What is Ambulatory Surgery Coding?

What is Ambulatory Surgery Coding?

INTRODUCTION

This coding paper will introduce AAOMS members and staff to the process of coding and billing for ambulatory surgery centers (ASC) and review resource materials, coding for surgical services, modifiers and billing formats for ambulatory surgery centers services. Oral and maxillofacial surgery has a long and successful history of providing anesthesia services in combination with surgical procedures in an office environment. Traditionally, the office equipment, supplies, personnel, and pharmaceuticals were reimbursed from the professional code component of the surgical fee and anesthesia fee. With the introduction of a Resource-Based Relative Value System (RBRVS), all surgical CPT codes were relative value adjusted based upon many factors, including the site of service. This resulted in significant downward pressure on surgical fees, especially in the office surgical environments of the oral and maxillofacial surgeon (OMS). Unlike the CDT coding systems for anesthesia, the Relative Value Units (RVUs) for medical anesthesia care only include reimbursement for the professional component of anesthesia and do not include allowances for drugs, equipment, and nursing staff. This has led to a reevaluation of the business logic of office-based surgery for medical procedures. Since the OMS provides both medical-surgical and dental-surgical services, a thorough understanding of the economic assumptions of the ambulatory surgery industry is useful in practice development and management. As the industry continues to evolve, it is imperative that the OMS has a working knowledge of ambulatory surgery center billing and coding in order to:

• understand how the medical industry and the federal government reimburses ambulatory surgical facilities;

• understand the difference between facility billing and reimbursement and non-facility billing and reimbursement; saving faces changing lives

• determine if OMS office-based surgical services remain economically feasible;

• understand how the medical industry and the federal government reimburses anesthesia drugs and supplies

• determine whether an ASC is a viable economic strategy for your practice to pursue

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RESOURCE MATERIAL

There is no comprehensive treatise or current publication that addresses all the nuances of ASC facility billing. Because the industry is constantly in a state of flux, a practice manager must continue to use the updated contemporary material. Essential coding tools and resources include:

• CPT Professional Edition www.ama-assn.org

• HCPCS Level II www.ama-assn.org

• ICD-9-CM Volumes 1 and 2 http://www.optumcoding.com

• CPT Assistant Archives www.ama-assn.org

• Medicare through CMS http://www.cms.gov/ASCPayment These coding resources give the practitioner and staff access to appropriate procedure and diagnosis codes for the reporting of ambulatory surgical services. In addition, there are several national groups and societies that deal specifically with the ASC from construction, design, and buildings, to surgical procedures and billing issues. These groups are easily located on the Internet. They have current websites, monthly publications, and regularly hold regional and annual meetings. These groups are also involved with advocacy issues on the state and federal levels.

AMBULATORY SURGERY CENTER FACILITY COVERED SERVICES

The federal government has been the leader in the ASC industry. Medicare publishes a list of covered CPT codes when performed in the ASC with periodic updates and deletions. Therefore, it is mandatory that facility billers continue to monitor the annual revisions that occur under the ASC payment system. As part of the process of evaluating procedures, CMS looks at historic billing, billing trends and site of service patterns from Medicare billings. These edits lead to suggestions that are referred by the insurance and provider industries. CMS introduced the methodology for ambulatory surgery center payment many years ago. CMS has recently implemented a complete revision of the way it will pay for ASC services and the method of billing. Until 2008, CMS placed covered services into 9 Groups or Groupers. The number of services was around 2,500 and fees ranged from $333 to $1,339. The new system has over 1,000 groups or APCs (Ambulatory Payment Classifications), which add over 3,300 more procedures. The fee paid ranges greatly but is based on 65% of the fees for the same procedure under the Hospital Out-Patient Prospective Payment System (OPPS). The CMS will automatically adjust the payment rates in the future. The new rates will be phased in over the next several years and will be at 100% of the OPPS 65% rate by 2011.

