Coding & Reimbursement in an ASC: Both Sides of the Coin Presented for the AAPC National Conference April 5, 2011 Penny Osmon, BA, CPC, CPC-I, CHC, PCS Jen Cohrs CPC, CPMA, CGIC CPT codes, descriptions and material only are Copyright 2010 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in applicable FARS/DFARS restrictions to government use Objectives Attendees will understand the differences between professional and ASC facility billing, coding and reimbursement Attendees will increase knowledge of ASC billing process for Medicare versus commercial payers Attendees will learn appropriate use of both professional and facility modifiers 1
Agenda ASC Definition Professional Vs. Facility Services Billing for Professional Services Billing for Facility services Modifiers Reimbursement Other need-to-knows Ambulatory Surgical Center (ASC) CPT Definition: An ASC is a freestanding facility, other than a physician s office, where surgical and diagnostic services are provided on an ambulatory basis 2
Ambulatory Surgical Center (ASC) CMS Definition: Distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients Independent, or Operated by a hospital Specialty code 49 CMS further requires that all pre- and postprocedural care must occur on the same day Change Happens Pursuant to the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) Big Changes for ASCs in 2008 ASC reimbursement system changed This system uses payment categories to reimburse This system uses payment categories to reimburse procedures performed at hospital outpatient departments (OPPS) 3
Change Happens CMS incorporated a four-year transition period for the phase-in of the new payment system Beginning in CY 2011, all ASC payment rates will be calculated according to the policies of the revised payment system Professional vs Facility Professional: physician (MD, DO) providing the service Results in professional claim Facility: ASC operating room, equipment, and ancillary staff Results in facility claim 4
Professional Billing In order to bill for a professional charge you must not include: Facility fees DME Assistant surgeon services Ancillary staff services Independent lab/path services Bill only the professional portion of the surgical services performed POS= 24 Must accept assignment Professional Billing Global package applies Typically 90 days for surgeries MPFSDB is your resource http://www.cms.gov/physicianfeesched/pfsrvf/list.asp Physicians paid the facility fee Reimbursement: Medicare pays 80% of allowed amount determined by physician fee schedule (PFS) Commericial payers by contract or standard cost 5
Professional Modifiers For discontinued procedures in an ASC 53 Discontinued Procedure 52 Reduced Services Not subject to multiple surgery reduction PT (colorectal cancer screening test; converted to diagnostic test or other procedure) New for 2011 for FFS Medicare only To be used on a colonoscopy or flex sigmoidoscopy initially performed as a screening procedure that turns diagnostic for any reason Professional Modifiers 50 Bilateral procedures 58 Staged or related procedure/service by the same physician during the postoperative period 59 Distinct procedural service CCI edits Mutually exclusive edits Both available for download:» http://www.cms.gov/nationalcorrectcodinited/01_over view.asp#topofpage 6
Place of service 24 Facility Billing Assignment must be accepted CMS 1500 or UB04 Varies by payer CMS 1500 for Medicare Covered facility procedures released annually http://www.cms.gov/ascpayment/11_addenda_ Updates Addendum B Facility Billing What is included? Nursing/technician i i services Use of the facility Lab services, if ASC has certified lab (CLIA) Drugs and biologicals and radiology services packaged under OPPS Supplies without pass-through status Equipment Surgical dressing Implanted prosthetics (including IOLs and NTIOLs) Splints/casts Blood, plasma, platelets unless deductible applies 7
Facility Billing When billing for a facility charge you must NOT include: Professional services Assistant surgeon services Professional anesthesia services DME/prosthetic devices Ambulance services Independent laboratory/pathology services Professional vs. Facility Billing Claim Data Professional Facility (ASC) Claim Form HCFA 150 HCFA 1500 or UB04 (varies by payer) Place of Service 24 24 NPI (box 24J) Provider of service (MD, DO) ASC Facility Modifiers Professional modifiers ASC/facility modifiers and some professional modifiers Service Codes CPT and/or HCPCS CPT and/or HCPCS Revenue Code 490 8
