meet inpatient criteria.

 

July 2013