Definition of Services in ASCs That Are Not ASC Facility Services
Physicians’ Services
This category includes most covered services performed in ASCs which are not considered ASC facility 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.
Physician Payment for Non-Covered ASC Procedures
Prior to January 1, 2008, physicians were paid for furnishing non-covered procedures in ASCs at the non-facility amount. Beginning January 1, 2008, Medicare revised this policy to require payment to physicians at the facility payment amount, which is an agreement with both the policy under the hospital OPPS and the revised ASC payment policy related to the list of covered services. The revised ASC payment system is based on the Ambulatory Payment Classification (APC) groups and payment weights of the OPPS.
CMS believes that ASC facilities are similar, insofar as the delivery of surgical and related non-surgical services, to hospital outpatient departments. Specifically, when services are provided in ASCs, the ASC, not the physician, bears the responsibility for the facility costs associated with the service. This situation parallels the hospital facility resource responsibility for hospital outpatient services.
Under the revised ASC payment system, CMS adopted a policy that identifies, and excludes from ASC payment, only those services that could pose a significant risk to beneficiary safety or that would be expected to require an overnight stay.
CMS believes that it would be inconsistent with the revised ASC payment system policies to pay the typically non-facility rate to physicians who furnish excluded ASC procedures. Because the excluded procedures have been specifically identified by CMS as procedures that could pose a significant risk to beneficiary safety or that would be expected to require an overnight stay, CMS does not believe it would be appropriate to provide a payment based on the non-facility rate to physicians who furnish them in the ASC setting.
Under the revised ASC payment system, CMS has determined that the only surgical procedures excluded from ASC payment are those that pose a significant safety risk to beneficiaries or that are expected to require an overnight stay when furnished in an ASC. Therefore, CMS provides no payment to ASCs for these procedures.
Note: CMS does not expect that these unsafe services will be furnished to Medicare beneficiaries in ASCs, and CMS expects that physicians and ASCs will advise beneficiaries of all of the possible consequences (including no Medicare ASC payments with concomitant beneficiary liability and significant surgical risk) if surgical procedures excluded from ASC payment were to be provided in ASCs.
Friday, July 30, 2010
Service performed in ASC but need claim seperately for billing
Services Furnished in an ASC Which Are Not ASC Facility Services
A single payment is made to an ASC, which includes all facility services furnished by the ASC in connection with a covered procedure. A number of items and services covered under Medicare may be furnished in an ASC, which are not considered facility services and that the ASC payment does not include.
The following are services not included in the ASC facility service:
• Physicians’ services (should be submitted by the physician).
• Physician payment for non-covered ASC procedures (should be submitted by the physician).
• Purchase or rental of non-implantable (DME to ASC patients for use in their home (should be submitted to
the DME MAC by the supplier).
• Implantable DME and accessories.
• Non-implantable prosthetic devices (should be submitted to the DME MAC by the supplier).
• Implantable prosthetic devices except certain intraocular lenses (IOLs and NTIOLs) and accessories.
• Ambulance services (should be submitted by the ambulance provider).
• Leg, arm, back and neck braces (should be submitted to the DME MAC by the supplier).
• Artificial legs, arms and eyes (should be submitted to the DME MAC by the supplier).
• Services furnished by an independent laboratory (should be submitted by the certified lab, or the ASC if the ASC has received lab certification and a CLIA number).
• Procedures not on the ASC list (should be submitted by the physician).
A single payment is made to an ASC, which includes all facility services furnished by the ASC in connection with a covered procedure. A number of items and services covered under Medicare may be furnished in an ASC, which are not considered facility services and that the ASC payment does not include.
The following are services not included in the ASC facility service:
• Physicians’ services (should be submitted by the physician).
• Physician payment for non-covered ASC procedures (should be submitted by the physician).
• Purchase or rental of non-implantable (DME to ASC patients for use in their home (should be submitted to
the DME MAC by the supplier).
• Implantable DME and accessories.
• Non-implantable prosthetic devices (should be submitted to the DME MAC by the supplier).
• Implantable prosthetic devices except certain intraocular lenses (IOLs and NTIOLs) and accessories.
• Ambulance services (should be submitted by the ambulance provider).
• Leg, arm, back and neck braces (should be submitted to the DME MAC by the supplier).
• Artificial legs, arms and eyes (should be submitted to the DME MAC by the supplier).
