BILLING FACILITY FEES

Transcription

1 BILLING FACILITY FEES Medicare ASC Payment Groups Once an ASC is approved for Medicare participation, the ASC can only be reimbursed for procedures that are on a list of procedures that Medicare will reimburse to an ASC. Procedures on the list fall into one of 9 groupings with a payment rate assigned to each group. The payment group is determined by the CPT procedure rendered. The groups actually have no clinical coherence but were based on a cost analysis survey last performed by CMS in Medicare Unadjusted National allowances per group as below were effective October 1, GROUP 1 -- $ GROUP 2 -- $ GROUP 3 -- $ GROUP 4 -- $ GROUP 5 -- $ GROUP 6 -- $ GROUP 7 -- $ GROUP 8 -- $ GROUP 9 -- $ (New) Medicare Covered ASC Pain Management Procedures CPT 2002 DESCRIPTION Group CPT 2002 DESCRIPTION Group Epidural lumbar/sacral/caudal Epidural, lumbar/caudal Epidural cervical/thoracic Trigeminal Nerve, any Inject. Incl.cath placement, continuous cervical/thoracic Inject. Incl. Cath placement, continuous lumbar/sacral Phrenic Nerve Brachial Plexus Axillary Nerve Block Intercostal, single Spinal puncture lumbar Intercostal: destruct 1 Destruct Paravetebral Facet, lumbar single Destruct Paravetebral Facet, lumbar ea. addt l Facet joint or facet joint nerve cerv/thor, 1 st level Facet joint or facet joint nerve cerv/thor, ea. addt l Intercostal, multiple Percutaneous lysis of adhesions Pudental Nerve Blood Patch Transforaminal, epidural cerv/thor, 1 st level Transforaminal, epidural cerv/thor, ea. addt l. Transforaminal epidural lumbar/sacral, 1 st level Transforaminal epidural lumbar/sacral, ea. addt'l Facet, lumbar/sacral single Celiac Plexus: destruct Analysis pump w/o reprogram 2 * Analysis pump with reprogram 2 * Implant Catheter 2 Remove implanted catheter Facet, lumbar/sacral addt l Nucleoplasty 9* Facet, cervical/thoracic single Non-programmable pump Facet, cervical/thoracic additional Programmable pump Stellate Ganglion Implanted pump Lumbar sympathetic Implant neurolectrode Celiac Plexus Revision/remove electrode Subarachnoid Implant spinal transmitter 2 G0260 Inj for sacroiliac jt anesth * Remove spinal transmitter *

2 * Indicated on the table above has an effective date of addition or deletion from the ASC payment list of July 1, Most covered Pain Management procedures fall into groups one or two. Some pain procedures are not on Medicare s payment list for ASC facility reimbursement. These procedures then fall under Medicare s site of service differential rule, meaning professional fees are paid at the higher office site of service differential. The place of service on the physician s bill is still ASC -24. It is important to monitor the explanation of benefits for correct site of service payment on these claims. Since a patient cannot be billed for facility fees from procedures not on the approved list, an ASC s only advantage from supporting such off list cases may be to charge non-owner physicians rent for use of the ASC These Medicare facility fees include: Use of the facility Nursing and technician services Drugs Biologicals Surgical dressings Materials for anesthesia Splints, casts and equipment directly related to the provision of the procedure Administrative, record-keeping and housekeeping items and services In addition to facility fees in the ASC setting, the following are paid separately: Physician services (Professional fees) Laboratory expenses (Must be CLIA certified to perform lab tests or CLIA waived to perform minor labs such as glucose or pregnancy testing) X-Rays Diagnostic procedures other than those directly related to the surgical procedure Prosthetic devices Leg, arm, back and neck braces Artificial limbs DME for use in the patients home (typically not applicable in pain management) Implantables such as neuorstimulators and drug infusion pumps are paid by the Part B carrier-not the DME carrier). Managed Care Facility Contracts As previously stated, in order to contract with other third party payers, Certification by Medicare as a provider of surgical services is mandatory. Many payers also require accreditation before the facility can obtain a contract with them. This process, however, should be started as soon as the proposed facility has filed a notice on intent as applicable in the State or the CMS applications have been filed. The credentialing process should be started by requesting facility applications and then completed when the facility is found to be in compliance. The contract proposal from the MCO should include a fee schedule for each CPT code that the ASC will be providing. Most Managed Care contracts typically do not send their entire fee schedule that represents all of their approved fees. For procedures that are not listed on their fee schedule, it is important to ascertain how non-covered services will be paid, such as fee for service and at what percentage of billed charges. Negotiations on the facility contract should include exclusions. Determine their policies on what is included in the facility fee rate. Many MCO s will reimburse for the technical component of fluoroscopy and drugs/supplies in addition to the flat rate.

