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CPC: Outpatient and Physician Services, Including Same-Day Surgical Centers

CPC · Work through your exam, one topic at a time.

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Outpatient and Physician Services, Including Same-Day Surgical Centers

This domain tests site-of-service rules, facility versus nonfacility payment, same-day surgery coding, and multiple-procedure logic. The exam expects you to distinguish what the physician reports from what the facility reports and to apply the correct modifier to same-day services.

Site of service and payment

  • The place of service code identifies where the service occurred: physician office 11, ambulatory surgical center 24, hospital outpatient 22, telehealth 02 or 10.
  • Facility and nonfacility payments differ. The facility bills a facility fee; the physician bills professional services.
  • Ambulatory surgical centers use the ASC covered procedures list and payment indicators; device-intensive procedures have special rules.
  • Multiple procedure discounts apply to the second and subsequent procedures in the same operative session.
  • Discontinued same-day surgery uses modifier 73 before anesthesia and 74 after anesthesia in the facility setting.
  • Bilateral procedures use modifier 50 or two lines according to payer instructions.

Coding across the same day

  • National Correct Coding Initiative edits pair codes; modifier 59 or an X modifier is used only with documentation of a distinct service.
  • An E/M on the day of a procedure requires modifier 25 when it is separately identifiable.
  • Assistant-at-surgery services require documentation and payer rules; modifiers 80, 82, or AS may apply.
  • Hospital outpatient clinic visits are reported with G0463; physician office visits use 99202-99215.

Worked example

A Medicare patient scheduled for a screening colonoscopy has a polyp removed by snare. Report 45385 with modifier PT to show that the screening procedure became diagnostic. In the ASC, the facility reports the same CPT® code with the appropriate facility modifiers and payment indicator; the physician reports the professional service. Do not report a screening code such as G0121 together with the polypectomy code.

Traps

  • Using nonfacility RVUs for ASC services.
  • Reporting a canceled procedure with normal modifiers instead of 73 or 74.
  • Omitting modifier 50 or the payer's bilateral adjustment.
  • Billing an E/M on the same day as a major procedure without a separately documented service.
  • Using the wrong place of service for telehealth or mobile services.