• Services furnished by an independent laboratory (should be submitted by the certified lab, or the ASC if the ASC has received lab certification and a CLIA number).
• Procedures not on the ASC list (should be submitted by the physician).
ASC services - Diagnostic or Therapeutic and Administrative, Recordkeeping and Housekeeping
Diagnostic or Therapeutic Items and Services
Diagnostic or therapeutic items and services 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. (See 42CFR416.49 at http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr416_06.html.) 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 the 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.
Beginning January 1, 2009, the ordering/referring physician must be reported on claims for diagnostic services submitted by the ASC.
Administrative, Recordkeeping and Housekeeping Items and Services
Administrative, recordkeeping and housekeeping items and services 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 limited to those 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, when 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.
Diagnostic or therapeutic items and services 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. (See 42CFR416.49 at http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr416_06.html.) 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 the 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.
Beginning January 1, 2009, the ordering/referring physician must be reported on claims for diagnostic services submitted by the ASC.
Administrative, Recordkeeping and Housekeeping Items and Services
Administrative, recordkeeping and housekeeping items and services 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 limited to those 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, when 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.
Thursday, July 29, 2010
Is it nursing services and drug, biological , surgical dressing covered under ASC billing
Definitions of Included 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 of the ASC Facilities by the Patient
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. Drugs and biologicals are limited to those that cannot be self-administered. See the Medicare Benefit Policy Manual, Chapter 15, Section 50.2 (http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf ), 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 Durable Medical Equipment Regional Contractor (DMERC) or Durable Medical Equipment Medicare Administrative Contractor (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.
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 of the ASC Facilities by the Patient
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. Drugs and biologicals are limited to those that cannot be self-administered. See the Medicare Benefit Policy Manual, Chapter 15, Section 50.2 (http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf ), 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 Durable Medical Equipment Regional Contractor (DMERC) or Durable Medical Equipment Medicare Administrative Contractor (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.
What are services are comes under ASC billing
ASC Services on ASC List
Covered ASC services are those surgical procedures that are identified by CMS on an annually updated ASC listing. Some surgical procedures covered by Medicare are not on the ASC list of covered surgical procedures. These may be billed by the rendering provider as Part B services but not as ASC services.
the ASC payment system, Medicare will make facility payments to ASCs only for the specific ASC-covered surgical procedures on the ASC list of covered surgical procedures. In addition, Medicare will make 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, prosthetic devices other than IOLs, anesthetist professional services and non-implantable Durable Medical Equipment (DME)).
Included Facility Services
• Nursing, technician and related services.
• Use of the facility where the surgical procedures are performed.
• Any laboratory testing performed under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver.
• Drugs and biologicals for which separate payment is not allowed under the hospital OPPS.
• Medical and surgical supplies not on pass-through status.
• Equipment.
• Surgical dressings.
• Implanted prosthetic devices, including IOLs, and related accessories and supplies not on pass-through status.
• Implanted DME and related accessories and supplies not on pass-through status.
• Splints and casts and related devices.
• 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.
• Administrative, recordkeeping, and housekeeping items and services.
• Materials, including supplies and equipment for the administration and monitoring of anesthesia.
• 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 Medicare 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.
Under the ASC payment system, there is a payment adjustment for the insertion of an Intraocular Lens (IOL) (one that is classified a New Technology Intraocular Lenses (NTIOL)) for a five-year period of time.
Covered ASC services are those surgical procedures that are identified by CMS on an annually updated ASC listing. Some surgical procedures covered by Medicare are not on the ASC list of covered surgical procedures. These may be billed by the rendering provider as Part B services but not as ASC services.
the ASC payment system, Medicare will make facility payments to ASCs only for the specific ASC-covered surgical procedures on the ASC list of covered surgical procedures. In addition, Medicare will make 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, prosthetic devices other than IOLs, anesthetist professional services and non-implantable Durable Medical Equipment (DME)).
Included Facility Services
• Nursing, technician and related services.
• Use of the facility where the surgical procedures are performed.
• Any laboratory testing performed under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver.
• Drugs and biologicals for which separate payment is not allowed under the hospital OPPS.
• Medical and surgical supplies not on pass-through status.
• Equipment.
• Surgical dressings.
• Implanted prosthetic devices, including IOLs, and related accessories and supplies not on pass-through status.
• Implanted DME and related accessories and supplies not on pass-through status.