3 You may find that these fee schedules are tied to the Medicare payment groups at a percentage of the national average allowance. Generally the contract fees are subject to change based on the contract with the payer. It is critical at contract negotiation time to identify the current fee schedule and how often the payer can change these fees and what notification timeframe is required when a change is made. The contract should have an escalator clause to account for time and inflation. Multiple Procedure Rule As many pain procedures involve bilateral injections and/or multiple levels, each procedure can yield two to three facility fees. Medicare and other payers currently pay 100 percent of the highest payment for multiple procedures in a single session and 50 percent for each additional procedure. Local Medical Review Policies and the Correct Coding Initiative apply to both professional fees and facility fees. Fluoroscopy in ASC s Medicare facility fees include the use of equipment that is directly related to the provision of the surgical service. The technical component of the use of the C arm is thus bundled into the Medicare facility fee payment. The physician performing the procedure would indicate the professional component (modifier -26) on his claim for services rendered for both needle localization and supervision and interpretation studies. The technical component would not be billed separately to Medicare on the ASC claim. Modifiers Recoup Costs CMS approves two modifiers that can be used in the ASC to report discontinued procedures. -73 Discontinued outpatient procedure prior to the administration of anesthesia -74 Discontinued outpatient procedure after the administration of anesthesia Medicare Billing Process A provider number is applied for by the ASC and issued by the Medicare carrier after approval from the State and the regional CMS carrier. This supplier number is applied for under the ASC Tax ID. Claims cannot be billed to Medicare for facility fees until the provider number is given by CMS regional and the actual billing number assigned by the carrier. The effective date is the date of survey compliance. Once approval is received, facility fees are billed to Medicare on the standard HCFA 1500 form using the CPT code with the modifier SG. Place of service is 24 (ASC) Type of Service Surgical services billed with the ASC facility service modifier SG must be reported as TOS F. The indicator F does not appear on the TOS table because its use is dependent upon the use of the SG modifier. On the HCFA 1500 list: CPT Code + SG modifier List highest group first Use -59 as applicable based on LMRP for multiple procedures or additional levels of the same procedure

4 Bilaterals - Use 50 (units 1) or RT/LT by line (increase fee x 2) Managed Care Billing Process: The signed contract will include the MCO s specific billing rules. Some third party payers require the UB92 form for filing the ASC facility fee. This should be clarified at contract negotiation time. Most payers that require the use of a UB92 form will accept the CPT and the standard ASC revenue code. It is important to be aware of incidentals that can be billed separately; all exclusions, special rules for bundling, handling of multiple services, multiple levels and bilateral services UB92 Example for most payers Type of Bill: Always 831 Revenue Code: 490 (ASC) (Note: most payers accept this revenue code for all line items) Procedure Code- Always use SG modifier plus 59 or 51 as applicable Revenue Code- 320 Fluoroscopy or Interpretation Code with the modifier -tc Revenue Code- 270 Supplies Itemized Supplies/Drugs Example: If the payer requests a break down of CPT code 99070, miscellaneous surgical supplies, the following would be included as appropriate Break Down of Supplies (Example) Cost: Price charged:( ) A4550 Epidural Tray A4649: Jelco IV Kit: Tegaderm Dressing: Adaptor: Syringe: Needle: Pulse Ox: O2 + Nasal Tubing: Sterile Surgical Gloves: J2250 Versed per 1 mg J3490 Marcaine.25% J1040 Depo-Medrol 80 mg: J1030 Depo-Medrol 40mg J3010 Fentanyl 2ml A4645 Isovue 200mg Iodine: Revenue Codes 490 AMBULATORY SURGICAL CARE This code indicates charges for ambulatory surgery that are not covered by any other revenue code category. According to national billing guidelines, CHAMPUS always requires the use of a specific detail code and the CPT-4 code rather than the General revenue code 490. For all other payers, HCPCS may be required for outpatient claims. Contact each third party payer to determine applicability.

5 Revenue Codes that may be applicable to Pain Management in an ASC: 250 Pharmacy 251 Generic drugs 252 Non-generic drugs 254 Drugs incident to other diagnostic services 255 Drugs incident to radiology 257 Nonprescription 258 IV solutions 259 Other pharmacy 260 General IV therapy 262 IV therapy/pharmacy services 263 IV therapy/drug/supply delivery 264 IV therapy/supplies 269 Other IV therapy 270 General medical/surgical supplies and devices 271 Non-sterile supply 272 Sterile supply (except to report certain supplies or devices that are paid a transitional pass-through payment) 278 Other implants (except to report certain supplies or devices that are paid a transitional pass-through payment) 279 Other supplies/devices 372 Anesthesia incident to other diagnostic services 379 Other anesthesia 621 Supplies incident to radiology 622 Supplies incident to other diagnostic services 624 FDA investigational devices 630 General drugs requiring specific identification 631 Single source drug 632 Multiple source drug 633 Restrictive prescription 637 Self-administrable drugs 710 General recovery room

