CODING & COMPLIANCE

Under the Radar Screen: ASC Reimbursement Issues

BY RIVA LEE ASBELL

Keeping up with the myriad of reimbursement and compliance issues in an ASC is a monumental task. Some issues are very specific, whereas others may be more generic. Subjects discussed in this review are applicable to the Centers for Medicare and Medicaid Services (CMS) and the Medicare program — some of them of longer duration, and others pertinent only for the current year. All of them are significant and bear consideration.

KERATOPROSTHESIS

As a result of a restructuring of the Ambulatory Payment Classifications (APCs) for ophthalmology in the Outpatient Prospective Payment System (OPPS), on which the ASC reimbursement is based, the reimbursement for keratoprosthesis surgery has been adversely affected when performed in the ASC. This is due to CPT code 65770 (keratoprosthesis) being packaged with 67027 (insertion of intravitreal implant).

For 2016, the facility reimbursement in a freestanding ASC has been reduced from $6,683.30 to $2,261.69 (national averages). The facility reimbursement includes the purchase of the keratoprosthesis.

On the other hand, keratoprosthesis surgery still can be performed as an outpatient hospital procedure with ample reimbursement. The Medicare facility reimbursement for 2016 is $9,398.42 (national average), including the hospital fee and the device.

Due to the restraints imposed by the Social Security Act and rulemaking, there is nothing further that can be done to alter the payments for the keratoprosthesis for 2016. It would literally take an act of Congress. This most likely will be resolved in 2017, and it will be back to “business as usual” for ASCs.

INTRACAMERAL DRUGS: TO BILL OR NOT TO BILL

Not To Bill: “Dropless” Cataract Surgery

A revised Coding Guidance for Intraocular or Periocular Injections of Combinations of Anti-Inflammatory Drugs and Antibiotics has been issued by CMS. Intraocular or periocular injections of combinations of anti-inflammatory drugs and antibiotics are being used with increased frequency in ocular surgery (primarily cataract surgery). One example of combined or compounded drugs includes triamcinolone and moxifloxacin with or without vancomycin. Such combinations may be administered as separate injections or as a single, combined injection. Because such injections may obviate the need for post-operative anti-inflammatory and antibiotic eye drops, some have referred to cataract surgery with such injections as “dropless cataract surgery.”¹

Sources cited include the following:

• The National Correct Coding Initiative (NCCI) Policy Manual states that injection of a drug during a cataract extraction procedure or other ophthalmic procedure is not separately reportable. Specifically, no separate procedure code may be reported for any type of injection during surgery or in the perioperative period. Injections are included as part of the ocular surgery and the HCPCS code used to report the surgical procedure.

• Chapter 17, Section 90.2 of the Medicare Claims Processing Manual specifies the compounded drug combinations described above and similar drug combinations should be reported with HCPCS code Q9977 (Compounded Drug, Not Otherwise Classified), and are packaged as surgical supplies in both the Hospital Outpatient Department (HOPD) and the ASC. These drugs are a covered part of the ocular surgery and no separate payment will be made. In addition, these drugs and drug combinations may not be reported with HCPCS code C9399.

• According to Chapter 30, Section 40.3.6 of the Medicare Claims Processing Manual, physicians or facilities should not give Advance Beneficiary Notices (ABNs) to beneficiaries for either of these drugs or for injection of these drugs because they are fully covered by Medicare. Physicians or facilities are not permitted to charge the patient an extra amount (beyond the standard copayment for the surgical procedure itself) for these injections, or the drugs used in these injections, because they are a covered part of the surgical procedure. Also, physicians or facilities cannot circumvent packaged payment in the HOPD or ASC for these drugs by instructing beneficiaries to purchase them and bring these drugs to the facility for administration.

To Bill: Pass-through Payment Drugs

Section 1833(t)(6) of the Social Security Act provides for temporary additional payments or “transitional pass-through payments” for certain drugs and biological agents, including orphan drugs and certain “new” drugs that were not paid for as a hospital outpatient service as of Dec. 31, 1996, and whose cost is not insignificant in relation to the OPPS payment for the procedures or services associated with the new drug. Under the statute, transitional pass-through payments can be made for at least 2 years but not more than 3 years.²

After that period of time, the costs are built into the reimbursement rates for procedures for both hospital outpatient and ASC procedures. In fact, the ASC payment system is based on a percentage of the OPPS APC group rate. (See Tables 43 and 44 from the Final Rule for 2016 that was published in the Federal Register.)³

Omidria (phenylephrine and ketorolac injection 1% / 0.3%, Omeros), a drug that helps maintain dilation of the pupil and prevents intraoperative miosis and pain during cataract and cataract-related surgery, received pass-through status effective Jan. 1, 2015 for Medicare patients and may be billed in addition to the surgery (use HCPCS code C9447). The pass-through status expires Dec. 31, 2017. Other insurers may cover the drug separately as well. It is best to check with each insurer individually to ensure coverage.

