Best ASC Billing Practices & Potential Issues

Transcription

1 Best ASC Billing Practices & Potential Issues Speaker: Stephanie Ellis, R.N., CPC Ellis Medical Consulting, Inc. (615) for SourceMedical

2 About STEPHANIE ELLIS Stephanie Ellis, R.N., CPC, founded Ellis Medical Consulting, Inc. (EMC) in EMC specializes in coding chart audits, business office operational assessments, litigation support, reimbursement research and difficult/challenging coding questions, outsourced coding, coding and billing training and compliance programs for ASC facilities, physician practices, hospitals, and clinics nationwide. Ms. Ellis gives seminars nationally on such topics as ASC Coding and Billing Issues, Documentation Issues, Fraud and Abuse Issues, Medicare Denials, Specialty Coding, RAC Audits and Compliance Plans. She is on the Advisory Board of OR Manager magazine and Family Practice Coding Advisor. She also served on the Editorial Advisory Board of The Coding Institute s Outpatient & ASC Coding Alert publication. She writes numerous articles on compliance, coding and billing issues for such national magazines as Outpatient Surgery Magazine, Beckers ASC Review, ASCA Focus, AORN Magazine, OR Manager Magazine, AAPC, JustCoding.Com, etc.) on a regular basis. Prior to starting EMC, Ms. Ellis worked as a Fraud Investigator at the Tennessee Medicaid Program. Ms. Ellis is an active member of the national Ambulatory Surgery Center Association and speaks at many of their meetings and at Beckers ASC national meetings. She is also a member of the AAPC, AHIMA, MGMA, HFMA, HCCA and AORN. She served as a Board Member for nine years and is past Treasurer of FASCA of TN, the Tennessee state surgery center association.

3 Billing Compliance Issues for ASCs Billing non-covered CPT codes for ASC services with CPT codes for covered services, which do not properly describe the procedure performed). Billing for new procedures with a code for a procedure that does not fit. Billing Medicare for Cataract Extraction procedures when the ASC does NOT purchase the IOL for the case. Upcoding of procedures. Inappropriate Unbundling of CPT codes. Failure to refund Credit Balances in a timely manner. Medical Necessity issues. Billing improperly for cancelled cases vs. terminated cases. Medical Necessity for Pain Management procedures.

4 Billing Compliance Issues for ASCs Place of Service code errors on claim forms. Physicians dictating OP Reports away from the ASC and reports are not clear the procedure was performed at the ASC facility. Changing the Date of Service on claims to correspond with coverage dates. What is Fraud? The Federal Government defines Fraud as willingly or knowingly engaging in a scheme to defraud or obtain by false or fraudulent pretenses money or property from a health care benefit program. What is Abuse? The Federal Government defines Abuse as involving actions that do not involve intentional misrepresentations in billing, but which result in improper conduct.

5 General Billing Basics and Tips Read the ENTIRE OP Report before coding the claim. Per Medicare, ONLY procedures documented in the body of the OP Report are billable. Physicians use of Canned OP Reports. Be sure each service billed is properly documented PRIOR to billing it. Review EOBs for denial reasons regularly look for trends. Sequence CPT codes for billing from Highest to Lowest Fee you will be paid by the payor not your facility s fee. Check Medicare Bulletins monthly for changes to policies for procedures performed in your ASC facility. Be aware of any Medicare LCD medical policies for procedures performed in your ASC be sure to follow diagnosis lists and list a covered diagnosis 1 st on claim. Check with payors for policies on billing for Implants.

6 Billing Bilateral Procedures The 5 usual methods for billing Bilateral procedures are: Bill the same code as two line items, using the RT modifier on one code and the LT modifier on the other code. (***OK for Medicare) RT $ LT $ Bill bilateral procedures as two line items with no modifier on the 1st code and the 50 modifier on the 2nd line item (same code) $ $ Bill the procedure as a single line item on the claim with a 50 modifier on the procedure code. Be sure to double the facility fee $1, Bill the same code as two line items with no modifiers. (***Medicare) $ $ Bill the procedure as a single line item on the claim form with no modifier on the code and put a 2 in the Units column on the claim. Be sure to double the facility fee. (***Medicare) $1, Units

