CODING & COMPLIANCE

Educational Resources for ASCs

BY RIVA LEE ASBELL

Whereas there are numerous resources for learning ophthalmic coding and reimbursement, it’s difficult to find comprehensive training, courses and resources for Medicare ASC regulations. This review provides some of those resources for you.

Medicare Regulations for ASC Reimbursement

The best source of information is CMS itself. On the CMS website (cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment), you’ll find links to the Final Rule and Proposed Rules that contain basic information for the following year’s regulations for payment. The Final Rule is published together with the Outpatient Prospective Payment System rule each year in the Federal Register, but may be accessed through the CMS website.

Be sure to click on the link under Spotlight and then on the 2015 Final Rule, which will bring you to Details for title: CMS-1613-FC. Scrolling to the bottom of the page under Related Links and clicking on AA, BB, DD1, DD2 and EE will bring you to an Excel file that is tabbed and provides most of the tools you need. Included are national averages for payments for procedures, lists of drugs with the indicators for packaging, and so on.

The “Download and Related Links” areas at the bottom of the CMS website pages should always be reviewed, as they contain important information. The sidebar on the upper left contains important subcategory links as well.

CMS also issues Medicare Learning Network (MLN) articles, which are easy to read articles filled with necessary basic information. Google is my best friend, and if you type “CMS ASC FEE SCHEDULES” in the search field, you’ll find MLN articles in PDF format. The Ambulatory Surgical Fee Schedule from the Payment System Fact Sheet Series is a good place to begin.

Surgical Coding

Professional coders are trained in surgical coding. However, there are many nuances and rules specific to ophthalmology that may be more esoteric than those of other specialties. Also, even if coders know ophthalmic coding, applying the rules to ASC coding is like an American learning to drive on the left side of the road — unfamiliar.

One great surgical coding resource is “Tips on Ophthalmic Surgical Coding by Subspecialty,” a book on physician surgical coding that can be purchased online. Another great resource is The Ophthalmic ASC — both various articles and specifically my coding column. These are available online.

Keep these in mind when coding surgery for physicians versus coding for procedures performed in the ASC:

Similarities

• Both use Current Procedural Terminology (CPT) codes

• Both use ICD-9-CM codes and will use ICD-10-CM codes effective October 1, 2015

• Both are governed by the National Correct Coding Initiative (NCCI) bundling guidelines

Differences

• Modifier usage varies and not all modifiers listed in CPT Appendix A, “Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use,” are accepted for Medicare ASC claims — or are even needed. Your Medicare Administrative Contractor (MAC) may have a list of modifiers, such as these, on the WPS Medicare website:

www.wpsmedicare.com/j8macpartb/resources/modifiers/ (general listing)

Or you can refer to the Global Surgery Modifier Fact Sheet (wpsmedicare.com/j8macpartb/resources/modifiers/globalsurgmodifiers.shtml). In the right hand column, it is noted if the given modifier does not apply to ASCs.

• Unlisted codes, such as 67999, cannot be used for ASC coding, as there is no method to adjudicate payment.

• The order of procedures (list by highest paying procedure first) may be different from that used in physician coding.

Chart Documentation

Some of the practice management listservs have posted discussions about physicians’ offices being swamped with requests from hospitals and ASCs for chart notes documenting medical necessity for blepharoplasty and cataract surgery.

It is in the ASC’s best interest to require this documentation prior to scheduling any surgery where there may be a question of medical necessity, as this is often the focus of CMS audits. (See Blepharoplasty RAC Audits in the ASC, Ophthalmic ASC, May 2014).

For all surgeries performed in an ASC, the chart should include the physician’s chart note for the date the decision for surgery was made, as well as completed Activity of Daily Living (ADL) forms signed by the patient. These forms should record the difficulties the patient is having with the performance of daily activities due to the condition.

Compliance Issues

Informed Consent. The Ophthalmic Mutual Insurance Company (OMIC.com) is a valuable resource for guidance on physician’s informed consent issues as well as other risk management concerns. There are numerous samples available, including ones for Off-Label use of devices or drugs. While this may not be a direct concern for ASC management, it is of great importance to the physician — specifically when touchy situations arises — so it would be wise for the ASC to ascertain that all paper work on the physician’s side is in order (see Coding & Compliance Column on Glaucoma Surgery, The Ophthalmic ASC, February 2015).

Inducements. The concept of inducement wherein an ASC may perform or fail to monitor certain activities that result in gaining more admissions from physicians may fall under inducement violations. This is a legal issue and advice is best obtained from healthcare attorneys (see Inducement article, The Ophthalmic ASC, February 2014).

A Quick Glance at Resources

For devices and drugs, it’s wise to check the FDA approval, the package insert and the company’s website. ■