Short answerAn ASC carve-out is a contract term that pays certain items (often implants or high-cost devices) separately from the facility's case rate. Carve-outs mainly affect the facility claim, but physicians are affected when facility and professional claims don't match, or when an out-of-network physician works at an in-network ASC under No Surprises Act rules.
Every ASC case creates at least two claims: the facility's and the physician's. When they disagree, one or both suffer.
Facility vs professional claims
| Element | Facility claim | Professional claim |
|---|---|---|
| Who bills | The ASC | The surgeon or anesthesiologist |
| Place of service | ASC | POS 24 |
| Implants | Often carved out by contract | Not billed by the physician |
| Imaging | Technical component | Professional component (modifier 26) where applicable |
Where physicians lose money
- procedure codes or dates that differ between the claims
- imaging components split incorrectly
- out-of-network physicians at in-network ASCs balance-billing patients when the No Surprises Act doesn't allow it, instead of contesting payment through IDR
Practical steps
- share final codes with the facility's billing team before claims go out
- confirm network status for each surgeon and anesthesia group at each ASC
- track out-of-network payments for open negotiation deadlines
Related: ASC billing and federal IDR for independent physicians.
This article is general billing information, not legal or coding-compliance advice. Payer rules, CPT descriptors and federal guidance change; check the current versions for your claims.