CODING & COMPLIANCE

Retina Surgery in ASCs: Financial, Coding & Compliance Decisions

BY RIVA LEE ASBELL

Both surgeons and patients prefer that ocular surgery be performed in an ASC. The initial movement, spurred by technology developments that made performing retina surgery in an ASC more feasible, began in the early 1980s. More and more ASCs are performing retina cases, while Medicare oversight has become more stringent and the auditing more intense. In this article, I discuss some of the issues that are key in making the decision regarding where to perform the procedure: ASC, outpatient hospital or office. Reimbursement, coding and compliance issues are specific to Medicare, although many other insurers may follow Medicare guidelines.

PLACE OF SERVICE (POS) ISSUES

Intravitreal Injections: Office vs. ASC. One of the most frequently asked questions by providers, billers and administrators is whether to perform intravitreal injections in the office setting or in an ASC. There are several factors that need to be taken into consideration when making this decision, including:

• Place of Service Differential. The differential in reimbursement, known as site-of-service differential, wherein intravitreal injections reimbursement is no longer considerably higher when performed in the office compared to when it is done in the ASC. The 2014 national average payment for CPT procedure code 67028 (intravitreal injection) is $106.39 when performed in the office and $104.96 when performed in the ASC. This is very different from 2008, when their offices received $50 more for performing the procedure.

   This may be a real paradigm shift for retina practices and make scheduling “injection days” more financially feasible and practice efficient.

• Ownership in the ASC. You may reap some additional reimbursement if you have an ownership position in the ASC. The national average for the intravitreal injection facility fee is approximately $48. The supply may be billed additionally, if not bundled with the procedure.

SUPPLY ISSUES

Medicare does not permit the surgeon to bring his/her own drugs and/or supplies to the ASC and bill Medicare for them. The ASC is not permitted to reimburse the surgeon for supplies and/or drugs since they are bundled in the facility payment. They can be billed separately only by the ASC when are used in the facility.

RETINA AND VITREOUS SURGICAL CODING

As more cases are being performed in ASCs, more attention is being given to which type of cases should be done there and if there should be restrictions. Financial issues, complexity of cases and surgical swiftness all appear as influencing factors. However, with an increase in ASC auditing by Recovery Auditors (RAC) for compliance issues and Medicare for Conditions of Coverage issues, compliance and reimbursement must be considered.

CPT Procedure Codes

The CPT surgical codes are updated annually and any Category III codes are updated semi-annually. The existence of a Category III code does not mean the Medicare Administrative Contractor (MAC) will pay for it. Furthermore, the lack of a payment determination mechanism for paying of an unlisted CPT code (67299 for retina/vitreous procedures) makes them unbillable by the ASC. If you anticipate performing a complicated case that might not have an existing CPT code, an outpatient hospital setting may be more appropriate.

Category III Codes (Emerging Technology Codes)

Category III codes are temporary codes for emerging technologies, services and procedures. One purpose of these codes is to allow the collection of data for services and procedures that could not be accomplished by using unlisted codes.

Category III codes are five-digit alphanumeric codes; the fifth digit is a letter. The assignment of codes is chronological — based on the date the code was approved by the CPT Editorial Panel.

The Category III codes are updated every 6 months and can be accessed online at the AMA website (www.ama-assn.org). This is somewhat confusing due to the vagaries of the system. The implementation date occurs 6 months after the release date. Note that most MACs pay on very few Category III codes for both physicians and ASCs.

Multiple Surgery Rules

Multiple surgeries are defined by Medicare as more than one procedure performed by the same surgeon during the same session. Payment is calculated as 100% of the allowable for the first (highest paying procedure) and a 50% reduction for the next four procedures. After five procedures are coded, the case is turned over for individual medical review and consideration. So, you can code up to five codes per surgical case without review. Note that this review mechanism is not in place for ASC coding. It’s best not to use more than five CPT codes on a given case.

