ASC reimbursement and surgical coding for Medicare

Part 2 of this two-part series explains rules and examples for ASC coding.

Issue: October 1, 2005

ByRiva Lee Asbell

Riva Lee Asbell

In part 1 of this two-part series, we outlined reimbursement rates, supplies and common mistakes in coding. In part 2, it is time to learn to drive on the left side of the road.

For those of you well entrenched in ophthalmic surgical coding, it would seem that just putting the procedures in groups is an easy task. As we proceed, you will find some roadblocks along the way.

Groups

Procedures on the list are assigned to one of nine groups, and each group has a fixed rate of reimbursement. Currently, the rates are frozen through 2009. Note that in groups 6 and 8 the rate is composed of a wage-adjusted portion plus the reimbursement for the IOL.

IOLs

Groups 6 and 8 are composed of a wage-adjusted portion plus $150 for the IOL. The wage-adjusted portion is determined by each carrier, varies with the carrier and is determined by a complicated formula based on the ASC’s geographic location. This becomes important when obtaining reimbursement for multiple procedures in different groups. The full instructions may be accessed at www.cms.hhs.gov/manuals/104_claims/clm104c14.pdf.

It has been my experience that some carriers simply halve group 8 rather than halving the wage-adjusted portion ($676 and $823 for groups 6 and 8, respectively), resulting in a loss of approximately $75 per case when this occurs.

Rules of the game

Multiple surgery rules. Multiple procedures are paid the same as on the physician side. You are paid 100% of the facility fee for the first procedure and 50% of the allowable for the subsequent procedures. Be sure to list the highest-paying procedure first. On the physician side, Medicare does this for you; on the ASC side if you make an error, you will get a reduction in payment.

Unlisted procedure codes. Unlisted procedure codes, those ending in “99” such as 67599 (unlisted procedure, orbit), cannot be billed since there is no associated monetary amount. I would be interested in hearing from anyone who has ever gotten paid using any of the unlisted codes.

Modifiers. Certain modifiers are approved for use in ASCs. Full descriptions are found in the modifier appendix in CPT. They are:

-50 Bilateral procedure
-51 Multiple procedures
-58 Staged or related procedure or service by the same physician during the postoperative period
-59 Distinct procedural service
-73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to administration of anesthesia
-74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia
-78 Return to the operating room for a related procedure during the postoperative period
-79 Unrelated procedure or service by the same physician during the postoperative period

SG is appended to CPT codes to indicate procedures performed in an ASC.

National Correct Coding Initiative. The same rules apply to ASC coding as to physician coding.

Terminated procedures. This is different from physician coding in that you can be paid for termination of a procedure before anesthesia (modifier 73) as well as after (modifier 74).

The Medicare Claims Processing Manual instructs carriers to deny payment when an ASC submits a claim for a procedure that is terminated either for nonmedical or medical reasons before the ASC has expended substantial resources. For example, payment is denied if scheduled surgery is canceled or postponed because the patient on arrival complains of a cold or flu.

Carriers are instructed to pay 50% of the rate if a surgical procedure is terminated due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating room but before anesthesia has been induced (use modifier 73). For example, 50% of the facility rate is paid if the patient develops an allergic reaction to a drug administered by the ASC prior to surgery or if upon injection of a retrobulbar block the patient experiences a retrobulbar hemorrhage that prevents continuation of the procedure. Although some supplies and resources are expended, they are not consumed to the same extent had anesthesia been fully induced and the surgery completed. Carriers may pay a different percentage of the rate if, in an individual case, documentation supports such action. Carriers use modifier 73 to indicate that the procedure was terminated prior to induction of anesthesia.

Carriers are instructed to make full payment of the facility rate if a medical complication arises that causes the procedure to be terminated after inducement of the anesthetic agent (use modifier 74). For example, carriers make full payment if, after anesthesia has been accomplished and the surgeon has made a preliminary incision, the patient’s blood pressure increases suddenly and the surgery is terminated to avoid increasing surgical risk to the patient. In this case, the resources of the facility are consumed in essentially the same manner and to the same extent as they would have been had the surgery been completed. Carriers use modifier 74 to indicate that the procedure terminated after inducement of anesthetic agent.

Carriers are instructed to deduct the allowance for an unused IOL prior to calculating payment for a terminated IOL insertion procedure.

