Required Documentation
ASC claims that involve a terminated surgery must be accompanied by an operative report that specifies all of the following:

• Reason for termination of surgery
• Description of services actually performed
• Description of supplies actually provided
• Services not performed that would have been if surgery had not been terminated
• Supplies that would have been provided if the surgery had not been terminated
• Time actually spent in each stage, e.g., pre-op, operative, post-op
• Time that would have been spent in each of these stages if the surgery had not been terminated
• CPT codes for procedures that were scheduled to be performed
• Tip: operative reports can be faxed to Palmetto GBA as supporting documentation for electronic claims. Visit the Palmetto GBA EDI Web page for complete details for your state or jurisdiction:
  • Jurisdiction 1 - Northern California: EDI Fax Form (PDF, 67 KB)
  • Jurisdiction 1 - Southern California: EDI Fax Form (PDF, 68 KB)
  • Jurisdiction 1 - Pacific/Hawaii/Nevada: EDI Fax Form (PDF, 65 KB)
  • Ohio: EDI Fax Form 
  • South Carolina: EDI Fax Form
  • West Virginia: EDI Fax Form

Reimbursement

Surgical procedures scheduled to be performed in an ASC that are terminated are subject to specific reimbursement rules:

• Procedure terminated before administration of anesthesia - 50 percent of fee schedule
• Procedure terminated after administration of anesthesia - 100 percent of fee schedule
• Procedures terminated before the ASC has expended substantial resources will not be covered
• If Intraocular Lens (IOL) Insertion is terminated, the allowance for the unused IOL will be deducted prior to payment
• Not otherwise classified (NOC) procedure codes may not be submitted for terminated ASC procedures

Applicable Modifiers

• HCPCS modifier SG: must be submitted with any ASC facility service that was performed on or before date of service 12/31/2007. HCPCS modifier SG is not valid for dates of service on or after January 1, 2008.
• CPT modifiers 73 & 74 (for ASC use only)
  • Use CPT modifier 73 for ASC procedures that are discontinued prior to the administration of anesthesia
  • Use CPT modifier 74 for ASC procedures that are discontinued after the administration of anesthesia
• CPT modifier 53 is for physician use only and may not be submitted by ASCs

Resources

• CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 14, sections 10.3 & 10.4: www.cms.hhs.gov/manuals/downloads/clm104c14.pdf (PDF 172 KB)
• Palmetto GBA Modifier Lookup: access specific guidance for all applicable ASC modifiers from the home page for your state or jurisdiction

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