Donna SanGiovanni icpc, CASCC,CHI AAPC National Advisory Board Disclaimer

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1 ASCs The Basic Principles of Management and Coding AAPC Regional Convention 2010 Donna SanGiovanni icpc, CASCC,CHI CHI AAPC National Advisory Board Disclaimer This presentation, or parts thereof, may not be reproduced, stored in a retrieval system or transmitted in any form by any means (electronic, mechanical, photocopying, recording or otherwise) without theexpress express prior written consent of he publisher. Pursuantto to the protection of proprietary documentation under established copyright laws, the attendee may not distribute and/or sell all or any portion of this material. This publication is designed to provide accurate and authoritative information I regard to the subject matter covered. The information herein is accurate as the publication date and is subject to change in interpretation. Failure to abide fully with all terms and conditions contained in this material may result in possible civil and criminal penalties including liquidating damages. Current Procedural Terminology (CPT) is copyright 2010 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. This material is the property of the American Academy of Professional Coders. 2 1

2 Definition of ASC Ambulatory Surgery Center (ASC) is a facility, other than a physician s i office, where diagnostic services and surgical procedures are provided on an ambulatory basis. Ambulatory patient can potentially walk into the facility on their own. Do not confuse with ambulance. 3 How do ASC Coder s fit in? 4 2

3 Professional Credentials Coders had various organizations that offer certifications for physician based coders as well as hospital based coders. AAPC offers Ambulatory Surgery Center specialty exam CASCC Certified Ambulatory Surgery Center Coder 5 The ASC CODER Have a good understanding of anatomy and body systems to code from operative reports Be familiar with Medical Terminology Get to know the Surgeon s style and lingo Be comfortable discussing procedure with Surgeons Continually seek education and networking Go into the OR it s the best classroom!! 6 3

4 The ASC Coder s Role cont d Educate coworkers and Surgeons on coding procedures Work closely with Surgeons on documentation issues Know your insurance contracts Understand exclusions, carve outs Help with contract negotiations Input is imperative 7 Tools to Do the Job 8 4

5 Coder s Toolbox Correct Coding Initiative 2010 CPT book 2010, CPT Assistant ICD book 2010, HCPCS book 2010 Medical Anatomy book, medical dictionary Part B News Internet access to AAPC members area CMS website Magazine/articles for up to date info 9 Coder s Weekly Checklist American Medical Association (AMA) Individual Carrier Websites Reports from your software company to alert you of errors, trends needed to be investigated. 10 5

6 Correct Coding Initiative CCI Edits are available free on the CMS website. Downloadable. +CCI Disk available for purchase. This is what I recommend, user friendly. Updates mailed each quarter. Printable great for appeals! 11 Coding Tips Understand your CCI Edit modifiers 0 under no circumstances would a modifier would be appropriate 1 a modifier is allowed providing documentation clearly states the component code was performed separately 9 the edits are not active Edits updated quarterly, policies annually 12 6

7 Medicare LMRP and LCD Medicare Local Medical Review Policies Medicare Local Coverage Determination Diagnosis codes not on these lists will cause the claim to be denied for lack of medical necessity Single specialty ASC s keep a hardcopy for quick reference. 13 Close the Gap Administrator Manager Supervisor Coder Biller don t tforget tthe Surgeons! identify potential issues Weekly meetings Newsletter Blog Drop box 14 7

8 The MD ASC Procedures Why can t I do it here? 15 Services Performed at an ASC: Commonly performed on an inpatient basis but may be safely performed in an ASC Procedures that cannot be performed safely in a physician's office Can be considered elective (cosmetic surgery) Can be urgent (arthroscopies) Arenot emergent or life threatening CPT code must appear on the ASC covered procedure list for Medicare payment. Negotiate fees for other carriers. 16 8

9 Medicare Procedure Criteria for the ASC Covered List Prior to 2008 Operating room limitation 90 minutes Anesthesia limitation 90 minutes PACU Post Anesthesia Care Unit (recovery room) time limitation4 hours 2010 CMS is not emphasizing time limitations 17 Procedure Criteria for the ASC Covered List cont d Does not involve major blood vessels Does not result in major blood loss Does not require prolonged invasion of the body cavity 18 9

