Monday, September 26, 2016

Calculating ASC surgical procedure payment

Rate-Setting Policies 

Generally, there are two primary elements in the total cost of performing a surgical procedure:

• The cost of the physician’s professional services for the performing the procedure; and

• The cost of services furnished by the facility where the procedure is performed (for example, surgical supplies and equipment and nursing services).

For ASC covered surgical procedures, the professional fee is paid to the physician; payments for facility costs are paid to the ASC.

Prior to the revised ASC payment system implemented January 1, 2008, the ASC payment rate was a standard overhead amount based on CMS’s estimate of a fair fee and the costs incurred by the ASCs providing the procedure. To estimate this cost, the CMS surveyed audit costs incurred by a sample of ASCs. There is an annual adjustment for inflation based on the percentage increase in the consumer price index for urban consumers in years when the ASC payment rates are not updated by a survey or otherwise. Over a number of years, there have been statutory requirements reducing or eliminating the inflation adjustment on a year by year basis. For example, the statute requires that the CPI adjustment factor be zero percent in FY 2005, the last quarter of CY 2005, and each CY from 2006 through 2009.

Beginning January 1, 2008, the revised ASC payment system includes the following features:
ASC payment rates for most services are based on a percentage of the hospital outpatient prospective payment system (OPPS) rates. Unless statutorily prohibited, there is annual adjustment of the payment rates for inflation based on the CPI-U. The update for inflation begins with the CY 2010 ASC payment rates when the statutory requirement for a zero update no longer applies.

In general, the Medicare program pays ASCs 80 percent of the lesser of the actual charge or the ASC facility payment rate for the covered services performed. The beneficiary pays 20 percent of the lesser of the submitted charge or the ASC facility payment rate for the covered services performed. An exception to this is screening flexible sigmoidoscopy and screening colonoscopy where Medicare pays 75 percent and the beneficiary pays 25 percent.

Beginning with the implementation of the 2008 revised payment system, the labor related adjustments to the ASC payment rates are based on the Core-Based Statistical Area (CBSA) methodology. Payment rates for most services are geographically adjusted using the pre-reclassification wage index values that CMS uses to pay non-acute providers. The adjustment for geographic wage variation will be made based on a 50 percent labor related share.
Detailed information on both the OPPS and ASC payment methodologies is available in the hospital outpatient and ASC final rules.

Thursday, September 22, 2016

Surgical procedure covered in ASC

 Types of Services Included on the List 

The ASC list of covered surgical procedures is comprised of surgical procedures that CMS determines do not pose a significant safety risk and are not expected to require an overnight stay following the surgical procedure.

Surgical procedures are defined as Category I CPT codes within the surgical range of CPT codes, 10000 through 69999. Also considered to be included within that code range are Level II HCPCS and Category III CPT codes that crosswalk to or are clinically similar to the
Category I CPT codes in the range.

The surgical codes that are included on the ASC list of covered surgical procedures are those that have been determined to pose no significant safety risk to Medicare beneficiaries when furnished in ASCs and that are not expected to require active medical monitoring at midnight of the day on which the surgical procedure is performed (overnight stay).

Procedures that are included on the inpatient list used under Medicare’s hospital outpatient prospective payment system are deemed to pose significant safety risk to beneficiaries in ASCs and are not eligible for designation and coverage as ASC covered surgical procedures. Procedures that can only be reported by using an unlisted Category I CPT code are excluded from consideration because there are no specifically descriptive codes that can be evaluated for safety risk.


Rebundling of CPT Codes 

The general CCI rebundling instructions apply to processing claims from ASC facilities services. In general, if an ASC bills a CPT code that is considered to be part of another more comprehensive code that is also billed for the same beneficiary on the same date of  service, only the more comprehensive code is covered, provided that code is on the list of ASC approved codes.

Saturday, September 17, 2016

Non ASC services coverage guidelines


Coverage of Services in ASCs Which Are Not ASC Facility Services or Covered Ancillary Services 

Physicians’ Services - This category includes most covered services performed in ASCs which are not considered ASC services. Physicians who furnish services in ASCs may bill for and receive separate payment under Part B. Physicians’ services include the services of anesthesiologists administering or supervising the administration of anesthesia to beneficiaries in ASCs and the beneficiaries’ recovery from the anesthesia. The term physicians’ services also includes any routine pre- or post- operative services, such as office visits, consultations, diagnostic tests, removal of stitches, changing of dressings, and other services which the individual physician usually includes in the fee for a given surgical procedure.

Implantable Durable Medical Equipment (DME) - If the ASC furnishes items of implantable DME to patients, the ASC bills and receives a single payment from the local contractor for the covered surgical procedure and the implantable device, as long as the implantable device does not have pass-through status under the OPPS. When the surgical procedure is not on the ASC list, the physician bills for his or her professional services and the ASC may bill the beneficiary for the facility charges associated with the procedure.