Items NOT Included in the ASC Facility Rate Where Payment is Made Bills Submitted to: Physician Services Physician A/B MAC or Legacy Contractor Purchase of non-implantable DME for home use Supplier DME MAC Implantable DME ASC A/B MAC or Legacy Contractor Non-implantable prosthetic Supplier DME MAC devices Implantable prosthetic devices ASC A/B MAC or Legacy Contractor except IOLs and NTIOLs Ambulance Services Certified Ambulance Supplier A/B MAC or Legacy Contractor Leg, arm, back and neck braces Supplier DME MAC Artificial legs, arms and eyes Supplier DME MAC Independent lab services Certified labs A/B MAC or Legacy Contractor Procedures not on the ASC list Physicians A/B MAC or Legacy Contractor Facility Exceptions Medicare pays separately for certain covered ancillary services that are provided integral to covered surgical procedures in ASCs The ancillary services must be provided immediately before, during, or after a covered surgical procedure to be considered integral and thereby, eligible for separate payment 18 9
Facility Exceptions Covered ancillary services: Brachytherapy sources Implantable devices that have pass-through status under OPPS Corneal tissue acquisition (V2785) and other carrier priced items CMS designates Drugs and biologicals reimbursed under OPPS Radiology services reimbursed separately under OPPS Drugs and Biologicals Reminder: if two or more drugs or biologicals are mixed together to facilitate administration, the correct HCPCS codes should be reported separately for each This is not a new drug Do not report with C9399 (Unclassified drug or biological) 10
Professional Exception If a Medicare covered service that is not on the list is provided in an ASC, the professional charges will paid by Medicare Part B The patient is responsible for the facility charges (provided the facility properly notified the patient using an ABN) No TC or global payment will made to the facility FDA Classification of IOLs Anterior chamber angle fixation lenses Iris fixation lenses Irido-capsular fixation lenses Posterior chamber lenses Presbyopis-Correcting (P-C-IOL) Astigmatism-Correcting (A-C-IOL) NTIOL Category 3 11
NTIOLs Category 3 New technology intraocular lenses (NTIOLs) Through February 26, 2011 An additional $50 payment Q1003 http://www.cms.gov/ascpayment/08_ntiols / / Presbyopia Correcting IOLs (P-C IOLS) and Astigmatism Correcting IOLs (A-C IOLs) There is no Medicare benefit category that allows payment of facility charges for adjustment, subsequent treatment, or monitoring of a P-C IOL or A-C IOL The facility and physician should notify the patient that Medicare will not make payment related to the functionality of the requested lens type No ABN is required Patient is responsible for charges related to services and supplies attributable to the P-C IOL 24 and/or A-C IOL functionality 12
Presbyopia Correcting IOLs (P-C IOLS) and Astigmatism Correcting IOLs (A-C IOLs) Effective for dates of service on and after January 1, 2008: When inserting an approved A-C IOL in an ASC, V2787 should be billed to report the non-covered charges for the A-C IOL functionality of the inserted intraocular lens When inserting an approved P-C IOL in an ASC, V2788 should be billed to report the non-covered charges for the P-C IOL functionality of the inserted intraocular lens Payment for the conventional lens portion of the A-C IOL and P-C IOL is packaged http://www.cms.gov/hospitaloutpatientpps/downl oads/pciol-aciol.pdf 25 Facility Exception Same-day global period Every procedure performed in the ASC has a same day global period In general, covered ASC services are not expected to require an overnight stay 13
Facility Modifiers in General The significance of modifiers increases under OPPS Modifiers add clarification and specificity to CPT/HCPCS codes Failure to use them or use of an incorrect modifier may adversely affect payment for some outpatient services adversely affect payment for some outpatient services CCI edits to apply to facility services ASC Facility Modifiers SG: Ambulatory Surgical Center (ASC) facility service The SG modifier must accompany all codes billed by an ASC on claims to most commercial insurances Not required on Medicare claims 14
ASC Facility Modifiers TC Technical Component Effective January 1, 2009: claims must contain the ordering/referring physicians name and NPI in 17A and B or electronic equivalent Modifier - TC is required unless the code definition is for the technical component only ASC Facility Modifiers For implant devices provided at no cost to the provider, supplier, or practitioner use modifier FB For implant devices provided where partial credit is received by the provider for a replaced device, see modifier FC Refer to handout for CY 2011 list 15
