ASC Plausibility

We use the AMSURG Medicare Certified ASC List to determine which codes are plausible for each ASC provider based on their specialty. If an ASC is not listed in AMSURG, we use the binary service flags from the provider spines data to determine which codes are plausible.

Logic:

• Specialty Mapping via AMSURG Data (Download):
  • ASC providers are matched to specialty data (AMSURG).
  • Only codes linked to the provider’s specialty and applicable service lines are marked as plausible.
  • Example: An ASC with a dermatology specialty can only bill dermatology codes.
• Fallback for Non-AMSURG Providers:
  • For ASCs not in AMSURG, binary service flags from provider spines data are used.
  • Only codes for services enabled (e.g., radiology, lab/pathology, etc.) are marked plausible.
• Multispecialty/Unknown Handling:
  • ASCs with “Multispecialty” or no specialty/services enabled can bill any ASC code across all service lines

Mappings:

Amsurg

(
    -- Direct specialty-based filtering using service_line
    (amsurg.specialty IN ('Dental') AND cs.service_line = 'Dental') OR
    (amsurg.specialty IN ('Dermatology') AND cs.service_line = 'Dermatology') OR
    (amsurg.specialty IN ('Gastroenterology') AND cs.service_line = 'Gastrointestinal') OR
    (amsurg.specialty IN ('General Surgery', 'Plastic Surgery', 'Bariatrics') AND cs.service_line IN ('Surgery', 'General Surgery')) OR
    (amsurg.specialty IN ('Gynecology') AND cs.service_line = 'Reproductive') OR
    (amsurg.specialty IN ('Ophthalmology', 'Oculoplastics', 'Retina') AND cs.service_line = 'Ophthalmology') OR
    (amsurg.specialty IN ('Orthopedic Surgery', 'Pain Management', 'Podiatry', 'Spine') AND cs.service_line = 'MSK') OR
    (amsurg.specialty IN ('Urology') AND cs.service_line = 'Urology') OR
    (amsurg.specialty IN ('Cardiovascular/Cardiology/Cardiac Cath', 'Vascular Surgery') AND cs.service_line = 'Cardiovascular') OR
    (amsurg.specialty IN ('Otolaryngology') AND cs.service_line = 'ENT') OR
    (amsurg.specialty IN ('Colon & Rectal Surgery') AND cs.service_line = 'Gastrointestinal')
)

Definitive

(
    (sp.services_lab = 1 AND cs.service_line = 'Lab/Path') OR
    (sp.services_radiology = 1 AND cs.service_line = 'Radiology') OR
    (sp.services_cardiology = 1 AND cs.service_line = 'Cardiovascular') OR
    (sp.services_dental = 1 AND cs.service_line = 'Dental') OR
    (sp.services_dermatology = 1 AND cs.service_line = 'Dermatology') OR
    (sp.services_ent = 1 AND cs.service_line = 'ENT') OR
    (sp.services_general_other = 1 AND cs.service_line = 'Surgery') OR
    (sp.services_endoscopy = 1 AND cs.service_line = 'Gastrointestinal') OR
    (sp.services_nephrology = 1 AND cs.service_line = 'Nephrology') OR
    (sp.services_neurology = 1 AND cs.service_line = 'Neurology') OR
    (sp.services_obgyn = 1 AND cs.service_line = 'Reproductive') OR
    (sp.services_opthalmology = 1 AND cs.service_line = 'Ophthalmology') OR
    (sp.services_orthopedic = 1 AND cs.service_line = 'MSK') OR
    (sp.services_pain = 1 AND cs.service_line = 'MSK') OR
    (sp.services_plastic_surgery = 1 AND cs.service_line = 'Surgery') OR
    (sp.services_podiatry = 1 AND cs.service_line = 'MSK') OR
    (sp.services_pulmonary = 1 AND cs.service_line = 'Pulmonology') OR
    (sp.services_urology = 1 AND cs.service_line = 'Urology')
)

ASC Plausibility Table:

CREATE TABLE IF NOT EXISTS tq_intermediate.cld_utils.asc_plausibility AS
WITH
-- ASC-specific plausibility (SE-12773)
-- Maps each ASC provider to the specific codes they can perform based on AMSURG specialty data
-- Uses AMSURG Medicare Certified ASC specialty mappings as the primary source with spines fallback
-- Updated to use service_line from code spine for direct mapping (no clinical_categories_index dependency)
asc_plausibility AS (
    -- AMSURG-based plausibility (using service_line from code spine)
    SELECT DISTINCT
        sp.provider_id,
        cs.bill_type,
        cs.billing_code_type,
        cs.billing_code,
        cs.facility,
        True as is_plausible
    FROM tq_production.spines.spines_provider_ascs sp
    INNER JOIN tq_intermediate.cld_utils.amsurg_asc_provider_types amsurg
        ON sp.npi = amsurg.npi
        AND amsurg.specialty != 'Multispecialty'  -- Handle multispecialty separately
        AND amsurg.specialty != '-'  -- Skip invalid entries
    CROSS JOIN tq_dev.internal_dev_csong_cld_dev.tmp_ref_code_spine_2025_06 cs
    WHERE cs.bill_type = 'Outpatient'
        AND cs.facility IS NULL  -- ASC codes are always NULL for facility
        AND (
            -- Direct specialty-based filtering using service_line
            (amsurg.specialty IN ('Dental') AND cs.service_line = 'Dental') OR
            (amsurg.specialty IN ('Dermatology') AND cs.service_line = 'Dermatology') OR
            (amsurg.specialty IN ('Gastroenterology') AND cs.service_line = 'Gastrointestinal') OR
            (amsurg.specialty IN ('General Surgery', 'Plastic Surgery', 'Bariatrics') AND cs.service_line IN ('Surgery', 'General Surgery')) OR
            (amsurg.specialty IN ('Gynecology') AND cs.service_line = 'Reproductive') OR
            (amsurg.specialty IN ('Ophthalmology', 'Oculoplastics', 'Retina') AND cs.service_line = 'Ophthalmology') OR
            (amsurg.specialty IN ('Orthopedic Surgery', 'Pain Management', 'Podiatry', 'Spine') AND cs.service_line = 'MSK') OR
            (amsurg.specialty IN ('Urology') AND cs.service_line = 'Urology') OR
            (amsurg.specialty IN ('Cardiovascular/Cardiology/Cardiac Cath', 'Vascular Surgery') AND cs.service_line = 'Cardiovascular') OR
            (amsurg.specialty IN ('Otolaryngology') AND cs.service_line = 'ENT') OR
            (amsurg.specialty IN ('Colon & Rectal Surgery') AND cs.service_line = 'Gastrointestinal')
        )
    