Non-implantable Durable Medical Equipment - If the ASC furnishes items of non-implantable DME to beneficiaries, it is treated as a DME supplier, and all the rules and conditions ordinarily applicable to DME are applicable, including obtaining a supplier number and billing the DME MAC where applicable.

Prosthetic Devices – Prior to January 1, 2008, an ASC was allowed to bill and receive separate payment for implantable prosthetic devices, other than intraocular lenses (IOLs) that were implanted, inserted, or otherwise applied by surgical procedures on the ASC list of approved procedures. The ASC billed the local Carrier and received payment according to the DMEPOS fee schedule. However, an intraocular lens (IOL) inserted during or subsequent to cataract surgery in an ASC was included in the facility payment rate.

Beginning January 1, 2008, payment for implantable prosthetic devices without OPPS pass-through status is included in the ASC payment for the covered surgical procedure. ASCs may not bill separately for implantable devices without OPPS pass-through status.
If the ASC furnishes non-implantable prosthetic devices to beneficiaries, the ASC is treated as a supplier, and all the rules and conditions ordinarily applicable to suppliers are applicable, including obtaining a supplier number and billing as directed by the jurisdiction list.

Ambulance Services - If the ASC furnishes ambulance services, the facility may obtain approval as an ambulance supplier to bill covered ambulance services.

Leg, Arm, Back and Neck Braces - These items of equipment, like non-implantable prosthetic devices, are covered under Part B, but are not included in ASC payment for ASC services. If the ASC furnishes these to beneficiaries, it is treated as a supplier, and all the rules and conditions ordinarily applicable to suppliers are applicable, including obtaining a supplier number and billing the DMERC where applicable.

Artificial Legs, Arms and Eyes - Like non-implantable prosthetic devices and braces, this equipment is not considered part of an ASC facility service and so is not included in ASC payment for ASC services. If the ASC furnishes these items to beneficiaries, it is treated as a supplier, and all the rules and conditions ordinarily applicable to suppliers are applicable, including obtaining a supplier number and billing the DMERC where applicable.

Services of Independent Laboratory - Only a very limited number and type of diagnostic tests are considered ASC facility services and these are included in the ASC payment for covered surgical procedures. In most cases, diagnostic tests performed directly by an ASC are not considered ASC facility services and are not covered under Medicare. Section 1861(s) of the Act limits coverage of diagnostic lab tests in facilities other than physicians’ offices, rural health clinics or hospitals to facilities that meet the statutory definition of an independent laboratory. In order to bill for diagnostic tests as a laboratory, an ASC’s laboratory must be CLIA certified and enrolled with the carrier as a laboratory and the certified clinical laboratory must bill for the services provided to the beneficiary in the ASC. Otherwise, the ASC makes arrangements with a covered laboratory or laboratories for laboratory services,

Wednesday, September 14, 2016

Billing guideline for Non ASC services under ASC setup

Services Furnished in ASCs Which Are Not ASC Facility Services or Covered Ancillary Services 

A single payment is made to an ASC for facility services furnished by the ASC in connection with a covered surgical procedure. Additional payments may be made to the ASC for covered ancillary services, specifically brachytherapy sources, certain implantable devices with pass-through status under the OPPS, corneal tissue acquisition, drugs and biologicals for which separate payment is allowed under the OPPS, and radiology services for which separate payment is allowed under the OPPS. To be covered ancillary services for which separate payment is made, these items and services must be provided integral to covered surgical procedures, that is, immediately before, during, or immediately after the covered surgical procedure.

However, a number of items and services covered under Medicare may be furnished in an ASC which are not considered ASC services, and which payment for ASC services does not include. These non-ASC services are covered and paid for under the applicable provisions of Part B. In addition, the ASC may be part of a medical complex that includes other entities, such as an independent laboratory, supplier of durable medical equipment, or a physician’s office, which are covered as separate entities under Part B. In general, an item or service provided in a separate part of the complex is not considered an ASC service, except as defined above.


Examples of payment and billing for items or services that are not ASC services:






Items not included in payment for ASC services Who may receive payment


Physicians’ services (including surgical procedures excluded from ASC payment)
  Physician



The purchase or rental of non-implantable durable medical equipment (DME) to ASC patients for use in their homes Supplier-
    An ASC can be a supplier of DME if it has a supplier number from the National Supplier Clearinghouse.




Non-implantable prosthetic devices
   Supplier. An ASC can be a supplier of non-implantable prosthetics if it has a supplier number from the National Supplier Clearinghouse.




Ambulanceservices
Certified Ambulance supplier



Leg, arm, back and neck braces
Supplier


Artificial legs, arms, and eyes
Supplier




Services furnished by an independent laboratory
Certified lab. ASCs can receive lab certification and a CLIA number.



