March 12, 2012
Breaking the ASC Codes
By Selena Chavis
For The Record
Vol. 24 No. 5 P. 10
Expert coders with experience at ambulatory surgery centers analyze the nuances that make coding at these institutions unique.
Few in the healthcare field would argue that coding is uniquely specialized.
One particular specialization that could be tagged as a subspecialty of the profession is ambulatory surgery center (ASC) coder. Because it’s considered a niche within the coding profession, finding coders with the base knowledge to survive in such a setting is not always easy.
“There are not many of us out there,” says Stephanie Ellis, RN, CPC, owner of Ellis Medical Consulting, who points out that a clear understanding of how CPT codes work alongside modifiers in ASCs is crucial to solid reimbursement practices.
Essentially outpatient surgery centers that perform procedures that typically do not require hospitalization, ASCs require coding practices that are different than their hospital and physician office counterparts. Bobbi Hyatt, RHIT, CCS, CCDS, CHPS, senior auditor and manager of HIM services with Healthcare Cost Solutions and an ICD-10 trainer, suggests that the nuances of an ASC can make coding much more of a challenge.
“You don’t have the opportunity like you do in a hospital to capture physicians and query them about [what] they did,” she says. “Physicians are in and out of an ASC quickly.”
Because many ASCs don’t have the volume of business to justify a credentialed coder, there also tends to be a lack of expertise in this area, Hyatt adds. “It often falls on the billing staff who may not be well versed in modifiers,” she explains, pointing out that ASCs often do not have access to a good encoder to provide alerts and warnings of potential mistakes. “They don’t always have that at their disposal.”
Since many ASC coding professionals also do not have a network of other professionals in their respective facilities to collaborate with on issues, it is important to draw knowledge from seasoned experts. Professionals in the field say there are basic fundamentals that will help promote a better understanding of ASC coding. In addition, they can offer best practice advice for avoiding pitfalls to ensure optimal reimbursement.
According to Ellis, Medicare provides a list of safe procedures that qualify for coverage if performed in an ASC. This list also becomes the basic list for many third-party payers.
“Medicare sets the basic rules for what can and can’t be performed in an ASC, and it primarily revolves around safety,” Ellis says, pointing out that the list includes lower-risk procedures where emergencies or overnight stays are not expected. “Procedures that pose a significant safety risk for patients would be excluded.”
Typical procedures that would not be covered by Medicare include those impacting major blood vessels and requiring invasion into major body cavities. Other reasons for excluding a procedure from the ASC list for reimbursement under Medicare include the following:
• The procedure generally results in extensive blood loss.
• The procedure is of an emergent nature or life threatening.
• The procedure commonly requires systemic thrombolytic therapy.
• The procedure is not recognized for payment to hospitals under the outpatient prospective payment system.
• The procedure can be reported using only an unlisted surgical procedure code.
Ellis recommends that coders pay particular attention to the exclusion of unlisted surgical codes. “If a complicated procedure which must be billed with unlisted CPT codes is requested to be performed in the ASC facility on a Medicare patient, the ASC should decline the case and divert it to the hospital at the time of scheduling,” she says, noting that such a scenario will most likely lead the ASC to be declined payment.
While these are basic rules of Medicare coverage, Ellis notes that they are not hard and fast. Coders can find some blood vessel procedures covered by Medicare, and third-party insurers often will have a broader definition of what’s covered. These points make it crucial that ASC coders are well versed in all the nuances.
Like at a physician’s office, an ASC will bill Medicare Part B as opposed to the hospital’s Part A procedures. Those services/items that Medicare considers to be “directly related and required to perform the procedure” are included in the CPT code and not billed separately. Examples include the following:
• use of the operating room;
• nursing staff;
• supplies; and
• some devices and implants. (However, Medicare will pay for some implant/device costs separately.)
The Centers for Medicare & Medicaid Services (CMS) keeps ASC coders on their toes. “Each year, CMS puts out new lists,” Hyatt says. “Make sure you have the most current list for CMS outpatient surgery procedures.” It may seem obvious, but Hyatt says ASCs should have the most current Medicare CPT code book, cautioning that using the same edition for several years should not be viewed as a cost-saving measure.
It’s sound advice, according to Ellis, who offers the following example as an indication of how small changes can have big impacts. In 2012, the American Medical Association revised the arthroscopic knee meniscectomy codes 29880 and 29881 to include a 29877 debridement/chondroplasty procedure in the same or other knee compartments. In 2011, the 29877 procedure was billed separately in such situations, but that is no longer the case.