ASC Facility Modifiers 73 Discontinued procedure prior to the administration of anesthesia Not subject to multiple procedure reduction 74 Discontinued procedure after the administration of anesthesia IVCS is considered anesthesia Subject to multiple procedure reduction 52 Used to indicate partial reduction or discontinuation of services for which anesthesia is not planned Not subject to multiple procedure reduction Modifier 73 For example, 50% is paid if the patient develops an allergic reaction to a drug administered by the ASC prior to surgery or if, upon injection of a retrobulbar block, the patient experiences a retrobulbar hemorrhage that prevents continuation of the procedure. Although h some supplies and resources are expended, they are not consumed to the same extent had anesthesia been fully induced and the surgery completed. 16
Modifier 74 Contractors may make full payment of the surgical procedure if a medical complication arises which causes the procedure to be terminated after the anesthesia has been induced or the procedure initiatedi i 33 Documentation for a Terminated Procedure Reason for termination Services actually performed Supplies provided Services and supplies not performed or used that would have been had the surgery not been terminated Time spent in each stage: pre, intra and post-operative Time that would have been spent in each state 17
PT Modifier New for 2011 for facility and professional claims To be used on a colonoscopy or flex sigmoidoscopy initially performed as a screening procedure that turns diagnostic for any reason The deductible d will be waived but the coinsurance will still apply applies to both professional and facility FFS Medicare claims Payment for Discontinued Radiology/Other Procedures Contractors apply a 50% payment reduction for discontinued radiology procedures and other procedures that do not require anesthesia use modifier 52 Not subject to multiple procedure discount 36 18
UB-04 Tips for Commercial Payers Type of Bill: 831 Revenue Code: 490 Some payers accept this rev code for all line items Always use SG modifier And modifier 51 or 59 as applicable Revenue Code: 320 sometimes required for: Fluoroscopy or interpretation (TC modifier) Revenue Code: 270 for supplies CPT 99070 ASC Facility Modifier Cautions Do NOT use the following modifiers with ASC facility claims: 25: Significant, separately identifiable E/M service by a physician 27: Multiple outpatient hospital E/M services on the same day 19
Facility Reimbursement Medicare pays the lesser of 80% of the actual charge or the ASC payment rate Beneficiary is liable for 20% Exception due to Affordable Care Act (ACA): all co-pays and deductibles are waived for preventive services with a USPSTF rate of A or B Example: screening colonoscopy Facility Reimbursement Ambulatory Payment Classifications (APCs) are the method of paying for facility outpatient services for the Medicare program. APCs are applicable to outpatient hospitals and ambulatory surgery centers Physicians are reimbursed via other methodologies, ie: RBRVS, PFS 20
Facility Reimbursement Outpatient Prospective Payment System (OPPS)process Every HCPCS codes received a status indicator Provides information on how/if codes is paid When a HCPCS code is separately payable under the OPPS based on status indicator, it is assigned to an Ambulatory Payment Classification (APC) group Grouped according to clinical similarities and facility resource use A Services furnished to a hospital outpatient that are paid under a fee schedule payment system other than OPPS (examples: Ambulance services, Diagnostic/Screening Mammography, or Speech Therapy) Not paid under OPPS. G Pass-through Drugs and Biologicals Paid under OPPS; separate APC payment includes pass-through amount H Pass-through Device categories Separate cost-based pass-through payment; not subject to Medicare copayment K Nonpass-through Drugs, Nonimplantable Biologicals Paid under OPPS; separate APC payment N Items and Services Packaged into APC rates Paid under OPPS; payment is packaged into payment for other services, including outliers. Therefore there is no separate APC payment S Significant Procedure, Not discounted when multiple Paid under OPPS; separate APC payment T Significant Procedure, Multiple reduction applies Paid under OPPS; separate APC payment X Ancillary services Paid under OPPS; separate APC payment 21