• Splints and casts and related devices.
• 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.
• Administrative, recordkeeping, and housekeeping items and services.
• Materials, including supplies and equipment for the administration and monitoring of anesthesia.
• 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 Medicare 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.
Under the ASC payment system, there is a payment adjustment for the insertion of an Intraocular Lens (IOL) (one that is classified a New Technology Intraocular Lenses (NTIOL)) for a five-year period of time.
What is ASC billing
Definition of ASC
An ASC for Medicare purposes is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. The ASC must enter into a “participating provider” agreement with CMS. An ASC is either independent (i.e., not a part of a provider of services or any other facility) or operated by a hospital (i.e., under the common ownership, licensure or control of a hospital). If an ASC is the latter type, it has the option either of being covered under Medicare as an ASC or of continuing to be covered as a hospital-affiliated outpatient surgery department as such entities were covered prior to the enactment of ASC legislation on December 5, 1980. To be covered as an ASC operated by a hospital, a facility:
• Elects to do so and continues to be so covered unless CMS determines there is good cause to do otherwise.
• Is a separately identifiable entity – physically, administratively and financially independent and distinct from other operations of the hospital with costs for the ASC treated as a non-reimbursable cost center on the hospital’s cost report.
• Meets all the requirements with regard to health and safety and agrees to the assignment, coverage and payment rules applied to independent ASCs.
• Is surveyed and approved as complying with the conditions for coverage for ASCs in 42 CFR 416.40-49 (http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr416_06.html).
Related survey requirements are published in the State Operations Manual. If a facility meets the above requirements, it bills the Medicare contractor on Form CMS-1500 or the related electronic data set and is paid the ASC payment amount.
If a hospital-based facility decides not to become a certified ASC, it bills the Fiscal Intermediary (FI) on Form CMS-1450 or the related EDI data set and is subject to hospital outpatient billing and payment rules. It is also subject to hospital outpatient certification and participation requirements.
Certain Indian Health Services (IHS) and tribal hospitals may elect to enroll and be paid as a certified ASC. See Pub. 100-04, Chapter 19 for more information at:
http://www.cms.hhs.gov/manuals/downloads/clm104c19.pdf
An ASC for Medicare purposes is a distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. The ASC must enter into a “participating provider” agreement with CMS. An ASC is either independent (i.e., not a part of a provider of services or any other facility) or operated by a hospital (i.e., under the common ownership, licensure or control of a hospital). If an ASC is the latter type, it has the option either of being covered under Medicare as an ASC or of continuing to be covered as a hospital-affiliated outpatient surgery department as such entities were covered prior to the enactment of ASC legislation on December 5, 1980. To be covered as an ASC operated by a hospital, a facility:
• Elects to do so and continues to be so covered unless CMS determines there is good cause to do otherwise.
• Is a separately identifiable entity – physically, administratively and financially independent and distinct from other operations of the hospital with costs for the ASC treated as a non-reimbursable cost center on the hospital’s cost report.
• Meets all the requirements with regard to health and safety and agrees to the assignment, coverage and payment rules applied to independent ASCs.
• Is surveyed and approved as complying with the conditions for coverage for ASCs in 42 CFR 416.40-49 (http://www.access.gpo.gov/nara/cfr/waisidx_06/42cfr416_06.html).
Related survey requirements are published in the State Operations Manual. If a facility meets the above requirements, it bills the Medicare contractor on Form CMS-1500 or the related electronic data set and is paid the ASC payment amount.
If a hospital-based facility decides not to become a certified ASC, it bills the Fiscal Intermediary (FI) on Form CMS-1450 or the related EDI data set and is subject to hospital outpatient billing and payment rules. It is also subject to hospital outpatient certification and participation requirements.
Certain Indian Health Services (IHS) and tribal hospitals may elect to enroll and be paid as a certified ASC. See Pub. 100-04, Chapter 19 for more information at:
http://www.cms.hhs.gov/manuals/downloads/clm104c19.pdf
Wednesday, July 28, 2010
ASC BILLING Type of service
Medicare Billing Process
A provider number is applied for by the ASC and issued by the Medicare carrier after approval from the State and the regional CMS carrier. This supplier number is applied for under the ASC Tax ID. Claims cannot be billed to Medicare for facility fees until the provider number is given by CMS regional and the actual billing number assigned by the carrier. The effective date is the date of survey compliance.