When performed in the ASC, the patient is responsible for the copayment if it is not covered by the insurance. Contact Omeros regarding assistance with payment to the facility for these patients (omidria.com).

MODIFIERS & MISCELLANEOUS

Modifiers. Among the most common modifiers used in ASC coding are modifiers 73 and 74, which are for discontinued procedures. However, there is some confusion on what other modifiers should be used. Although Appendix A in Current Procedural Terminology (CPT) lists modifiers that, theoretically, may be used in ASC coding, Medicare does not accept them all, and other insurers may have different rules all together. It is best to obtain the list from your Medicare administrative contractor and use that list as a guideline for your Medicare patients. If possible, do the same for other insurers as well. The modifiers used when procedures are performed in the global period of another operation (58, 78, and 79) are not required, as payment is based on the ASC fee schedule and is not influenced by whether or not the patient is in the global period of another surgery — unlike physician reimbursement.^4,5

Here are a few typical questions regarding ASC reimbursement:

• I was told today by a Medicare rep that as an ASC, we cannot use modifier 78 for an unplanned return to OR. Has anyone else run into this?

• I code for an ASC, and my payer won’t reimburse me for claims with modifiers 78 (Return to the operating room for a related procedure during the postoperative period) and/or 79 (Unrelated procedure or service by the same physician during the postoperative period) appended to them. Should we appeal?

• An oculoplastic surgeon is bringing a patient back 6 weeks after the original procedure for severing of a Hughes tarsoconjunctival flap. Because this is a staged procedure, should we use modifier 58?

It is evident that the claims payment problem is the same in all of these examples: the use of the global period modifiers (58, 78, 79), which do not apply to facility payment in an ASC.

Place of Service (POS) Issues. In addition to modifiers, there is some confusion regarding POS issues. The following question from a reader is a perfect example.

• I am hoping someone can help. My ASC was bought out by the hospital and has a new TIN and new NPI, which they are billing with. However, the NPI and TIN are linked to the hospital, not a freestanding ASC. I think I need to use POS 22, and not POS 24, as they are billing with the hospital ID numbers. Is this correct? Also, what if our bills do not match for POS? The billers are using POS 24. I just recently became aware of the ID numbers changing.

This is a moving target. Effective Jan. 1, 2016, there was an addition and revision for claims processed after that date for hospital outpatient facilities:

• POS 19 Off Campus-Hospital Outpatient Hospital (new code)
Descriptor: A portion of an off-campus hospital provider based department, which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

• POS 22 On Campus-Outpatient Hospital (revised code)
Descriptor: A portion of a hospital’s main campus, which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

• POS 24 Ambulatory Surgery Center

The Medicare Claims Processing Manual Ch. 14 §10.1 notes the definition of an ASC for Medicare purposes is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. The ASC must have an agreement with CMS obtained in accordance with 42CFR 416 subpart B (General Conditions and Requirements [Code of Federal Regulations]). An ASC is either independent (i.e., not a part of a provider of services or any other facility), or operated by a hospital (i.e., under the common ownership, licensure, or control of a hospital). A hospital-operated facility has the option of being considered by Medicare either an ASC or a provider-based department of the hospital as defined in 42 CFR 413.65.⁶

So, this is very confusing for all. The best advice I would give the reader is to contact hospital administration and determine the current status of the formerly independent ASC with CMS, and then follow the guidelines.^6,7

A New Business Model. In the May 2016 issue of OutpatientSurgery.net,⁸ the header proclaimed “Nation’s First Dual-Licensed Surgery Center Opens in Colorado.” Timesharing of condos is not new; timesharing of ASCs surely is. A joint venture between a hospital and a neurosurgeon who will lease one operating room and staff on the first and third Friday of each month is reported in the context of a dual-licensed ASC in Colorado. According to the article, the timeshare arrangement was enabled by a little-known CMS ruling that lets ASCs operate as timeshare properties if they are dually licensed by the states in which they operate. Where permitted under state law, multiple ASCs may use the same physical space, including the same ORs, as long as they do not have concurrent or overlapping hours of operation. ■

References & Resources