    UNION
    
    -- Fallback: Use spines binary service flags for ASCs not in AMSURG data
    SELECT DISTINCT
        sp.provider_id,
        cs.bill_type,
        cs.billing_code_type,
        cs.billing_code,
        cs.facility,
        True as is_plausible
    FROM tq_production.spines.spines_provider_ascs sp
    LEFT JOIN tq_intermediate.cld_utils.amsurg_asc_provider_types amsurg
        ON sp.npi = amsurg.npi
    CROSS JOIN tq_dev.internal_dev_csong_cld_dev.tmp_ref_code_spine_2025_06 cs
    WHERE cs.bill_type = 'Outpatient'
        AND cs.facility IS NULL
        AND amsurg.npi IS NULL  -- Only for ASCs not in AMSURG data
        AND (
            (sp.services_lab = 1 AND cs.service_line = 'Lab/Path') OR
            (sp.services_radiology = 1 AND cs.service_line = 'Radiology') OR
            (sp.services_cardiology = 1 AND cs.service_line = 'Cardiovascular') OR
            (sp.services_dental = 1 AND cs.service_line = 'Dental') OR
            (sp.services_dermatology = 1 AND cs.service_line = 'Dermatology') OR
            (sp.services_ent = 1 AND cs.service_line = 'ENT') OR
            (sp.services_general_other = 1 AND cs.service_line = 'Surgery') OR
            (sp.services_endoscopy = 1 AND cs.service_line = 'Gastrointestinal') OR
            (sp.services_nephrology = 1 AND cs.service_line = 'Nephrology') OR
            (sp.services_neurology = 1 AND cs.service_line = 'Neurology') OR
            (sp.services_obgyn = 1 AND cs.service_line = 'Reproductive') OR
            (sp.services_opthalmology = 1 AND cs.service_line = 'Ophthalmology') OR
            (sp.services_orthopedic = 1 AND cs.service_line = 'MSK') OR
            (sp.services_pain = 1 AND cs.service_line = 'MSK') OR
            (sp.services_plastic_surgery = 1 AND cs.service_line = 'Surgery') OR
            (sp.services_podiatry = 1 AND cs.service_line = 'MSK') OR
            (sp.services_pulmonary = 1 AND cs.service_line = 'Pulmonology') OR
            (sp.services_urology = 1 AND cs.service_line = 'Urology')
        )
    
    UNION 
    -- Multispecialty ASCs (or unknown) get all ASC service lines
    SELECT DISTINCT
        sp.provider_id,
        cs.bill_type,
        cs.billing_code_type,
        cs.billing_code,
        cs.facility,
        True as is_plausible
    FROM tq_production.spines.spines_provider_ascs sp
    LEFT JOIN tq_intermediate.cld_utils.amsurg_asc_provider_types amsurg
        ON sp.npi = amsurg.npi
    CROSS JOIN tq_dev.internal_dev_csong_cld_dev.tmp_ref_code_spine_2025_06 cs
    WHERE cs.bill_type = 'Outpatient'
        AND cs.facility IS NULL
        AND cs.service_line IN (
            'Surgery', 'MSK', 'Gastrointestinal', 'Ophthalmology', 'Urology', 'Cardiovascular',
            'Radiology', 'Lab/Path', 'Dermatology', 'ENT', 'Reproductive', 'Nephrology',
            'Neurology', 'Pulmonology', 'Dental'
        )
        AND (
            amsurg.specialty = 'Multispecialty'
            OR
            (
                sp.services_lab = 0 AND
                sp.services_radiology = 0 AND
                sp.services_cardiology = 0 AND
                sp.services_dental = 0 AND
                sp.services_dermatology = 0 AND
                sp.services_ent = 0 AND
                sp.services_general_other = 0 AND
                sp.services_endoscopy = 0 AND
                sp.services_nephrology = 0 AND
                sp.services_neurology = 0 AND
                sp.services_obgyn = 0 AND
                sp.services_opthalmology = 0 AND
                sp.services_orthopedic = 0 AND
                sp.services_pain = 0 AND
                sp.services_plastic_surgery = 0 AND
                sp.services_podiatry = 0 AND
                sp.services_pulmonary = 0 AND
                sp.services_urology = 0
            )
        )
)
SELECT *
FROM asc_plausibility