Once approval is received, facility fees are billed to Medicare on the standard HCFA 1500 form using the CPT code with the modifier –SG. Place of service is 24 (ASC)
Type of Service
Surgical services billed with the ASC facility service modifier SG must be
reported as TOS F. The indicator F does not appear on the TOS table because its
use is dependent upon the use of the SG modifier.
On the HCFA 1500 list:
• CPT Code + SG modifier
• List highest group first
• Use -59 as applicable based on LMRP for multiple procedures or additional levels of the same procedure
• Bilaterals - Use –50 (units 1) or RT/LT by line (increase fee x 2)
A provider number is applied for by the ASC and issued by the Medicare carrier after approval from the State and the regional CMS carrier. This supplier number is applied for under the ASC Tax ID. Claims cannot be billed to Medicare for facility fees until the provider number is given by CMS regional and the actual billing number assigned by the carrier. The effective date is the date of survey compliance.
Once approval is received, facility fees are billed to Medicare on the standard HCFA 1500 form using the CPT code with the modifier –SG. Place of service is 24 (ASC)
Type of Service
Surgical services billed with the ASC facility service modifier SG must be
reported as TOS F. The indicator F does not appear on the TOS table because its
use is dependent upon the use of the SG modifier.
On the HCFA 1500 list:
• CPT Code + SG modifier
• List highest group first
• Use -59 as applicable based on LMRP for multiple procedures or additional levels of the same procedure
• Bilaterals - Use –50 (units 1) or RT/LT by line (increase fee x 2)
Mangaged care billing UB 92 example
Managed Care Billing Process:
The signed contract will include the MCO’s specific billing rules. Some third party payers require the UB92 form for filing the ASC facility fee. This should be clarified at contract negotiation time. Most payers that require the use of a UB92 form will accept the CPT and the standard ASC revenue code. It is important to be aware of incidentals that can be billed separately; all exclusions, special rules for bundling, handling of multiple services, multiple levels and bilateral services
UB92 Example for most payers
•Type of Bill: Always 831
•Revenue Code: 490 (ASC) (Note: most payers accept this revenue code for all line items)
•Procedure Code- Always use –SG modifier plus –59 or –51 as applicable
•Revenue Code- 320 Fluoroscopy or Interpretation Code with the modifier -tc
•Revenue Code- 270 Supplies - 99070
Itemized Supplies/Drugs Example:
If the payer requests a break down of CPT code 99070, miscellaneous surgical supplies, the following would be included as appropriate
The signed contract will include the MCO’s specific billing rules. Some third party payers require the UB92 form for filing the ASC facility fee. This should be clarified at contract negotiation time. Most payers that require the use of a UB92 form will accept the CPT and the standard ASC revenue code. It is important to be aware of incidentals that can be billed separately; all exclusions, special rules for bundling, handling of multiple services, multiple levels and bilateral services
UB92 Example for most payers
•Type of Bill: Always 831
•Revenue Code: 490 (ASC) (Note: most payers accept this revenue code for all line items)
•Procedure Code- Always use –SG modifier plus –59 or –51 as applicable
•Revenue Code- 320 Fluoroscopy or Interpretation Code with the modifier -tc
•Revenue Code- 270 Supplies - 99070
Itemized Supplies/Drugs Example:
If the payer requests a break down of CPT code 99070, miscellaneous surgical supplies, the following would be included as appropriate
| Break Down of Supplies (Example) | ||||
| Cost:______Price charged:( ) | ||||
| A4550 Epidural Tray | Syringe: | J3490 Marcaine .25% | ||
| A4649: | Needle: | J1040 Depo-Medrol 80 mg: | ||
| Jelco | Pulse Ox: | J1030 Depo-Medrol 40mg | ||
| IV Kit: | O2 + Nasal Tubing: | J3010 Fentanyl 2ml | ||
| Tegaderm Dressing: | Sterile Surgical Gloves: | A4645 Isovue 200mg Iodine: | ||
| Adaptor: | J2250 Versed per 1 mg | |||
ASC billing - surgical coding crosswalk
Surgical Coding Crosswalk
Some payers will only accept the Surgical Code Crosswalk (ICD9 Volume 3). This code is used instead of the CPT code on the UB92 claim form. The crosswalk is published by Medicode. This crosswalk is based on the surgery section of the CPT and link to a data driven code. To use this book, you would look up the CPT code numerically and the code will list the ICD-9 procedural code. Many pain procedures fall into the same crosswalk code. For instance: Crosswalk code 03.91 crosswalks to single and continuous epidurals. Many of the crosswalk codes are driven by the type of medication that is injected. Once your billing system has been loaded with crosswalk codes, you should be able to simply link the payer to the claim form and choose crosswalk or CPT.