Facility services for surgical procedures excluded from the ASC list
ASC





Friday, September 9, 2016

Definitions of ASC Facility Services:

Nursing Services, Services of Technical Personnel, and Other Related Services

These include all services in connection with covered procedures furnished by nurses and technical personnel who are employees of the ASC. In addition to the nursing staff, this category includes orderlies, technical personnel, and others involved in patient care.


Use by the Patient of the ASC Facilities

This category includes operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use by the patient’s relatives in connection with surgical services.


Drugs, Biologicals, Surgical Dressings, Supplies, Splints, Casts, Appliances, and Equipment

This category includes all supplies and equipment commonly furnished by the ASC in connection with surgical procedures. See the following paragraphs for certain exceptions. Drugs and biologicals are limited to those which cannot be self-administered. See the Medicare Benefit Policy Manual, Chapter 15, §50.2, for a description of how to determine whether drugs can be self-administered.

Under Part B, coverage for surgical dressings is limited to primary dressings, i.e., therapeutic and protective coverings applied directly to lesions on the skin or on openings to the skin required as the result of surgical procedures. (Items such as Ace bandages, elastic stockings and support hose, Spence boots and other foot coverings, leotards, knee supports, surgical leggings, gauntlets and pressure garments for the arms and hands are used as secondary coverings and therefore are not covered as surgical dressings.)

Although surgical dressings usually are covered as “incident to” a physician’s service in a physician’s office setting, in the ASC setting, such dressings are included in the facility’s services.

However, surgical dressings may be reapplied later by others, including the patient or a member of his family. When surgical dressings are obtained by the patient on a physician’s order from a supplier, e.g., a drugstore, the surgical dressing is covered under Part B. The same policy applies in the case of dressings obtained by the patient on a physician’s order following surgery in an ASC; the dressings are covered and paid as a Part B service by the DME MAC.

Similarly, “other supplies, splints, and casts” include only those furnished by the ASC at the time of the surgery. Additional covered supplies and materials furnished later are generally furnished as “incident to” a physician’s service, not as an ASC facility service. The term “supplies” includes those required for both the patient and ASC personnel, e.g., gowns, masks, drapes, hoses, and scalpels, whether disposable or reusable. Payment for these is included in the rate for the surgical procedure.

Beginning January 1, 2008, the ASC facility payment for a surgical procedure includes payment for drugs and biologicals that are not usually self-administered and that are considered to be packaged into the payment for the surgical procedure under the OPPS. Also, beginning January 1, 2008, Medicare makes separate payment to ASCs for drugs and biologicals that are furnished integral to an ASC covered surgical procedure and that are separately payable under the OPPS.


Diagnostic or Therapeutic Items and Services

These are items and services furnished by ASC staff in connection with covered surgical procedures. Many ASCs perform diagnostic tests prior to surgery that are generally included in the facility charges, such as urinalysis, blood hemoglobin, hematocrit levels, etc. To the extent that such simple tests are included in the ASC facility charges, they are considered facility services. However, under the Medicare program, diagnostic tests are not covered in laboratories independent of a physician’s office, rural health clinic, or hospital unless the laboratories meet the regulatory requirements for the conditions for coverage of services of independent laboratories. Therefore, diagnostic tests performed by the ASC other than those generally included in the facility’s charge are not covered under Part B and are not to be billed as diagnostic tests. If the ASC has its laboratory certified, the laboratory itself may bill for the tests performed.

The ASC may make arrangements with an independent laboratory or other laboratory, such as a hospital laboratory, to perform diagnostic tests it requires prior to surgery. In general, however, the necessary laboratory tests are done outside the ASC prior to scheduling of surgery, since the test results often determine whether the beneficiary should have the surgery done on an outpatient basis in the first place.


Administrative, Recordkeeping and Housekeeping Items and Services

These include the general administrative functions necessary to run the facility e.g., scheduling, cleaning, utilities, and rent.


Blood, Blood Plasma, Platelets, etc., Except Those to Which Blood Deductible Applies

While covered procedures are not expected to result in extensive loss of blood, in some cases, blood or blood products are required. Usually the blood deductible results in no expenses for blood or blood products being included under this provision. However, where there is a need for blood or blood products beyond the deductible, they are considered ASC facility services and no separate charge is permitted to the beneficiary or the program.



Materials for Anesthesia

These include the anesthetic agents that are not paid separately under the OPPS, and any materials, whether disposable or re-usable, necessary for its administration.



Intraocular Lenses (IOLs) and New Technology IOLs (NTIOLs)

The ASC facility services include IOLs (effective for services furnished on or after March 12, 1990), and NTIOLs (effective for services furnished on or after May 18, 2000), approved by the Food and Drug Administration (FDA) for insertion during or subsequent to cataract surgery.

