ASC Hot-button Issues
What to look forward to — and look out for — in 2008.
Stephen C. Sheppard, C.P.A., C.O.E. (moderator): It's been about 25 years since the Centers for Medicare & Medicaid Services (CMS) last enacted sweeping changes to the way ASCs do business. Based on the final rule, announced in July 2007, ASC payment rates will be set at no more than 67% of the corresponding outpatient prospective payment system (OPPS) rates for hospital outpatient department (HOPD) surgical procedures.
A 4-year phase-in is planned to begin in 2008, when ASC payments will be based 25% on HOPD rates and 75% on the current reimbursement rates for ASCs. In 2009, the ASC payment rate will be based 50% on 2007 rates and 50% on HOPD rates. In 2010, ASC payments will be 75% HOPD-based, and the full, 100% HOPD rate basis kicks in for calendar year 2011.
We have a group of ASC experts here today, so I'm going to take this opportunity to ask you for some forecasts.
Jo Ann Steigerwald, R.H.I.T.: The billing in ASCs has been very simple and easy. There were nine payment categories and a limited number of procedures, so it was basically a one-line claim. In 2008, it will be possible to perform a number of new ophthalmic procedures in the ASC, and ASCs will be able to bill some things they couldn't bill before, like imaging procedures, drugs and biologic treatments.
Lou Sheffler: I feel the most significant change is that we'll be tied into the hospital reimbursement system. ASCs have been separated from hospitals for many years, and now we're in the same program starting in 2008. Suddenly, we have a shared interest with the hospitals instead of a competitive relationship. That's going to be an interesting paradigm shift.
| In 2008, it will be possible to perform a number of new ophthalmic procedures in the ASC, and ASCs will be able to bill some things they couldn't bill before, like imaging procedures, drugs and biologic treatments. — Jo Ann Steigerwald, R.H.I.T. |
Mr. Sheppard: What do you think will be the most significant changes in the Medicare reimbursement system?
Ms. Steigerwald: In 2008, claims from ASCs will be based on the hospital OPPS, so many cases will have drugs and imaging added to the claims. As hospitals learned when they changed to this system, these things have to be documented. Clinical staff must be fully aware of these significant changes, so they can highlight these items for their coders and billers. Coders and billers aren't used to dealing with these issues.
In particular, the staff will see something extremely important in the fee schedule called "payment indicators," which identify the separate line items that can be billed in addition to the surgical procedure. So staff members in the ASCs — everyone from the administrator to the person who processes the bill and writes off the amount at the end of the billing cycle — need to be aware of these payment indicators to avoid significant losses.
| EMR Advantages and Pitfalls Mr. Sheppard: Do the changes to ASCs illuminate any advantages or pitfalls to using electronic medical records (EMRs)? Mr. Sheffler: Recently, one of our third-party payers contacted us with questions. First, they asked if we were an accredited ASC, which we are. But then they told us that we still could lose our contract with them if we didn't have EMRs in 6 months. Margaret G. Acker, R.N., M.S.N.: They gave you 6 months? Mr. Sheffler: Yes, and we were surprised by that, but we're well on our way to compliance. Some insurance companies are moving toward doing audits remotely from their main offices, rather than sending auditors into the field, so EMRs will become more important as time goes on. They may even become a requirement for accreditation. But I've already discovered that EMRs are almost too automatic. You can click on something and have a whole page filled out, but it's not necessarily accurate. Defining how the system should be working will be a challenge for the accrediting agencies. Ms. Steigerwald: I started my career in hospital medical records, so I keep up with medical record issues, including EMRs. The EMR is a wonderful tool, but you need to use it correctly. For example, if you can hit a button and fill out a whole page, then what you have is a cloned medical record. In an audit, cloned records are considered undocumented services. In other words, some payers (both Medicare and private insurers) are recovering payments made when they audit ASC records and discover the cloned notes. Also, several Part B Medicare carriers have issued strong cautionary statements about cloned notes. |
Mr. Sheppard: What are some other issues?
Barbara Ann Harmer, R.N., B.S.N., M.H.A.: Education and staff development will be top priorities. As I travel throughout the country, I've noted that for the very first time in my clinical lifespan, we have a generation of clinicians (doctors, nurses and technicians) who have never had the experience of working in a hospital. They've been able to move directly from training into an entrepreneurial setting, and therefore, they don't have the basics that many of us had when we began our careers in a hospital setting that provided educational opportunities. These practitioners need training, and it has be considered important by the folks at the top of the organizational chart.
Thomas Brown, J.D.: I've worked with retina surgeons who have almost no hospital experience, and they're pleased that some of the procedures they had to perform in the hospital environment are now migrating back to the ASC. I think it's an exciting time.
I have experience with a number of ophthalmology surgery centers, and that often has meant cataract business. With the new reimbursement guidelines, there's potential to bring retina surgery and many other procedures into the ASC setting.
Mr. Sheppard: Remember, too, that we now have a whole new class of intraocular lenses. That introduces a number of business issues into the surgery center that we may not have dealt with before, such as handling cash and some sales functions.
Overall, it's my impression that ophthalmology will emerge as a big winner over the next 4 years, with healthy increases in premium IOL implantations, retina procedures, oculoplastics and treatment of strabismus, glaucoma and corneal problems. There will be an adjustment phase, particularly in the area of retina procedures, which we'll discuss next. OM
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