10 ASC Facility Covered Services included in payment Administrative, recordkeeping, housekeeping items and services Nursing services, services of technical personnel Facility use: pre operative areas, operating room, recovery room areas Diagnostic or therapeutic items and services Materials and supplies used for anesthesia Drugs and biologicals Blood, blood plasma, platelets, etc., except for those applied to the blood deductible dd Surgical dressings, supplies, splints, casts, appliances and equipment Intraocular lenses ( except NEW TECHNOLOGY Lens) 19 ASC Facility Services not included in payment Physician service fee Anesthesiologist/ CRNA fee Independent Laboratory fees Sale, rental of any DME (durable medical equipment) to the patient for home use Ambulance services necessary Prosthetic devices (including implants when they meet the criteria ) 20 10

11 Reimbursement The most important question? Reimbursement rates for Medicare and other Carriers How to calculate your payments, and loses Where to go from here 21 APC s Instead of being called groupers as the classifications used for ASC payment were known, these payment groups are now known as ambulatory payment classifications, or APCs. Medicare uses the same APCs for ASCs as are used for HOPDs. Each CPT code that an ASC can use is now assigned to an APC, and each APC has a specific payment rate. Although CMS uses APCs to determine the rates that are paid

12 ASC Payment CALCULATING MEDICARE PAYMENT FOR LOCAL AREAS Fifty percent of the national rate will be adjusted by the local wage index. The formula for calculating your local rate can be found on 23 Medicare's 2011 ASC Payments: Rates and Policies Proposed 2011 Medicare Rates and Payment Policies Released! On July 2, 2010 the Centers of Medicare and Medicaid Services (CMS) released its proposal for 2011 ASC Medicare payments. It is expected that the proposal will be finalized in November. Changes in ASC Rates for 2011 The proposal does not provide an update in ASC reimbursement rates. The change in the Consumer Price Index for Urban Consumers (CPI-U) is estimated to be +1.6%, however the health reform legislation adopted earlier this year requires a1.6% offset resulting in a 0% proposed update for ASC 2011 payment rates will none-the-less be different than the 2010 rates due to several other factors. You will need to review payment changes at the procedure level to determine the impact of the proposed changes on your particular ASC

13 2011 Proposed ASC List Additions. HCPCS Description Proposed 2011 National ASC Rate Reason for Addition 0226T Anosc high resol dx + coll $26.78 New Code Billable July 1, T Anosc high resol dx w/bx $ New Code Billable July 1, T US tfrml edrl inj crv/t 1lvl $ New Code Billable July 1, T US tfrml edrl inj crv/t +lvl $ New Code Billable July 1, T US tfrml edrl inj l/s 1lvl $ New Code Billable July 1, T US tfrml edrl inj l/s +lvl $ New Code Billable July 1, T Inj plsm img guid hrvst&prep $26.78 New Code Billable July 1, Transcatheter occlusion $3, Previously Excluded Procedure Transcath iv stent, percut $2, Previously Excluded Procedure Transcath hi iv stent/perc addl $1, Previously Excluded dprocedure Embolization uterine fibroid $2, Previously Excluded Procedure Perc cryo ablate renal tum $2, Previously Excluded Procedure Prostate laser enucleation $1, Previously Excluded Procedure C9800 Dermal filler inj px/suppl $ New Procedure Billable March 23, Must we match? Professional side coders vs. ASC coders different number ofglobal days different series of modifiers different aspect on billing Whatever type of a coder you are, obtain the knowledge necessary for you. If you are audited, and found you coded incorrectly can you say, I wanted to match? 26 13

14 The Negotiator 27 Contracts based off Medicare Rates Balancing it in your ASC s favor to prevent loss of revenue Understand Payment Methodology 28 14

15 Payment Methodology For Medicare and Carrier Contracts using MC Baseline A procedure done at an ASC provides the same level of patient care and safety as HOPDreimbursement should be the same. One would think this makes sense, right? 29 Think Again Medicare and Carriers who follow MC baseline: 2008 ASC s were paid 63% of HOPD rates 2009 ASC s are paid 59% of HOPD rates 30 15

16 Let s talk turkey! Insurance Contracts 31 Payer Source for Multi Specialty ASC s commercial other (cosmetic) Medicare Worker's Comp Medicaid 32 16

17 Contract Tips Focus on your specialty & future specialties Know your geographical area Know the needs of your community Who are your patients? What procedures could you add? Consider inflation rates (5% at least) Staffing costs/ equipment/ supplies consider cost to net revenue. 33 Contract Negotiations Coder know what procedures pay well, any issues with reimbursement, etc. Do not allow Carriers to purchase Worker s Compensation Claims from WC Carrier. This is lost revenue. Clarify implants vs. Hardware and reimbursement for each. Know preferred modifiers, submission rules. Get input from your coders and billers not just reports! 34 17