7 Separate Procedure Status of CPT Codes The Separate Procedure designation indicates that a procedure or service may be: Performed independently; Unrelated or distinct from other procedures/services provided at the same time/in the same case; or Considered an integral component of another procedure/service. Codes designated as Separate Procedures are usually not billable unless it is the ONLY procedure performed. It may be billable with the use of the 59 modifier, to indicate that the procedure is not considered a component of another procedure, but a distinct, independent procedure, under circumstances such as: Different site or organ system; Separate incision/excision; Separate compartment; Separate lesion

8 Unbundling Check each procedure code to be billed with every other procedure code to be billed in the current Medicare CCI Unbundling Edits to see if any of them are components of another code to be billed. If codes are Unbundled, they might both be billable (using -59 modifier on the Unbundled code) under the following circumstances: 1. Performed at a different site or in a different organ system; 2. Separate incision/excision; 3. Separate compartment; 4. Separate lesion Fragmenting Fragmenting of claims is billing CPT codes for the same patient, on the same date of service, performed by the same service provider (surgeon), and during the same case on separate claim forms to the same payor. It is a serious compliance issue with Medicare.

9 Medicare ASC Billing Rules Terminated Surgical Procedure Rules Cancelled or Postponed Procedures Not billable. Terminated before Anesthesia is induced - use modifier -73 reimbursed at 50% of allowable. To bill using the -73 modifier, the patient MUST be in the OR or procedure room where the procedure was to be performed. If in the Pre-OP area, it is not billable. Terminated after Anesthesia is induced - use modifier -74 reimbursed at 100% of allowable. Termination of an IOL Procedure.

10 Medicare ASC Billing Rules Terminated Surgical Procedure Rules Required Documentation of Terminated Procedures for Medicare patients: Reason surgery was terminated Services actually performed Supplies actually provided/used Services not performed Supplies not provided/used Time actually spent in each surgical stage Time that would have been spent had the intended procedure(s) been completed CPT codes for procedure (had full procedure been performed) This information can be documented by a nurse, but must be signed by the surgeon.

11 Be Sure You are Billing IOLs for Cataract Cases Correctly When your ASC facility has a Medicare patient who requests a Premium Lens (Presbyopia-Correcting (PC) lens or an Astigmatism- Correcting (AC) lens), there are special guidelines that must be followed to stay in compliance with Medicare rules. Billing Correctly These Premium Lenses are the ONLY IOLs for which Medicare allows patients to be charged. Medicare won t reimburse any more than they usually do for regular IOLs for these cases the usual reimbursement of $ is included in the payment of the usual 66984, 66982, etc. cataract extraction procedure code. While it is not mandatory to have the patient sign an ABN, since Premium IOLs are never covered by Medicare, it is a good idea, so that there will be no misunderstandings with patients as to his/her owing portion.

12 Medicare Reimbursement When you bill the 66984, or other Cataract Extraction procedure code to Medicare, the code includes the insertion of an IOL in the procedure, and Medicare s payment of the cataract CPT code will include a $ allowance for payment of a regular posterior chamber or anterior chamber IOL. That does not change when you use the Premium IOL in the case, instead of a regular IOL. Your facility is still being reimbursed for the placement of an IOL, even though it is a different type of IOL, it does not change that you have been paid for the IOL by Medicare.

13 Compliance Issues when using Premium Lenses The compliance issues which can occur when using Premium Lenses are outlined as follows: 1. When the surgeon wants to purchase an AC or PC IOL for the case and bring it into the ASC, it is a compliance issue. Medicare does not allow the ASC to bill for cataract extraction procedures with placement of an IOL with the -52 Reduced Services Modifier or use any other billing method to convey to Medicare that the ASC did not purchase the IOL and should not be reimbursed for the IOL supply. Since there is no provision to allow the ASC to break out the implant portion from the cataract extraction CPT code, Medicare requires the ASC facility to supply (purchase) the IOL for these and ALL cataract cases - always. Medicare considers it to be a False Claim for the ASC to submit a cataract extraction claim for which they are receiving payment for the IOL when the ASC did not purchase the IOL. 2. If the ASC has purchased the IOL (as required), Medicare does not allow the physician to collect the patient owing portion on behalf of the ASC from the patient - ONLY the ASC can charge a Medicare patient for his/her owing portion for a Premium IOL.

