CODING AND REIMBURSEMENT for ASC facility and pyhsician

CODING AND REIMBURSEMENT

Facility and Physician Allowance
Generally, there are two primary elements in the total cost of performing a surgical procedure:
• Cost of the physician’s professional services for performing the procedure; and
• Cost of services furnished by the facility where the procedure is performed (for example, surgical supplies, equipment, and nursing services).

The professional fee is paid to the physician; the facility fee is paid to the ASC. Physician coding and ASC coding of the procedures performed should match.

Facility Services
Prior to January 1, 2008:
The ASC payment rate is a standard overhead amount based on CMS’s estimate of a fair fee and the costs incurred by the ASCs providing the procedure. The HCPCS procedures for services covered by the ASC are grouped into pricer groups and a rate is set for each group. The ASC payment rates for each ASC covered procedure is based on the payment rates for the pricer groups, but capped at the hospital outpatient prospective payment system (OPPS) payment rate for the procedure. The Metropolitan Statistical Areas (MSAs) are used as the basis for ASC wage adjustments.

Effective January 1, 2008:
With implementation of the revised ASC payment system, the payment rates for most covered ASC surgical procedures and covered ancillary services are established prospectively based on a percentage of the hospital OPPS rates. There is an annual adjustment of the payment rates for inflation. The update for inflation begins with the CY 2010 ASC payment rates when the statutory requirement for a zero update no longer applies.
CMS adjusts for geographic differences in wages using the Core Based Statistical Area geographic locality definitions established in 2003 by the Office of Management and Budget (OMB).

ASC facility services are subject to the usual Medicare Part B deductible and coinsurance requirements. 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.

EXCEPTION on coinsurance and deductible: Effective for colorectal cancer screening colonoscopies (G0105 and G0121) performed on and after January 1, 2007, there is no deductible and a 25 percent coinsurance payment applies.