18 Poor Contracts- OUCH! Break even at best? Common myth I can go back after we sign Can threaten the financial foundation in a very short time. Payor mix wasn t thought out Duration of contract too long 35 Other Management Tips Staff costs : Analyze staff hours per patient. LPN vs. RN? Evaluate benefit costs, but don t run on all part time staff. Implement Billing Protocol: 48 hours from dos to submission What % is electronic? What % are clean claims? What % are rejections? 36 18

19 Danger Signs Case volume is slow/ declining Concentrate on cutting costs Trouble generating new procedures Cannot attract new physicians With ASC s closing all over the country, special attention is needed for survival. 37 Solve the mystery Things to know in the ASC coding world 38 19

20 Claim Forms Forms used for claim submission: CMS 1500 (08 05) used for Medicare And some other carriers UB 04 used for most other insurances require place of service (POS) 24 and/or revenue code 490 for surgeries Some payers require CPT code, others ICD 9 vol. 3 As well as, additional revenue codes for implants 39 ASC List Revisions Prior to 2008 list was revised every two years. As of January 1, 2008 The list is revised annually. quarterly updates are available on the CMS web site org is also a wonderful web site for any updates, news, education and current actions in legislature 40 20

21 Coding Covered Procedures Wait for Surgeon s signed operative report and pathology report Code according to standard coding concepts: Code according to the body of reports, not headings Location, approach, extent, etc.. Use most recent CCI edits (Correct Coding Initiative) Do not submit a code that will be paid because the correct code will not be paid Educate your scheduling department, physician s office staff, as well as the surgeon 41 Code Sequencing Think high to low Select CPT codes Highest to Lowest reimbursement listed on ASC list for Medicare. Use Highest to the lowest rule for other carriers that categorize CPT codes into groups. Some carriers will use RVU s 42 21

22 Non Covered Procedures The facility will not receive payment for procedures that are not covered in the ASC list for Mdi Medicare. Check other carrier contracts. t Do not have the patient sign an ABN (advance beneficiary notice) it is just not covered /ASC Do not bill the patient Do not write off as a bad debt (compliance risk) Bill the surgeon the difference between the facility and non facility reimbursement 43?????????????? Whentwo procedures are performed and only one is on the ASC List, you must bill the surgeon 50% of the facility/ non facility difference for the second procedure. Check the website for appropriate fees Many ASC s choose not to do non covered procedures 44 22

23 LET S TALK MODIFIERS Technical Component Modifier Requirement: report the TC modifier when billing for facility charges associated itdwith HCPCS codes that have both a technical ( TC) component and a professional component (ex: radiology services) CMS suggests facilities check the local Medicare websites for additional information 46 23

24 SG No Longer Required that is the question AS of January 1, 2008, ASCs were no longer required to include the SG modifier on facility claims in Medicare. The contractors shall assign TOS code F to codes billed by specialty 49 for Place of Service 24 (see the Medicare Claims Processing Manual, Chapter 14, Section 50) 47 CPT Modifiers for ASC s SG appended first????? 50 bilateral (RT LT) check with carrier on which to use. Payment should be 150% 51 multiple procedures (not for Medicare)?? 52 reduced services. Use when procedure is not completed as described in CPT description. Do not use for discontinued procedures 58 staged or related procedure by same MD/day 59 distinct procedural service 48 24

25 Modifier 52 Medicare will apply a 50 % payment reduction for discontinued d radiology procedures and other procedures that do not require anesthesia use modifier 52 when reporting. MedicareClaims ProcessingManual, Chapter 14, Section CPT Modifiers for ASC s cont d 73 discontinued procedure prior to anesthesia administration Patient must be in room where procedure will take place. Payable at 50% 74 discontinued procedure after the anesthesia administration Patient must be in room where procedure will take place. Payable at 100% Documentation must be submitted with claim stating the CPT Code, reason for discontinuation, what was actually performed, what supplies were used, time spent in preoperative area, operating room, recovery area

