Beginning January 1, 2008, the CMS publishes updates to the list of procedures for which an ASC may be paid each year. In addition, CMS publishes quarterly updates to the lists of covered surgical procedures and covered ancillary services to establish payment indicators and payment rates for newly created Level II HCPCS and Category III CPT Codes. The complete lists of ASC covered surgical procedures and ASC covered ancillary services, the applicable payment indicators, payment rates for each covered surgical procedure and ancillary service before adjustments for regional wage variations, the wage adjusted payment rates, and wage indices are accessible on the CMS Web site.
To be paid under this provision, a facility must be certified as meeting the requirements for an ASC and must enter into a written agreement with CMS. ASCs must accept Medicare’s payment as payment in full for services with respect to those services defined as ASC services. The physician and anesthesiologist may bill and be paid for the professional component of the service also.
Certain other services such as lab services or non-implantable DME may be performed when billed using the appropriate certified provider/supplier UPIN/NPI. The understanding basics of ambulatory surgery center (ASC) coding and billing aren’t hard to master, but they do differ from physician and facility requirements. The following overview will help you know what’s most important in the ASC setting.
Medicare Claims Submissions
There is a separate set of billing rules for ASCs. While some issues may be addressed by CMS, most billing guidelines are best obtained from your local carrier or intermediary. Some carriers/intermediaries issue very detailed guides (e.g., Trailblazer), while others may simply provide a list of links to the CMS website (e.g., Empire).
To reiterate, an ASC must not report separate line items, HCPCS Level II codes, or any other charges for procedures, services, drugs, devices, or supplies that are packaged into the payment allowance for covered surgical procedures. The allowance for the surgical procedure itself includes these other services or items. CMS does, however, strongly encourage billing for drugs and biologicals that are eligible for separate payment. ASCs should report supplies with the correct HCPCS Level II code and the correct number of units on the claim form.
Coding for ASC
Coding for Ambulatory Surgery Centers is a specialty unto itself. It is a facility service, but Medicare requires ASC’s to send their bills to the professional fee (Part B) payers but using the facility fee (Part A) claim form. There is a whole different set of regulations and bundling edits to use for ASCs. Many ASCs use the same codes as the surgeons, but that can be a revenue “kiss of death” and create compliance exposure for every shareholder-or-partner in the ASC. The rules of the game are different for ASCs than for surgeons or for hospitals; at times ASCs must follow the rules for doctors, and at other times they must adhere to the hospital’s rules. A simple modifier used incorrectly can deliver a “fatal blow” to an otherwise clean claim for thousands of dollars.
Approved Surgical Procedures
For Medicare patients, you cannot perform just any procedure in the ASC setting. Medicare has an “approved” list of procedures for the ASC that CMS has determined not to pose a significant safety risk, and that is not expected to require an overnight stay following the surgical procedure. Medicare publishes this list of covered procedures annually. Updates are published quarterly, or as necessary.
The list of approved procedures is based on the criteria:
- They are NOT emergent or life-threatening (for example, a heart transplant or reattachment of a severed limb).
- They cannot be performed safely in a physician’s office.
- They can be elective.
- They can be urgent.
- Procedures also do not involve major blood vessels or result in major blood loss, and cannot involve prolonged invasion of a body cavity.
Device Intensive Procedures
A modified payment methodology is used for device-intensive procedures (i.e., procedures done specifically to insert a device, such as a pacemaker). The ASC will get paid for the device but does not submit a separate line item for the device. The ASC would instead include the cost of the device in the procedure code and submit one line item.
ASCs are not allowed to base price on the allowable code from the Medicare Physician Fee Schedule (MPFS). For example, if a device intensive procedure is performed, and the formula is to bill the Medicare allowable plus 10 percent, you may be leaving money on the table. If the 10 percent increase does not cover the cost for the device, the money will not be recouped. It is important to know the cost to the ASC and add the cost of the device into the allowable.
Modifiers in the ASC
Some modifiers used in the ASC are the same as those used by physicians, while others are unique to the ASC facility. ASCs have their own modifiers for a discontinued procedure. Modifier 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia is used when preparation for surgery has begun, but anesthesia has not been administered. The patient is taken back to the “prep” area and has completed paperwork, etc. The reasons may be the patient has a low-grade temperature, or has eaten within the past four hours. The facility charges for the preparation, etc., but adds the modifier to show the procedure was not completed.
Modifier 74 Discontinued outpatient hospital/ambulatory surgery centers (ASC) procedure after administration of anesthesia is used when the procedure is terminated after anesthesia is administered. Plans can pay from 25 percent to 65 percent of the allowable amount, based on the modifier and documentation of how much of the service was performed.
New modifier PT Colorectal cancer screening test; converted to diagnostic test or other procedure designates that screening colonoscopy was converted to a diagnostic or therapeutic service. For example, a patient presents to the ASC for a screening colonoscopy. He is not high risk and has no symptoms or complaints. During the colonoscopy, a polyp is found in the sigmoid.
The ASC reports 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple instead of 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without the collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) or G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk. Modifier PT designates the procedure was planned as a screening but resulted as a diagnostic procedure. For Medicare patients, this allows the procedure to be paid as a screening with no co-insurance.
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