FDA has classified IOLs into the following categories, any of which are included:

1. Anterior chamber angle fixation lenses;

2. Iris fixation lenses;

3. Irido-capsular fixation lenses; and

4. Posterior chamber lenses.

5. NTIOL Category 1 (as defined in “Federal Register” Notice, VOL 65, dated May 3, 2000). Note: This category expired May 18, 2005

6. NTIOL Category 2 (as defined in “Federal Register” Notice, VOL 65, dated May 3, 2000). Note: This category expired May 18, 2005

7. NTIOL Category 3 (as defined in Federal Register Notice, 71 FR 4586, dated January 27, 2006): This category will expire on February 26, 2011.

Note that while generally no separate charges for intraocular lenses (IOLs) are allowed, approved NTIOLS may be billed separately and an adjustment to the facility payment will be made for those lenses that are eligible.

Services Furnished

Monday, September 5, 2016

Usage of Modifier TC under ASC setup - Guideline

Effective for dates of service on or after January 1, 2009 for allowed ASC claims, if modifier = TC, contractors must ensure that either:

• ordering physician name and NPI or

• referring physician name and NPI are present on electronic or paper claims.

If this information is missing, contractors shall return as unprocessable and use Claim Adjustment Reason Code 16 - Claim/service lacks information which is needed for adjudication. Also use the appropriate remittance advice remark codes:

N264 - Missing/incomplete/invalid ordering provider name

N265 - Missing/incomplete/invalid ordering provider primary identifier

N285 - Missing/incomplete/invalid referring provider name

N286 - Missing/incomplete/invalid referring provider primary identifier

Wednesday, August 31, 2016

Service can be rendered under ASC setting ?

Ambulatory Surgical Center Services on ASC List 

Covered ASC services are those surgical procedures that are identified by CMS on a listing that is updated at least annually. Some surgical procedures covered by Medicare are not on the ASC list of covered surgical procedures. For surgical procedures not covered in ASCs, the related professional services may be billed by the rendering provider as Part B services and the beneficiary is liable for the facility charges, which are non-covered by Medicare.

Under the ASC payment system, Medicare makes facility payments to ASCs only for the specific ASC covered surgical procedures on the ASC list of covered surgical procedures. In addition, Medicare makes separate payment to ASCs for certain covered ancillary services that are provided integral to a covered ASC surgical procedure. All other non-ASC services, such as physician services and prosthetic devices may be covered and separately billable under other provisions of Medicare Part B. The Medicare definition of covered ASC facility services for a covered surgical procedure includes services that would be covered if furnished on an inpatient or outpatient basis in connection with a covered surgical procedure. This includes operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to patients needing surgical procedures. It includes all services and procedures provided in connection with covered surgical procedures furnished by nurses, technical personnel and others involved in patient care. These do not include physician services or medical and other health services for which payment may be made under other Medicare provisions (e.g., services of an independent laboratory located on the same site as the ASC, anesthetist professional services, non-implantable DME).

ASC services for which payment is included in the ASC payment for a covered surgical procedure under 42CFR416.65 include, but are not limited to-

(a) Included facility services:

(1) Nursing, technician, and related services;

(2) Use of the facility where the surgical procedures are performed;

(3) Any laboratory testing performed under a Clinical Laboratory Improvement  mendments of 1988 (CLIA) certificate of waiver;

(4) Drugs and biologicals for which separate payment is not allowed under the hospital outpatient prospective payment system (OPPS);

(5) Medical and surgical supplies not on pass-through status under Subpart G of Part 419 of 42 CFR;

(6) Equipment;

(7) Surgical dressings;

(8) Implanted prosthetic devices, including intraocular lenses (IOLs), and related accessories
and supplies not on pass-through status under Subpart G of Part 419 of 42 CFR;

(9) Implanted DME and related accessories and supplies not on pass-through status under Subpart G of Part 419of 42 CFR;

(10) Splints and casts and related devices;

(11) 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;

(12) Administrative, recordkeeping and housekeeping items and services;

(13) Materials, including supplies and equipment for the administration and monitoring of anesthesia; and

(14) Supervision of the services of an anesthetist by the operating surgeon.

Under the revised ASC payment system, the above items and services fall within the scope of ASC facility services, and payment for them is packaged into the ASC payment for the covered surgical procedure. ASCs must incorporate charges for packaged services into the charges reported for the separately payable services with which they are provided. Because contractors pay the lesser of 80 percent of actual charges or the ASC payment rate for the separately payable procedure, and because this comparison is made at the claim line-item level, facilities may not be paid appropriately if they unbundle charges and report those charges for packaged codes as separate line-item charges.

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