Some payers will only accept the Surgical Code Crosswalk (ICD9 Volume 3). This code is used instead of the CPT code on the UB92 claim form. The crosswalk is published by Medicode. This crosswalk is based on the surgery section of the CPT and link to a data driven code. To use this book, you would look up the CPT code numerically and the code will list the ICD-9 procedural code. Many pain procedures fall into the same crosswalk code. For instance: Crosswalk code 03.91 crosswalks to single and continuous epidurals. Many of the crosswalk codes are driven by the type of medication that is injected. Once your billing system has been loaded with crosswalk codes, you should be able to simply link the payer to the claim form and choose crosswalk or CPT.
| CPT | DESCRIPTION | SURGICAL CODING CROSSWALK |
| 11900 | Scar Infiltration (up to 7) | 99.29 |
| 11901 | Scar Infiltration (over 7) | 99.29 |
| 20550 | Injection Tendon | 81.92 Joint |
| 83.97 Tendon | ||
| 20552 | Trigger Point 1 or 2 | 83.98 |
| 20553 | Trigger Points 3 or more | 83.98 |
| 20600 | Small Joint Injection | 81.91 Arthrocentesis |
| 81.92 Injection of therapeutic substance into joint or ligament | ||
| 82.92 Aspiration of bursa of hand | ||
| 82.94 Injection of therapeutic substance into bursa of hand | ||
| 82.95 Injection of therapeutic substance into tendon of hand | ||
| 83.94 Aspiration of bursa | ||
| 83.96 Injection of therapeutic substance into bursa | ||
| 20605 | Medium Joint Injection | 76.96 Injection of therapeutic substance into temporomandibular joint |
| 81.91 Arthrocentesis | ||
| 81.92 Injection of therapeutic substance into joint or ligament | ||
| 83.94 Aspiration of bursa | ||
| 83.96 Injection of therapeutic substance into bursa | ||
| 20610 | Large Joint Injection | 81.91 Arthrocentesis |
| 81.92 Injection of therapeutic substance into joint or ligament | ||
| 83.94 Aspiration of bursa | ||
| 83.96 Injection of therapeutic substance into bursa | ||
| 27096 | SI Joint Injection | 81.92 |
| 99.23 Steroid | ||
| 99.29 Other agent | ||
| 62263 | Percutaneous lysis of adhesions | 86.09 |
| 62270 | Spinal puncture lumbar | 03.31 |
| 62273 | Blood Patch | 03.95 |
| 62280 | Subarachnoid | 03.8 Dest agent |
| 03.92 Other | ||
| 62281 | Epidural, cervical/Thoracic | 03.8 Dest agent |
| 03.92 Other | ||
| 62282 | Epidural, lumbar/caudal | 03.8 Dest agent |
| 03.92 Other | ||
| 62287 | Percutaneous Laser Discectomy | 80.59 |
| 62290 | Discography, lumbar | 03.92 + 87.22 |
| 62291 | Discography, cervical | 03.92 + 87.24 |
| 62310 | Epidural cervical/thoracic. | 03.91 Anesthestic |
| 03.92 Other | ||
| 62311 | Epidural lumbar/sacral/caudal | 03.91 Anesthestic |
| 03.92 Other | ||
| 62318 | Inject. Incl.cath placement, continuous cervical/thoracic | 03.9 Cath Insert |
| 03.91 Anesthestic | ||
| 03.92 Other | ||
| 62319 | Inject. Incl.cath placement, continuous Lumbar/sacral | 03.9 Cath Insert |
| 03.91 Anesthestic | ||
| 03.92 Other | ||
| 62350 | Implant Catheter | |
| 62355 | Remove implanted catheter | |
| 62361 | Implant non-programmable pump | |
| 62362 | Implant programmable pump | 86.06 Insertion totally implanted pump |
| 62365 | Remove implanted pump | |
| 62367 | Analysis pump w/o reprogram | |
| 62367-26 | Analysis pump w/o reprogram | |