“What this means is that if a chondroplasty is performed on the same knee in the same surgical case as a meniscectomy—even if it was the only procedure performed in a knee compartment—it cannot be separately billed with chondroplasty code 29877,” Ellis explains. ”This policy applies for all payers, not just Medicare, because it is a change to the CPT guidelines rather than a payer requirement.”
This situation may arise in the case of a knee scope procedure performed on the right knee in which a synovectomy (29875) is performed in the patella, a meniscectomy (29881) is performed in the medial compartment, and a chondroplasty (29877) is performed in the lateral compartment. If the claim for this surgery were being filed to Aetna, Ellis says the coding would be 29881-RT and 29875-59-RT.
“The 29877 chondroplasty procedure would not be billable because it was performed in the same surgery on the same knee as the meniscectomy procedure,” Ellis says. “Because of the new CPT guideline, it is not billable, even using a -59 modifier.”
In this case, the -59 modifier, which is essentially an indicator that a procedure or service was distinct or separate from other services performed on the same day, should be used on the 29875 synovectomy procedure to avoid a payer denial. The 29875 code is designated as a separate procedure in the CPT book, and code 29875 is unbundled from code 29881 in the Medicare Correct Coding Initiative unbundling edits.
The Waiting Game
In an ASC, patience is a virtue when it comes to coding. Hyatt points out that ASC environments don’t lend themselves to easy follow-up on procedural documentation because physicians tend to move in and out of the facilities rather quickly. Coders don’t have the luxury of walking down the hall to consult with a physician about a procedure or provide a reminder that an operative report is due.
Because of this nuance, it is easy for coders to rush and try to code before the final documentation or operative report is complete. Hyatt cautions that this practice can create compliance issues and is likely to leave revenue on the table.
“When they [physicians] get in the operating room, the procedure tends to change from what might have been included in the brief op report,” she says. “Coders need to pull from the full op report and the pathology report. You need to make sure that any tissue that might have been removed is not cancerous.”
Hyatt offers the example of a shoulder repair to demonstrate how failing to wait for the full report can impact reimbursement. In this case, the brief op report denotes that a patient is having a rotator cuff repair that will require an arthroscopic procedure.
If the coder uses this information, the bill will include one code for that particular procedure. By looking at the full operative report, the coder may learn that a subacrominal decompression procedure and a debridement of another tendon was also required. During the procedure, the physician may have also decided the rotator cuff procedure needed to be open instead of arthroscopic.
The open procedure requires a whole different code set, and all these procedures would need to be billed separately, according to Hyatt. The subacrominal decompression and the tendon procedure each would be reimbursed at a rate of $1,084.92, and the open rotator cuff procedure would bring in $3,473, for a total reimbursement of $5,642.84. (Note: Rates could vary by region.)
Under the one arthroscopic code, the ASC would have been reimbursed $4,171.42. “You would lose out on payment without waiting for the op report,” Hyatt notes.
Which Payers Follow CMS?
According to Ellis, most payers use Medicare reimbursement as a guide for their own reimbursement practices, but there are exceptions. “Payers don’t really publish guidelines,” she notes, adding that coders will have to explore the differences to ensure they are reimbursed properly. “They don’t really give you a lot of other procedural guidelines other than a list and payment amounts.”
For example, in the case of implants, Medicare often includes the reimbursement of the implant in the procedural CPT code. That may not be the case with other payers.
Consider a cataract repair that requires a false lens implant. The procedure and implant would fall under the CPT code 66984 for Medicare. Ellis points out that other payers may allow the implant to be billed separately.
“Medicare does pay for some implants, but it varies greatly from state to state,” she says.
Also, Medicare does not pay for a lot of X-rays because imaging is often included in the CPT code. Ellis notes that some payers allow for separate billing.
To further muddy the waters, she notes there are exceptions when Medicare will allow imaging to be billed separately—for example, a retrograde pyelogram case in which an image of the urinary system is required. In this circumstance, however, Blue Cross Blue Shield and some other payers will not allow separate billing.
Hyatt notes that in a general sense, she sticks to CMS guidelines as the rule, even with other payers. “They are usually more strict and stringent guidelines,” she notes. “If another payer is less stringent, we stick with CMS because you can’t go wrong that way.”
— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.