Pass-Through Payments Pass-through payments are transitional payments established by Medicare for new drugs, biologicals, radiopharmaceutical agents, and medical devices Drugs and devices having a status indicator of G and H receive a pass-through payment. In some instances, the procedure code may have an APC code assigned. The fee is either the APC-based fee or a percentage of charges Pass-Through Drug Example IV ibuprofen: C9279 APC status indicator: G ASC payment indicator: K2 What does this mean? Separate payment is available for IV ibuprofen (Advil, Motrin) when provided d integral to a surgical procedure that is covered in an ASC 22
Packaged Services Services having a status indicator of N are considered packaged or bundled into other services. The costs of these services are allocated to the APC, but are not paid separately The relative weights for surgical, medical and other types of visits were developed to reflect packaged services in the APC-based fee Example of APC Status Indicator N A patient comes in for a bony correction bunionectomy. The physician performs the Keller/Mayo-type procedure on the right foot with a metatarsal joint implant The physician bills 28292 for the professional claim The ASC bills 28292 and L8641 for the facility claim 23
Device-Intensive Procedures Payment for high cost devices are packaged into the associated procedure payments under the revised ASC system, as it is under the OPPS 47 Payment for Multiple Procedures When more than one surgical procedure is performed in the same operative session, special payment rules apply, even if the procedures have the same code If subject to the multiple procedure discount, contractors pay: 100% of the highest paying surgical procedure on the claim plus 50% of the applicable payment rate(s) for other ASC covered surgical procedures subject to the multiple procedure discount 48 24
Payment for Bilateral Procedures Should be reported as two separate lines using modifier 50 on the second line item, or As two procedures on one line with (2) units Varies by contractor Multiple procedure reduction logic applies Reimbursement will be 150% Procedures with modifier 52 & 73 are not further reduced Bilateral Example A physician performs a bilateral sinusotomy, maxillary; intranasal during the same operative session. CPT 31020 is reported with 2 units, or reported twice on two separate lines (with modifier 50) 25
More Examples Example 1 A patient has a colonoscopy with cold biopsies and a hot biopsy polypectomy in an ASC The MD performing the biopsy bills 45384 and 45380-59 for the professional services The ASC bills 45384 and 45380-5959 for the facility services Use of the 59 modifier is determined by CCI edits for both facility and professional services 26
Example 2 A 40 year old patient has a bilateral inguinal hernia repair, with mesh placement on both sides The professional claim reflects CPT code 49505 and 49505-50 The facility claim would include CPT code 49505 and 49505-50 Example 3 A patient comes in for an upgrade of implanted pacemaker. The patient t has a conversion of a single chamber system to a dual chamber system. The new implant (dual chamber, non rate-responsive) is provided at no cost to the ASC The cardiologist bills 33214 for the professional claim The ASC bills 33214 and C2619-FB for the facility claim. C2619 is a pass-through item, with APC status indicator of 'N' 33214 will then be reimbursed under the device offset, no cost rates because the implant was cost-free 27
Consolidated Billing in an ASC OIG release of Dec 2010 data revealed that ASC incorrectly billed and received payment for services while a patient was in a SNF If a service was paid to the ASC under part B and the service was performed during a patients SNF stay, it is likely the SNF was also reimbursed under Part A Example 4 A SNF patient (in a Medicare covered Part A stay) has an upper EGD at an ASC The professional claim would be billed with CPT 43235 This claim is paid under Medicare part B The ASC facility claim should be sent to the SNF for payment, as part of consolidated billing Do not send a facility claim for reimbursement to Medicare part B 28
Resources http://www.cms.gov/center/asc http://www.cms.gov/manuals/downloads/clm104c14.pdf http://www.cms.gov/mlnmattersarticles/downloads/mm 7078.pdf https://www.cms.gov/hospitaloutpatientpps/ Thank you! penny.osmon@wismed.org org jennifer.cohrs@aspirus.org 29