| 62368 | Analysis pump with reprogram | |
| 62368-26 | Analysis pump with reprogram | |
| 63650 | Percutaneous implant neurolectrode | 3.93 |
| 63660 | Revision/remove electrode | 03.21 Percutaneous chordotomy |
| 03.32 Biopsy of spinal cord or spinal meninges | ||
| 03.39 Other diagnostic procedures on spinal cord and spinal canal structures | ||
| 03.4 Excision or destruction of lesion of spinal cord or spinal meninges | ||
| 03.92 Injection of other agent into spinal canal | ||
| 63685 | Implant spinal transmitter | 03.93 |
| 63688 | Revision/remove spinal transmitter | 03.93 |
| 64400 | Trigeminal Nerve, any | 04.81 |
| 64402 | Facial Nerve | 04.81 |
| 64405 | Greater/lesser Occipital nerve | 04.81 |
| 64408 | Vagus Nerve | 04.81 |
| 64410 | Phrenic Nerve | 04.81 |
| 64412 | Spinal Accessory Nerve | 03.91 Anesth into spinal canal |
| 04.81 Anesth into peripheral nerve | ||
| 64413 | Cervical Plexus | 04.81 |
| 64415 | Brachial Plexus | 04.81 |
| 64417 | Axillary Nerve Block | 04.81 |
| 64418 | Suprascapular Nerve | 04.81 |
| 64420 | Intercostal, single | 04.81 |
| 64421 | Intercostal, multiple | 04.81 |
| 64425 | Ilionguinal, Iliohypogastric Nerve | 04.81 |
| 64430 | Pudental Nerve | 04.81 |
| 64445 | Sciatic Nerve | 04.81 |
| 64450 | Other peripheral | 04.81 |
| 64470 | Facet, cerv./thoracic single | 04.81 |
| 64472 | Facet, cervical/thoracic additional | 04.81 |
| 64475 | Facet, lumbar/sacral single | 04.81 |
| 64476 | Facet, lumbar/sacral additional | 04.81 |
| 64479 | Transforaminal, epidural cerv/thor. 1st level | 03.91 Aesthetic into spinal canal |
| 03.92 Other | ||
| 64480 | Transforaminal, epidural cerv/thor. Ea. Addt'l | 03.91 Aesthetic into spinal canal |
| 03.92 Other | ||
| 64483 | Transforaminal epidural lumbar/sacral, 1st level | 03.91 Aesthetic into spinal canal |
| 03.92 Other | ||
| 64484 | Transforaminal epidural lumbar/sacral ea. addt’l | 03.91 Aesthetic into spinal canal |
| 03.92 Other | ||
| 64505 | Sphenopalatine | 05.31 |
| 64510 | Stellate Ganglion | 05.31 |
| 64520 | Lumbar sympathetic | 05.31 |
| 64530 | Celiac Plexus | 05.31 |
| 64550 | Tens application | 04.19 |
| 64600 | Trigeminal Nerve, any | 04.2 |
| 64612 | Sphenopalatine | 04.2 |
| 64613 | Botox injection | 04.2 |
| 64620 | Intercostal: destruct | 04.2 |
| 64622 | Destruct Paravetebral Facet, lumbar single | 04.2 |
| 64623 | Destruct Paravetebral Facet, lumbar ea. addt’l | 04.2 |
| 64626 | Facet joint or facet joint nerve cerv/thor. 1st level | 04.2 |
| 64627 | Facet joint or facet joint nerve cerv/thor, ea. add’l | 04.2 |
| 64640 | Other peripheral | 04.2 |
| 64680 | Celiac Plexus: destruct | 05.32 Neurolync agent |
| 05.39 Other |
ASC billing for wroker compensation
Commercial Payers and Workers Compensation Billing Process:
Some states use set fee and coding schedules for Worker’s Comp facility fees. In states that do not have a set facility fee payment schedule, the facility fee reimbursement is based on their assumption of customary rates and paid at fee for service. All commercial and Workers Compensation claims are billed on a UB92. With Workers Compensation, many require that the provider send copy of the procedure notes and will typically also require a breakdown of the itemized supplies and drugs as well.