6 Surgical Coding Crosswalk Some payers will only accept the Surgical Code Crosswalk (ICD9 Volume 3). This code is used instead of the CPT code on the UB92 claim form. The crosswalk is published by Medicode. This crosswalk is based on the surgery section of the CPT and link to a data driven code. To use this book, you would look up the CPT code numerically and the code will list the ICD-9 procedural code. Many pain procedures fall into the same crosswalk code. For instance: Crosswalk code crosswalks to single and continuous epidurals. Many of the crosswalk codes are driven by the type of medication that is injected. Once your billing system has been loaded with crosswalk codes, you should be able to simply link the payer to the claim form and choose crosswalk or CPT. CPT DESCRIPTION SURGICAL CODING CROSSWALK Scar Infiltration (up to 7) Scar Infiltration (over 7) Injection Tendon Joint Tendon Trigger Point 1 or Trigger Points 3 or more Small Joint Injection Medium Joint Injection Large Joint Injection SI Joint Injection Arthrocentesis Injection of therapeutic substance into joint or ligament Aspiration of bursa of hand Injection of therapeutic substance into bursa of hand Injection of therapeutic substance into tendon of hand Aspiration of bursa Injection of therapeutic substance into bursa Injection of therapeutic substance into temporomandibular joint Arthrocentesis Injection of therapeutic substance into joint or ligament Aspiration of bursa Injection of therapeutic substance into bursa Arthrocentesis Injection of therapeutic substance into joint or ligament Aspiration of bursa Injection of therapeutic substance into bursa Steroid Other agent Percutaneous lysis of adhesions Spinal puncture lumbar Blood Patch Subarachnoid Epidural, cervical/thoracic Epidural, lumbar/caudal 03.8 Dest agent 03.8 Dest agent 03.8 Dest agent Percutaneous Laser Discectomy Discography, lumbar

7 CPT DESCRIPTION SURGICAL CODING CROSSWALK Discography, cervical Epidural cervical/thoracic Epidural lumbar/sacral/caudal Inject. Incl.cath placement, continuous cervical/thoracic Inject. Incl.cath placement, continuous Lumbar/sacral Anesthestic Anesthestic 03.9 Cath Insert Anesthestic 03.9 Cath Insert Anesthestic Implant Catheter Remove implanted catheter Implant non-programmable pump Implant programmable pump Remove implanted pump Insertion totally implanted pump Analysis pump w/o reprogram Analysis pump w/o reprogram Analysis pump with reprogram Analysis pump with reprogram Percutaneous implant neurolectrode Revision/remove electrode Percutaneous chordotomy Biopsy of spinal cord or spinal meninges Other diagnostic procedures on spinal cord and spinal canal structures 03.4 Excision or destruction of lesion of spinal cord or spinal meninges Injection of other agent into spinal canal Implant spinal transmitter Revision/remove spinal transmitter Trigeminal Nerve, any Facial Nerve Greater/lesser Occipital nerve Vagus Nerve Phrenic Nerve Spinal Accessory Nerve Anesth into spinal canal Anesth into peripheral nerve

8 CPT DESCRIPTION SURGICAL CODING CROSSWALK Cervical Plexus Brachial Plexus Axillary Nerve Block Suprascapular Nerve Intercostal, single Intercostal, multiple Ilionguinal, Iliohypogastric Nerve Pudental Nerve Sciatic Nerve Other peripheral Facet, cerv./thoracic single Facet, cervical/thoracic additional Facet, lumbar/sacral single Facet, lumbar/sacral additional Transforaminal, epidural cerv/thor. 1st level Transforaminal, epidural cerv/thor. Ea. Addt'l Transforaminal epidural lumbar/sacral, 1 st level Transforaminal epidural lumbar/sacral ea. addt l Aesthetic into spinal canal Aesthetic into spinal canal Aesthetic into spinal canal Aesthetic into spinal canal Sphenopalatine Stellate Ganglion Lumbar sympathetic Celiac Plexus Tens application Trigeminal Nerve, any Sphenopalatine Botox injection 04.2

9 CPT DESCRIPTION SURGICAL CODING CROSSWALK Intercostal: destruct Destruct Paravetebral Facet, lumbar single Destruct Paravetebral Facet, lumbar ea. addt l Facet joint or facet joint nerve cerv/thor. 1 st level Facet joint or facet joint nerve cerv/thor, ea. add l Other peripheral Celiac Plexus: destruct Neurolync agent Other Commercial Payers and Workers Compensation Billing Process: Some states use set fee and coding schedules for Worker s Comp facility fees. In states that do not have a set facility fee payment schedule, the facility fee reimbursement is based on their assumption of customary rates and paid at fee for service. All commercial and Workers Compensation claims are billed on a UB92. With Workers Compensation, many require that the provider send copy of the procedure notes and will typically also require a breakdown of the itemized supplies and drugs as well. April 2006