CODING & COMPLIANCE

Medicare ASC Surgical Coding & Claims Processing Potpourri

BY RIVA LEE ASBELL

Treatment of complications related to surgery presents ASC management problems involving many aspects including: the actual surgery, financial issues, scheduling details as well as getting paid, and paid properly, for the cases. Here, we will discuss Medicare payment issues related to ASC reimbursement.

Coding For Surgical Complications

Primarily, ASC coding differs significantly from physician surgical coding in that you are billing a facility fee — not a fee for the surgeon’s work. In Medicare parlance, that means you’re getting reimbursed for such things as equipment usage, supplies, staff salaries, and so on, and the fee for a given procedure on CMS’s fee schedule includes all of those items. It makes no difference if the procedure performed is the original procedure, or results from an untoward result, or is or is not in the postoperative period.

Using CPT Unlisted Codes

Perusal of CPT (Current Procedural Terminology) codes reveals unlisted codes — those that end in xxx99 — for various categories of surgeries. These are codes that are mandated for use when the proper and exact code for a given procedure doesn’t match the description of any one of the existing CPT codes. An example of an unlisted code is CPT code 67999 described as: “Unlisted procedure, eyelids.” The physician payment of any xxx99 code involves Medicare removing the claim from routine processing and reviewing it individually for payment. There is no such mechanism for processing xxx99 ASC claims. Therefore, codes ending in ‘99’ cannot be used for ASC coding.

Modifiers

Modifiers used in Medicare ASC surgical coding differ significantly from those used in physician surgical coding. See the “Excerpts from WPS Medicare Global Modifier Fact Sheet,” which provides a listing of the most common modifiers you’ll be using when coding surgery in the ASC for Medicare claims. Below are links to WPS Medicare’s website and the Modifier Fact Sheets:

http://www.wpsmedicare.com/j8macpartb/resources/modifiers/

http://www.wpsmedicare.com/j8macpartb/resources/modifiers/globalsurgmodifiers.shtml

Notably absent from ASC use are modifiers 58, 78 and 79, which are used for enabling payment for physician surgical procedures performed in the global period that fall into one of the following categories: lesser to greater, diagnostic to therapeutic or staged procedures (modifier 58); procedures related to the original procedure (modifier 78); procedures unrelated to the original operation (modifier 79). There is no global period in facility billing.

When a patient is readmitted to an ASC during the global surgery period, it is important to keep in mind, once again, that the ASC payment varies from physician payment methodology and only appropriate modifiers approved for ASC use by Medicare — not the ASC modifier section in CPT — should be used. Complications related to an original surgery should not be coded with modifier 78 for the ASC claim even though it would appear on the physician claim. Nor should modifiers 58 or 79 be used, even though they might be applicable to physician coding. The ASC is entitled to full payment according to the ASC fee schedule.

Order of Procedures

The CPT codes should be placed on the claim in descending order of reimbursement with the highest paying procedure first. Currently, more codes are reimbursed at the same amount for the same family of codes in ASC payment, but there remains a differential on the physician side. Inadvertently, a given claim may not be put in the same order on the ASC claim. ASC coders should be aware of the physician side in order to make the claims have the same order (Figure 1).

Figure 1. ASC versus Physician Payment

Claims Processing/Claims Splitting Prohibition

There have been recent communications from various Medicare Administrative Contractors (MACs) warning ASC billers not to split claims for multiple procedures performed at the same session by the same physician. This warning applies to:

• Submitting separate claims for each side when coding bilateral procedures, such as a bilateral functional blepharoplasties or entropion repairs

• Submitting separate claims for multiple procedures performed by the same surgeon during the same session, such as repair of retinal detachment with removal of an IOL that dropped into the vitreous using pars plana posterior vitrectomy + removal of IOL from posterior vitreous + insertion of secondary intraocular lens + suturing of the intraocular lens

ASC claims are paid by Part B Medicare and follow the payment rules for multiple procedures performed at the same session (applies to both ASC and physician payment), wherein the first procedure is paid at 100% of the allowed amount and the next four procedures are paid at 50% of the allowable for each procedure. When the claims are split, each claim is processed independently, and the facility may be erroneously paid at 100% of the fee schedule amount for each claim. In Figure 1, this would result in an erroneous payment of $1767.16 (2 x $883.58) instead of the correct payment of $1325.37 (1.5x $883.58).

The Office of the Inspector General (OIG) highlighted this problem in its January 2003 report, titled “Review Of Claims For Multiple Procedures Performed In The Same Operative Session In Ambulatory Surgical Centers” (http://oig.hhs.gov/oas/reports/region7/70302665.pdf). ■