Some states use set fee and coding schedules for Worker’s Comp facility fees. In states that do not have a set facility fee payment schedule, the facility fee reimbursement is based on their assumption of customary rates and paid at fee for service. All commercial and Workers Compensation claims are billed on a UB92. With Workers Compensation, many require that the provider send copy of the procedure notes and will typically also require a breakdown of the itemized supplies and drugs as well.
Tuesday, July 27, 2010
ASC billing multiple procedure rule
Multiple Procedure Rule
As many pain procedures involve bilateral injections and/or multiple levels, each procedure can yield two to three facility fees. Medicare and other payers currently pay 100 percent of the highest payment for multiple procedures in a single session and 50 percent for each additional procedure. Local Medical Review Policies and the Correct Coding Initiative apply to both professional fees and facility fees.
Fluoroscopy in ASC’s
Medicare facility fees include the use of equipment that is directly related to the provision of the surgical service. The technical component of the use of the C’arm is thus bundled into the Medicare facility fee payment. The physician performing the procedure would indicate the professional component (modifier -26) on his claim for services rendered for both needle localization and supervision and interpretation studies. The technical component would not be billed separately to Medicare on the ASC claim.
Modifiers – Recoup Costs
CMS approves two modifiers that can be used in the ASC to report discontinued procedures.
-73 Discontinued outpatient procedure prior to the administration of anesthesia
-74 Discontinued outpatient procedure after the administration of anesthesia
As many pain procedures involve bilateral injections and/or multiple levels, each procedure can yield two to three facility fees. Medicare and other payers currently pay 100 percent of the highest payment for multiple procedures in a single session and 50 percent for each additional procedure. Local Medical Review Policies and the Correct Coding Initiative apply to both professional fees and facility fees.
Fluoroscopy in ASC’s
Medicare facility fees include the use of equipment that is directly related to the provision of the surgical service. The technical component of the use of the C’arm is thus bundled into the Medicare facility fee payment. The physician performing the procedure would indicate the professional component (modifier -26) on his claim for services rendered for both needle localization and supervision and interpretation studies. The technical component would not be billed separately to Medicare on the ASC claim.
Modifiers – Recoup Costs
CMS approves two modifiers that can be used in the ASC to report discontinued procedures.
-73 Discontinued outpatient procedure prior to the administration of anesthesia
-74 Discontinued outpatient procedure after the administration of anesthesia
Managed Care Facility Contracts
Managed Care Facility Contracts
As previously stated, in order to contract with other third party payers, Certification by Medicare as a provider of surgical services is mandatory. Many payers also require accreditation before the facility can obtain a contract with them. This process, however, should be started as soon as the proposed facility has filed a notice on intent as applicable in the State or the CMS applications have been filed. The credentialing process should be started by requesting facility applications and then completed when the facility is found to be in compliance.
The contract proposal from the MCO should include a fee schedule for each CPT code that the ASC will be providing. Most Managed Care contracts typically do not send their entire fee schedule that represents all of their approved fees. For procedures that are not listed on their fee schedule, it is important to ascertain how non-covered services will be paid, such as fee for service and at what percentage of billed charges.
Negotiations on the facility contract should include exclusions. Determine their policies on what is included in the facility fee rate. Many MCO’s will reimburse for the technical component of fluoroscopy and drugs/supplies in addition to the flat rate.
You may find that these fee schedules are tied to the Medicare payment groups at a percentage of the national average allowance. Generally the contract fees are subject to change based on the contract with the payer. It is critical at contract negotiation time to identify the current fee schedule and how often the payer can change these fees and what notification timeframe is required when a change is made. The contract should have an escalator clause to account for time and inflation.
As previously stated, in order to contract with other third party payers, Certification by Medicare as a provider of surgical services is mandatory. Many payers also require accreditation before the facility can obtain a contract with them. This process, however, should be started as soon as the proposed facility has filed a notice on intent as applicable in the State or the CMS applications have been filed. The credentialing process should be started by requesting facility applications and then completed when the facility is found to be in compliance.
The contract proposal from the MCO should include a fee schedule for each CPT code that the ASC will be providing. Most Managed Care contracts typically do not send their entire fee schedule that represents all of their approved fees. For procedures that are not listed on their fee schedule, it is important to ascertain how non-covered services will be paid, such as fee for service and at what percentage of billed charges.
Negotiations on the facility contract should include exclusions. Determine their policies on what is included in the facility fee rate. Many MCO’s will reimburse for the technical component of fluoroscopy and drugs/supplies in addition to the flat rate.