NATIONAL CORRECT CODING INITIATIVE (NCCI) IN ASC CODING

The NCCI is a document that lists CPT code pairs that can’t be billed together. It is also known as the CCI or “bundling lists.” It is the objective of the NCCI to aid the Centers for Medicare and Medicaid Services (CMS) in their goal of decreasing fraud and abuse as well as decreasing the amount of overpayments erroneously being made to providers. The NCCI is issued quarterly.

Since an ASC bills to Part B of Medicare, the Physician NCCI edits apply. The list of edits is updated quarterly and coding personnel need to be up-to-date on this. Books containing the information that are published annually cannot keep up, so it’s better to subscribe to an electronic program that updates the bundles quarterly. I personally use EyeCodingToday.com.

MODIFIERS

There is a CPT Appendix titled “Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use.” However, not all of those listed in the appendix are accepted by Medicare. Here are some highlights regarding using modifiers when the ASC is billing Medicare:

• Medicare discontinued using the SG modifier with the advent of ASC Payment Reform in 2008.

• Modifier 52 has a special use in ASC coding that differs from what is published in CPT. It is used for coding reduced services for discontinued radiology procedures and other procedures not requiring anesthesia that are partially reduced or discontinued at the physician’s discretion. In this usage, the payment is 50% of the allowed amount.

• Modifiers 73 and 74 are ASC-specific and often overlooked by physician coders.

• Modifier 73 is to be used prior to anesthesia administration but not when there is an elective cancellation of the procedure. The surgical or diagnostic procedure may be canceled subsequent to surgical preparation, but before the administration of anesthesia. Payment is at 50% of the allowable amount for the procedure.

• Modifier 74 is to be used after the procedure has commenced or after the anesthesia was administrated. Payment is at 100% of the allowable amount for the procedure.

• Do not use modifier 50. Even though modifier 50 appears in the appendix, it should not be used. The Medicare contractors have issued instructions regarding this. Instead, use a two-line entry with a single unit of service on each line or two units of service on a single line. Use of modifier 50 will result in payment for only one side when bilateral surgery was performed. Instructions in the NHIC, Corp. Ambulatory Surgery Billing Guide state, “A procedure performed bilaterally in one operative session is reported as two procedures. Report the CPT code as two line items, not one line item with two units. Enter the 76 modifier on the second line item. Procedures eligible for the bilateral procedures will be reimbursed at 150% of the applicable rate. Procedures eligible for the bilateral payment adjustment are determined by CMS.” I suggest you confirm this methodology with your MAC before using it since it varies with each one.

• Modifier 78 should not be used for ASC coding although it is mandatory for physician coding when performing a procedure in the global period of another procedure if the surgery is related to the original one or is for complications related to the original surgery. The ASC payment is a facility payment and should not be subject to reduction due to the surgery being performed in a global period. Modifiers 58, 78 and 79 are not appropriate for ASC coding of cases.

• Advanced Beneficiary Notice (ABN): if an ABN is used by the ASC then the claim should reflect the proper modifier – GA, GY or GZ.

• Payment:

• ASC surgical services billed with either the 52 or 73 modifier are not subjected to further reductions.

• Procedures billed with modifier 74 are subject to multiple procedure discounts.

• Claims submitted with Modifier 73 are paid at 50% of the allowable for the procedure.

• Claims submitted with Modifier 74 are paid at 100% of the allowable for that procedure.

• Drugs and Biologicals: those designated with N1 are bundled into payment for the procedure. Those designated with K2 may be billed separately.

COVERAGE DETERMINATIONS

MLN Matters (MM8675) states specifically, “The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the ASC payment system does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. Carriers/MACs determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, Carriers/MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.”

There has been an increase in the types of retina/vitreous surgery that are being efficiently and safely performed in the ASC. Therefore, it’s critical that the physician and ASC coder coordinate on coding all cases including the order of procedures, the use of modifiers, and the billing of drugs. ■