26 CPT Modifiers for ASC s cont d 76 repeat procedure by same physician (same CPT code, same day) 77 repeat procedure by different physician (same CPT code, same day) 78 return to the operating room for a related procedure same day 79 return to the operating room for an unrelated procedure same day, same MD 51 FB Modifier Used when a replacement device is supplied to the ASC at no cost or with full credit by the manufacturer. * Have a written policy at your ASC* ASCs should report the occurrence of a no cost or full credit device to CMS by reporting the FB modifier on the line with the procedure code in which the no cost or full credit device is used when the device is on the list of specified devices to which this policy applies. Remember that payment for devices is typically packaged into payment for the device implantation procedure, and ASCs should not report packaged devices as a separate line item on the claim. The lists of affected devices, covered ASC surgical procedures, and reduction amounts are located

27 FC Modifier Used when a replacement device is supplied to the ASC at partial credit by the manufacturer. * Have a written policy at your ASC* CMS reduces payment to ASCs for instances in which manufacturers provide ASCs with partial credit for replacement devices due to warranty, recall, or field action. ASCs should report the occurrence of a partial credit device to CMS by reporting the FC modifier on the line with the procedure code for all cases in which the device being implanted is on the list of creditable devices; the procedure code in which the device is used is on the list of covered ASC surgical procedures to which h this policy applies; and the ASC received a credit of 50 percent or more of the estimated cost of the new replacement device Podiatry Modifiers Modifier SG listed first (check w/ Medicare) Phalange procedures use TA T9 Metatarsal procedures use RT, LT Example: Bunion can only be a RT or LT or

28 Integumentary System Tip Includes skin, nails, hair, glands. The Integumentary system does not extend into muscle and bone. Watch terminology, such as simple, superficial, or partial thickness. 55 Lesions Lesion size plus margins = code used Measurement is done before excision and must be documented Code morphology but not size from pathology report. The tissue will shrink while in the solution. If this information is not obtained, you must code the smallest in the available CPT group and may receive reduced or no reimbursement. Lesions located in deep subfascial/sub muscular tissues should be reported using the Musculoskeletal System codes

29 Wound Repair Simple ligation (tying) of vessels in an open wound is considered d as part of any wound closure. Simple exploration of vessels, tendons, etc. is also considered part of the would closure. For multiple repairs, add together to get the sum of lengths for each anatomic site for the same repair. 57 Adjacent Tissue Transfer or Rearrangement Primary defect results from the excision Secondary defect results from the design of the flap used to perform reconstruction The defect size is the total size of the primary and secondary defects added together Choose code by anatomic site and defectsize Common terms: Z plasty, advancement flap, rotation flap etc

30 Tips on: Breast Coding Codes represent ese unilateral a codes When multiple biopsies are removed from the same lesion, use only one biopsy code Multiple samples from different lesions, code each biopsy Open, incisional 19101: Open, excisional Codes (breast excision) are included in all Mastectomy Codes 59 Cosmetic Procedures 60 30

31 Cosmetic Procedures Becoming more popular Not Covered by Insurance Cash service Plastic Surgeon is paid up front. Common collection of fees is through Surgeon directly Fee schedule is determined by time Can be calculated : Incision to closure In the OR to Out of OR 61 Coding Tips: Musculoskeletal System Payment for screws, pins, wires, etc. are included in the ASC Payment rate for Medicare Do not charge for these devices. Only bill for the removal of an external fixator if the procedure is done with general anesthesia. When an arthroscopy and an arthrotomy are performed both may be coded if done in different compartments append a 59 Abrasion Arthroplasty Detail drilling, Microfracturing, Debridement to bleeding bone If operative report does not support above narrative, code only a chondroplasty

32 Chondroplasty Dilemma The answer is NO NO NO Per CCI Edits bundles into other arthroscopy codes. Through the years we have been allowed to bill for it, then not allowed, then allowed, right now it is NOT allowed!! Some ASC s have tried G0289, it is not a facility code sorry 63 Cardiovascular Procedures Pacemaker Insertion /replacement National Rate $ 6, $ 8,606,03 Look carefully at supply cost vs. reimbursement 64 32

33 New Technology Intraocular Lens HCPCS code Q1003 $50.00 additional Medicare payment February 27,2006 through February 26,2011 Advanced Medical Optics (AMO) Tecnis IOL models Z9000, Z9001, Z9002, ZA9003, AR40xEM and Tecnis 1 Piece model ZCB00 Alcon Acrysof IQ Model SN60WF and Acrysert Delivery System model SN60WS Bausch & Lomb Sofport AO models LI61AOV, and LI61AOV STAAR Affinity Collamer model CQ2015A, CC4204A, and Elastimide AQ2015A 65 Gastroenterology Tips: Polyp removal codes are intended to represent the technique used while removing polyp. You may only use the code once, regardless of how many polyps were removed by that t technique during that session. If a single lesion is biopsied but not excised (removed) use biopsy code. If a single lesion is biopsied then excised (removed) use the excision code. If one lesion is biopsied and another lesion (different location) is excised, code the excision first, biopsy second andappenda append a 59 Do not code rule outs/suspected conditions BOTOX INJECTION used on hemorrhoids