COVERED COMPONENTS OF ASC SERVICES

Each APC is selected by using the appropriate CPT codes and each procedure contains a spectrum of services that are bundled into the ASC fee. Medicare defines the following list as included in the fee:

• Nursing services, services of technical personnel and other related services;

• The use by the patient of the ASC facilities to include pre-operative, intra-operative and post-operative care, operating room and equipment;

• Drugs and biologicals for which separate payment is not allowed under the OPPS;

• Equipment;

• Surgical dressings;

• Medical and surgical supplies not on pass-through status under the OPPS,

• Splints, casts, appliances;

• Diagnostic or therapeutic items and services;

• Administrative, record keeping and housekeeping items and services;

• Blood, blood plasma, platelets, etc., except for those to which the blood deductible applies;

• Materials, including supplies and equipment used for the administration and monitoring of anesthesia;

• Intraocular lenses (IOLs);

Radiology services for which separate payment is not allowed under the OPPS and other diagnostic tests or interpretive services that are integral to a surgical procedure.

CODING FOR ASC SERVICES

In describing surgical services provided in a facility, the code is determined based on the operation performed. Coding can either be performed by submitting codes described by the surgeon or by retrospectively coding from an operative report. The coding language that is used is CPT. This needs to be supplemented with an appropriate ICD-9-CM diagnosis code in order to complete the data requirements for ASC billing.

MODIFIERS

A great number of modifiers are used on ASC billing. These include the following:

• -76 Repeat procedure or service by the same physician

• -77 Repeat procedure by another physician

• -78 Unplanned return to the operating/procedure room for a related procedure on the SAME DAY

• -79 Unrelated procedure or service by the same physician on the SAME DAY

• -50 Bilateral procedure

• -51 Multiple procedures (not for Medicare)

• -52 Reduced services

• -58 Staged or related procedure or service by the same physician on the same day

• -59 Distinct procedural service

• -73 Discontinued outpatient procedure prior to administration of anesthesia

• -74 Discontinued outpatient procedure after administration of anesthesia.

BILLING FORMATS FOR ASC SERVICES

The preparation of a billing document for an ASC is variable. The format for the transactions will be clarified as part of the contracting process that occurs between a payer and an ASC. The standard industry format for Medicare and Medicaid is for services to be reported on a CMS-1500 form. It is imperative that the modifier SG be appended to every CPT code in order to inform the carrier that the claim is actually billing for a surgical facility as opposed to the professional component of care.

DIFFERENCES BETWEEN PROFESSIONAL BILLING & FACILITY BILLING

One of the most fundamental differences between billing for professional services and billing for ambulatory surgery center services is the concept of the global surgical package. The global package applies to the professional component of a surgical service that is performed when using a surgical CPT code. On the professional side, this typically encompasses a 90-day follow-up. In the ASC billing methodology, no such surgical package exists. Therefore, each time a patient enters the operating room represents a unique and separate encounter and has no historical economic relationship to previous encounters. This is a very important difference and very often leads to the need for qualifying modifiers. Those modifiers listed above tend to clarify a situation such as return to the operating room on the same day or return to the operating room by another doctor on a different date.

ASC BILLING FOR NON-COVERED SERVICES

There is considerable variation in the industry as to how ASC billing is performed for Medicare non-covered services. In general, most billing departments will assign an ASC APC “0” to designate that a certain code or code sets are not on the ASC list, which automatically puts them in a self-pay status. The facility knows a bill will not be sent out to a third party carrier and that it will be the patient’s responsibility. This methodology is appropriate for procedures that are not on the ASC list and do not have a practice expense built into the CPT code on the professional side. In such cases, Medicare has increased the RVU to include the practice expense and so the procedure cannot be performed in an ASC. Therefore, it is inappropriate to additionally bill the patient a facility fee. However, services that fall totally outside of the coverage of Medicare and the ASC list can appropriately be billed at a usual and customary rate.