ASC Compliance & Coding

ASC Medicare Compliance and Chart Documentation in Cataract Surgery

By Riva Lee Asbell

According to statistics compiled in 2010 by the Association of American Medical Colleges/Physician Specialty Book, there were approximately 18,000 practicing ophthalmologists, rankings ophthalmologists twelfth in volume out of all specialists. Statistics from CMS, also from 2010, show that for allowed charges of all specialties, CPT code 66984 (phacoemulsification with IOL) ranks #4, CPT code 66982 (complex phacoemulsification with IOL) ranks #65 and CPT code 66821 (YAG posterior capsulotomy) ranks #69. No wonder CMS is always carefully re-evaluating these procedures.

OOSS has gleaned statistics showing that there are approximately 5300 Medicare certified ASCs of which 900-950 are ophthalmology specific and a few hundred others are multispecialty but perform a high volume of cataract and related procedures.

With these types of statistics showing a huge volume of procedures being performed on a national basis and accounting for a serious expenditure of Medicare funds, it’s not surprising that some administrative details become neglected and that some regulations were never known. This article reviews some of the important issues in compliance and chart documentation that an ASC may encounter.

Chart Documentation

With so much attention focused on Medicare ASC audits involving the medical issues and Conditions for Coverage, it’s important that compliance issues be a concern as well. The ASC chart should be able to withstand scrutiny from a compliance/reimbursement auditor. It’s recommended that the following items are incorporated into the ASC chart:

• The Activities of Daily Living (ADL) form is a questionnaire the patient completes and signs, and is dated and witnessed. The form substantiates the medical necessity for the surgery. It should be an ASC requirement that the physician supplies a copy of the ADL when the scheduling information is sent to the ASC. If a form hasn’t been completed, then the ASC personnel should have the patient complete the form prior to surgery.

• It’s recommended that part of the ASC chart documentation include the physician visit when the procedure was scheduled.

• If there were complications during surgery, operative note documentation should not come from only templates.

For complex cataract surgery, the first paragraph of the operative note should outline why it was a complex case.

Covered vs. Non-covered Procedures

Medicare has issued a Fact Sheet titled “Medicare Vision Services,” last revised in December 2012, which reviews many covered versus non-covered issues. (See www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/VisionServices_FactSheet_ICN907165. pdf.) Medicare states that in order for a service or item to be covered it must satisfy three basic requirements:

• The service must be in a category of services that by statute is a defined benefit.

• The service must be reasonable and necessary for the diagnosis or treatment of illness of injury or to improve the functioning of a malformed body part.

• The item or service must not be excluded from coverage.

Premium IOLs. Medicare reimbursement policy underwent a radical change with the advent of premium IOLs. Medicare refers to them as Presbyopia-Correcting (P-C) IOLs and Astigmatism-Correcting (A-C) IOLs. Medicare covers cataract surgery as well as one pair of glasses or contact lenses postoperatively for each cataract surgery performed using a conventional IOL. On that basis, premium IOLs are neither glasses nor contact lenses, even though they may serve the same function. The insertion doesn’t fall into a benefit category and the portion that deals with refractive services is not a covered service.

This historic decision allowed physicians and facilities to charge patients for that portion of the service that was statutorily excluded from the Medicare program, namely, the refractive portion of the IOL. Certain other expenses could be billed to the patient as well. You would be in violation of compliance if you billed Medicare for these services. These are considered non-covered services. The Medicare Vision Services fact sheet states: “…Any additional provider or physician services required to insert the P-C IOL or A-C IOL or to monitor a patient receiving a P-C IOL or A- C IOL are also not covered. For example, the rotation of an A-C IOL to properly align the axis is non-covered.”

Femtosecond Laser-assisted Cataract Surgery. The AAO and ASCRS published “Guidelines for Billing Medicare Beneficiaries When Using the Femtosecond Laser” that were revised in November 2012 as a result of CMS issuing its own guideline, in which it focused on misleading and unacceptable promotional advertising. The listservs are replete with questions and answers, and many practices still are under the false impression that the patient may be billed for the use of the laser when used in cataract surgery. This is completely incorrect; the only time the patient can be charged is when the laser is used in conjunction with a non-covered service, namely, a refractive service.

Coding/Reimbursement Issues

Each ASC deals with the surgical coding in a different fashion — some only have the physicians code, some have coding personnel while others have a combination of both. Regardless of the system, anyone who handles coding should be well versed in CPT rules and regulations including mastery of the modifiers. Below are some of the more important uses of some of the key modifiers.

Modifiers

• The SG modifier is not to be appended effective with the new system.

• Modifier 73 is only to be used after anesthesia is administered and not when there is an elective cancellation of the procedure. Payment is at 50% of the allowable amount for the procedure.

• Modifier 74 is only to be used after procedure has commenced; in other words, the incision has been made. Payment is 100 % of the allowable amount for the procedure.

• Do not use modifier 50. Even though modifier 50 appears in the appendix it shouldn’t be used because the Medicare contractors have issued instructions regarding this. Instead, use a two-line entry with a single unit of service on each line or 2 units of service on a single line. Use of modifier 50 will result in payment for only one side when bilateral surgery was performed.

Complex Versus Complications in Coding Cataract Surgery. CPT code 66982 is used for complex cataract extraction with insertion of IOL, whereas CPT code 66984 is used for regular cataract extraction with insertion of IOL. While the ASC reimbursement may be the same, CMS has been concerned with the possible overutilization of the complex code. ASCs may have their records requested in conjunction with these audits.

Examples of complications include expulsive hemorrhage, dropping the nucleus or the IOL into the vitreous, and loss of vitreous during the procedure but these situations don’t qualify as complex. I’ve written numerous articles on this and you should read the CPT definition. Surgeons often confuse complex with complications. As the local coverage determination from Palmetto GBA stated, “The billing of [the complex cataract] has nothing to do with the surgeon’s perception of the degree of difficulty. It should be noted that the use of this code is governed specifically by the fact that the surgery require(s) devices or techniques not generally used in routine cataract surgery.” ◊