34 Screening vs. Diagnostic Colonoscopies Screening colonoscopies are performed for early dt detection ti of colorectal lcancer in both high risk and average risk patients. Appropriate V codes apply to screenings. family or personal history colorectal cancer adenomatous polyps inflammatory bowel disease 67 Screening Colonoscopies If during the course of a screening colonoscopy a lesion or mass is identified which results in biopsy or removal, code the V76.51 first, then findings. Surveillance Colonoscopies V67.09, followed by reason for surveillance. Check chart for patients history as well as pre operative diagnosis for signs and symptoms

35 Medicare GI Alert 0 % deductible and 25 % coinsurance is applied to colorectal lcancer screening colonoscopies. 0 % deductible and 25 % coinsurance is applied to screening flexible sigmoidoscopies. G0105 and G0121 Medicare pays 75%, NOT the traditional 80% 69 Podiatry Tip: Bunionectomy Repairs Bunionectomy Codes include the following: Capsulotomy Arthrotomy, Removal of bursa Synovial biopsy, Synovectomy, Neuroplasty Tendon release, Tenotomy, Tenolysis Articular shaving, excision of scar (revision) Placement of internal fixation 70 35

36 Implants vs. Hardware Understand that Medicare s definition of an implant replaces a body part Example :prosthetics Screws, pins, plates and other fixation devices are considered supplies/hardware not implants for Medicare. Check carrier contracts for specifics, as well as local carrier guidelines. 71 Paravertebral Facet Joint Injections An anesthetic is injected into the facet joint or the two medial branch nerves that supply each joint. This section has numerous add on codes Watch modifiers for bilateral injections If multiple injections are given at a single level, only code once Medicare states it is not considered acceptable to perform beyond three levels of injections. It also states that documentation must support the reasoning for beyond three levels. Check with individual and local carriers 72 36

37 Diagnostic vs. Therapeutic Diagnostic injections areto determine the source of pain for the patient Therapeutic injections is to relieve the pain the patient is experiencing Watch the ICD 9 codes carefully 73 Durable Medical Goods DME include: wheelchairs, walkers, oxygen, crutches,etc... etc Use E codes from HCPCS To supply a DME, you must be a certified provider and have a current DME number Some DME s are paid at a monthly rate Updated diagnosis codes for DME s can be found on

38 Devise Intensive Device intensive procedures are specified ASC covered surgical procedures that, are assigned to certain device dependent procedures that require the insertion / implantation of expensive devices. Payment for the high cost devices is packaged into the procedure payments. For the device dependent CMS estimates of the proportion of the procedures costs that are attributable to the cost of the device. 75 Device Intensive Procedures Under the current Medicare system, there are two exceptions to the general rule that ASC rates are based on 65% of the HOPD rate. One exception results in ASCs being paid more than 65% of the HOPD rate for procedures that require the use of a device that costs more than 50% of the total APC reimbursement. For these procedures, known as deviceintensive procedures, the ASC are paid the same amount as an HOPD for the device and only the remainder of the APC reimbursement is discounted to 65% of the HOPD rate

39 Physicians with Ownership in ASC January 1, 2008, CMS revised the definitions of radiology and certain other imaging services and outpatient prescription drugs so that these services could be provided in ASCs by physicians who have an ownership interest in the ASC. Bill Medicare for these separately payable, covered ancillary services when beneficiaries are referred by a physician with an ownership or financial interest in the ASC. 77 Ancillary Services Familiarize yourself with the Payment Indicator, multiple procedure discounting, and packaged procedures and services Some Radiology services are covered if: 1. The service would be payable separately in a HOPD 2. The service is required for successful performance of procedure 3. Service is immediately preceding, during or immediately following the procedure

40 Ancillary Services Separate payment may be made for certain covered ancillary services that are integral to a covered procedure. Examples: Brachytherapy sources Some implantable items (pass through) Certain items and services including corneal tissue Certain drugs, biologicals, and radiology services FC(ASC).asp 79 Questions??? Donna SanGiovanni, CPC donnasang@sbcglobal.net 80 40