An ASC claim for payment for terminated surgery must be accompanied by an operative report that specifies:

Reason for termination of surgery;
Services actually performed;
Supplies actually provided;
Services not performed that would have been performed if surgery had not been terminated;
Supplies not provided that would have been provided if the surgery had not been terminated;
Time actually spent in each stage, eg, preoperative, operative, and postoperative;
Time that would have been spent in each of these stages if the surgery had not been terminated; and
CPT code for procedure had the surgery been performed.

Case Studies
Case 1 Patient was scheduled for cataract extraction with insertion of IOL in the right eye. Patient also had pseudoexfoliation glaucoma and required a trabeculectomy. Preoperatively, the pupil did not dilate well, and the use of iris hooks for pupillary expansion was anticipated and performed. Both procedures were planned to be performed by the same surgeon at the same session. Code all procedures. Physician billing
Diagnosis:	1) 365.52 Pseudoexfoliation glaucoma 2) 366.10 Cataract 3) 366.11 Pseudoexfoliation of lens capsule
Surgery:	Diagnosis	Procedure codes	Modifiers
	1) 1	66170 Trabeculectomy	-RT
	2) 2, 3	66982 Complex cataract extraction with insertion of IOL	-51 -RT
Tip: When coding for complex cataract extraction, make sure your office notes indicate the prospective planning and put the same information in the introductory part of the operative note. Under audit, only the hospital may be asked to supply operative notes that do not have any indication that the case was complex. ASC billing Correlating diagnoses remain the same.
Procedure codes		Group	Modifiers
1) 66982 Complex cataract extraction with IOL		8	-SG -RT
2) 66170 Trabeculectomy		4	-SG -51 -RT
Note: The order is reversed for physician billing vs. ASC billing.
Case 2 Patient had previously undergone surgery consisting of penetrating keratoplasty in the right eye. There was graft rejection, and the current surgery consists of repeat penetrating keratoplasty, phacoemulsification cataract extraction with insertion of IOL and lysis of posterior synechiae. Code all procedures. Physician billing
Diagnosis:	1) 996.51 Mechanical complication of corneal graft 2) 366.10 Cataract 3) 364.71 Posterior synechiae
Surgery:	Diagnosis	Procedure codes	Modifiers
	1) 1	65730 Penetrating keratoplasty except in aphakia	-SG -RT
	2) 2,3	66982 Complex cataract extraction with insertion of IOL	-SG -RT
Tip: When coding keratoplasty surgeries, select the CPT code by the state of the eye when the surgery begins, not at completion of the operation. ASC billing Correlating diagnoses remain the same.
Procedure codes		Group	Modifiers
1) 65730 Penetrating keratoplasty		7	-SG -RT
2) 66982 Complex cataract extraction with IOL		8	-SG -RT
Tip: Be sure that you are paid correctly. You should be paid 100% of the first procedure ($995) plus 50% of the wage-adjusted portion of the cataract with IOL ($823 divided by 2 is $411.50) plus $150 for the IOL.
	$995 vs. + $411.50 + $150 $1,556.50	$995 $486.50 $1,481.50
Case 3 Patient had previously undergone surgery consisting of insertion of an aqueous shunt for treatment of uncontrolled glaucoma in the right eye. There was conjunctival erosion over the shunt tube in the right eye. The current surgery consists of revision of the tube placement, insertion of a Tutoplast graft and conjunctivoplasty with graft from inferior fornix. Code all procedures. Physician billing
Diagnosis:	1) 996.59 Mechanical complication of implant, right eye
Surgery:	Diagnosis	Procedure codes	Modifiers
	1) 1	67255 Scleral reinforcement	-RT
	2) 1	66185 Revision of aqueous shunt	-51 -RT
	3) 1	68320 Conjunctivoplasty with graft	-51 -RT
ASC billing Correlating diagnoses remain the same.
Procedure codes		Group	Modifiers
1) Conjunctivoplasty		4	-SG -RT
2) 67255 Scleral reinforcement		3	-SG -51 -RT
3) 66185 Aqueous shunt revision Tutoplast supply L8610 Shunt supply L8612		2	-SG -51 -RT
Tip: Be sure to capture all supply codes. For each shunt placement there are two supply codes — L8610 for the graft material and L8612 for the shunt, unless the surgeon is using an express shunt, in which case use only L8612.
Source: Asbell RL

For Your Information:

Riva Lee Asbell can be reached at www.rivaleeasbell.com.

CPT codes, copyright 2004, American Medical Association.

Part 1 of this series appeared in the September 1, 2005 issue on page 20.