14 3. Also, what you charge patients for the Premium lenses can be another compliance issue, as Medicare directs what you can charge patients for Premium IOLs. Overcharging patients for these lenses can be a compliance issue. Therefore, you need to be sure you aren t overcharging Medicare patients for Premium lenses. For example, if the ReSTOR PC IOL is used and your facility s cost is $1,100.00, what can you charge the Medicare patient for the IOL? Keep in mind that you are receiving the usual $ payment for an IOL from Medicare as part of the cataract CPT code, so that amount must be subtracted from the amount you charge the patient. Medicare allows you only a modest mark-up of $25-$50 on the IOL for handling on Premium IOLs. That is all you can charge the patient. Medicare does not allow you to charge the patient a massive mark-up (2-3 times cost or more) on these lenses. Following is an example of how to correctly charge a Medicare patient for a Premium lens: $1, Lens Cost - $ Medicare reimbursement for regular IOL $ $50.00 ASC s cost for handling of lens $1, Maximum amount ASC can charge patient

15 Claim Form Issues Medicare requires that the CPT procedure codes submitted on the ASC facility and the surgeon s claims should be identical. There should be no discrepancies. However, if you know the surgeon is not billing the correct CPT codes, the ASC should bill codes which are supported by the OP Report documentation. Incomplete or incorrectly completed claim forms can result in unnecessary denials for ASC facilities. Be sure to check that electronic and paper claim fields are populating correctly and claims are running smoothly through your claims clearinghouse.

16 Guidelines for Clean Claims Check every claim field to be sure they are correct and complete Keep insurance and demographic information on patients up-to-date. Verify insurance and precertifications for every case performed in your ASC Update ASC facility fees every year Avoid duplicate claim filings Submit all records requested and additional information requested by payors in a timely manner Submit only current records for that patient relating to the surgical case in question not information for cases performed on other dates of service

17 Medicare Billing for Non-ASC List Procedures Medicare s direction is that when procedures which are not on Medicare s ASC List of approved procedures are performed in an ASC, the case should be diverted to a place of service (the physician s office or the hospital) where that procedure is covered. Medical Record Documentation Issues The OP Report must support the Medical Necessity of all CPT and Diagnosis codes billed. The patient s name and/or Medical Record Number should be on every page in the medical record. The medical record should be complete and legible. Handwritten entries should be made in black ink.

18 Medical Record Documentation Issues (cont.) Be sure staff and surgeons sign records where required OP Report Addendums Documentation of imaging/fluoroscopy services Medical Record Errors Patient Insurance and Demographic Information/Dates Don t allow physicians to use Signature Stamps on OP Reports, H&Ps or other medical records

19 The Most Common Reasons for Medicare Claim Rejections The patient s ID/Subscriber number is incorrect, missing, or placed in the wrong field on the claim form. The provider s signature in the appropriate field on the claim form is missing. Incorrect Dates of Service or required dates are missing on the claim form. The billed diagnosis code does not or support the services billed or lacks specificity. Procedure codes are missing, incorrect, or unlisted codes were used, without justification/explanation given. The field for the ASC s fee on the claim is left blank. The referring/ordering physician s name and/or NPI # are missing from the claim form. Duplicate Claims. Claims not being filed in keeping with the payor s timely filing requirements.

20 Appeals of Denied Claims Medicare s appeal guidelines have five levels: 1. Redetermination 2. Reconsideration by Qualified Independent Contractor (QIC) 3. Administrative Law Judge Hearings 4. Departmental Appeals Board/Appeals Council Reviews 5. U.S. District Court Review

21 Other Billing Issues Correct Handling of Credit Balances New Procedures/Technology Waiving Co-Pays/Deductibles Upcoding and Undercoding Diagnosis Coding Issues Scheduling Issues Insurance Verifications and Pre-Certifications Injections for Post-Operative Pain Control Billing for Implants Correct Use of Modifiers and Revenue Codes Medicare RAC Audits

22 LIVE QUESTIONS? For further information, contact: Stephanie Ellis, R.N., CPC Ellis Medical Consulting, Inc SourceMedical