ASC Compliance & Coding

ASC Compliance: Are You Close?

By Riva Lee Asbell

Ask this regarding your ASC compliance: Are you even close? Most efforts to obtain ASC compliance focus on Conditions for Coverage and the more clinical and technical aspects. Very few ASCs actually focus on ensuring their coding, chart documentation and other compliance-related functions are being accomplished in accordance with Medicare’s rules and regulations.

Medicare audits for correct ASC coding and reports of compliance violations happen less frequently than do physician audits, but they certainly occur. Let’s review some of the basics you need to know to protect your facility.

Medical Necessity

The foundation of Medicare compliance and ASC reimbursement is firmly based on medical necessity, as is physician reimbursement.

For example, it’s often difficult to discern from the ASC chart if there’s medical necessity for a given cataract procedure or other surgery. Attorneys caution that procedure codes and other pertinent chart documentation should correlate with the physician’s chart. The ASC chart should be able to stand on its own if audited. In other words, the documentation establishing the medical necessity of a given procedure should be included in the ASC chart as well as the physician’s chart.

It’s probably a good idea to also incorporate the physician’s office notes on the date the surgery is scheduled into the ASC chart. I’ve reviewed many History and Physicals that didn’t address the patient’s Activities of Daily Living (ADL) problems for cataract and YAG surgery, thus no foundation for medical necessity of the procedure was established in the ASC chart.

Rules of Surgical Coding

Cosmetic versus Functional Procedures: Patient, Facility Fees and Anesthesia. If the surgery is cosmetic or another noncovered procedure, the patient is obligated to pay the facility fee. The procedures can’t be performed with “no charge.” This applies even when the ASC owner is the surgeon. Cosmetic procedures performed without charge can be considered an inducement for a surgeon to bring other cases to that ASC. If a procedure is partially cosmetic, the portion of the facility fee and anesthesia fee attributable to cosmetics should be charged to the patient.

Code Selection. The most frequent error in surgical coding is selecting a code that approximates the surgery performed rather than one that describes it accurately. CPT surgery rules are explicit in stating that if the exact code is not found, you must use an unlisted code. Your worst nightmare in ASC coding is when Medicare doesn’t accept the unlisted codes (the ones ending in 99) and the patient must pay for the procedure, the facility and anesthesia fees.

Femtosecond-assisted Laser Procedures. Please refer to the August 2012 issue of Ophthalmology Management (pages 24-25) for a complete article on the rules and regulations for femtosecond laser usage. There are strict rules that govern when you can and can’t charge a Medicare patient for its use.

Premium/Regular IOL Issues. There are several critical issues facing the ASC when a surgeon arrives with, and uses, an IOL that is given to him and it’s part of a clinical trial or comes from another external source. CMS expects the ASC to reduce its fee accordingly. Medicare prohibits physicians from purchasing IOLs. These issues are best resolved using the advice of a qualified health care attorney.

Chart Documentation Issues & Tips

• ADL. Be sure formal documentation (a completed form that’s form signed by the patient) is present for each eye for all cataract and YAG procedures — this is for the ASC chart as well as the physician chart.

• It’s a good idea to maintain a copy of the surgeon’s office notes from the day the surgery was scheduled in the ASC chart.

• Make sure the ASC has its own Advanced Beneficiary Notice or Notice of Exclusion of Medicare Benefits signed and kept on file.

• Surgical encounter forms should be completed and signed by the surgeon. CPT codes as well as modifiers should be selected by the surgeon.

• Codes provided by the physician’s office when the case was scheduled are often erroneous.

• Academic centers must ensure the operative notes are in compliance with Teaching Physician Documentation Requirements and that the GC modifier is applied to resident cases.

Pitfalls in ASC Reimbursement

Here are some of the most common violations I’ve found in my ASC auditing:

• Cosmetic procedures being performed without charging the patient for all noncovered procedures including the facility fee (or portion thereof) and the anesthesia fee (or portion thereof).

• Miscoding adventures such as using CPT code 65772 (Corneal relaxing incision for correction of surgically induced astigmatism) when refractive corneal relaxing procedures such as astigmatic keratectomy/limbal relaxing incisions (AK/LRI) are actually performed.

• Upgrading the size of lesions to qualify for reimbursement or coding them using higher paying excision and repair codes.

• Allowing unlisted or cosmetic procedures to be routinely performed without charging the patient in order to accommodate big-time players.

• Not charging the physician fee, but charging the facility fee for surgery relating to complications of a prior procedure in order to avoid “upsetting the patient.”

On the other hand, I have seen significant revenue not being captured by some of the following errors:

• Failure to capture all separately billable drugs on a given case.

• Erroneous use of procedure codes due to lack of understanding of surgical coding.

• Insufficient listing of all procedures performed. ◊