You may find that these fee schedules are tied to the Medicare payment groups at a percentage of the national average allowance. Generally the contract fees are subject to change based on the contract with the payer. It is critical at contract negotiation time to identify the current fee schedule and how often the payer can change these fees and what notification timeframe is required when a change is made. The contract should have an escalator clause to account for time and inflation.
ASC facility fee inclusive services and non inclusive services
Most covered Pain Management procedures fall into groups one or two. Some pain procedures are not on Medicare’s payment list for ASC facility reimbursement. These procedures then fall under Medicare’s site of service differential rule, meaning professional fees are paid at the higher “office” site of service differential. The place of service on the physician’s bill is still ASC -24. It is important to monitor the explanation of benefits for correct site of service payment on these claims.
Since a patient cannot be billed for facility fees from procedures not on the approved list, an ASC’s only advantage from supporting such “off list” cases may be to charge non-owner physicians rent for use of the ASC
These Medicare facility fees include:
Use of the facility
Nursing and technician services
Drugs
Biologicals
Surgical dressings
Materials for anesthesia
Splints, casts and equipment directly related to the provision of the procedure
Administrative, record-keeping and housekeeping items and services
In addition to facility fees in the ASC setting, the following are paid separately:
Physician services (Professional fees)
Laboratory expenses (Must be CLIA certified to perform lab tests or CLIA waived to perform minor labs such as glucose or pregnancy testing)
X-Rays
Diagnostic procedures other than those directly related to the surgical procedure
Prosthetic devices
Leg, arm, back and neck braces
Artificial limbs
DME for use in the patients home (typically not applicable in pain management) Implantables such as neuorstimulators and drug infusion pumps are paid by the Part B carrier-not the DME carrier).
Since a patient cannot be billed for facility fees from procedures not on the approved list, an ASC’s only advantage from supporting such “off list” cases may be to charge non-owner physicians rent for use of the ASC
These Medicare facility fees include:
Use of the facility
Nursing and technician services
Drugs
Biologicals
Surgical dressings
Materials for anesthesia
Splints, casts and equipment directly related to the provision of the procedure
Administrative, record-keeping and housekeeping items and services
In addition to facility fees in the ASC setting, the following are paid separately:
Physician services (Professional fees)
Laboratory expenses (Must be CLIA certified to perform lab tests or CLIA waived to perform minor labs such as glucose or pregnancy testing)
X-Rays
Diagnostic procedures other than those directly related to the surgical procedure
Prosthetic devices
Leg, arm, back and neck braces
Artificial limbs
DME for use in the patients home (typically not applicable in pain management) Implantables such as neuorstimulators and drug infusion pumps are paid by the Part B carrier-not the DME carrier).
Medicare ASC Payment Groups
Medicare ASC Payment Groups
Once an ASC is approved for Medicare participation, the ASC can only be reimbursed for procedures that are on a list of procedures that Medicare will reimburse to an ASC. Procedures on the list fall into one of 9 groupings with a payment rate assigned to each group. The payment group is determined by the CPT procedure rendered. The groups actually have no clinical coherence but were based on a cost analysis survey last performed by CMS in 1994.
Medicare Unadjusted National allowances per gr
oup as below were effective October 1, 2002.
GROUP 1 -- $ 333.00
GROUP 2 -- $ 446.00
GROUP 3 -- $ 510.00
GROUP 4 -- $ 630.00
GROUP 6 -- $ 826.00
GROUP 7 -- $ 995.00
GROUP 8 -- $ 973.00
GROUP 9 -- $1339.00 (New)
GROUP 5 -- $ 717.00
Medicare Covered ASC Pain Management Procedures
Once an ASC is approved for Medicare participation, the ASC can only be reimbursed for procedures that are on a list of procedures that Medicare will reimburse to an ASC. Procedures on the list fall into one of 9 groupings with a payment rate assigned to each group. The payment group is determined by the CPT procedure rendered. The groups actually have no clinical coherence but were based on a cost analysis survey last performed by CMS in 1994.
Medicare Unadjusted National allowances per gr
oup as below were effective October 1, 2002.
GROUP 1 -- $ 333.00
GROUP 2 -- $ 446.00
GROUP 3 -- $ 510.00
GROUP 4 -- $ 630.00
GROUP 6 -- $ 826.00
GROUP 7 -- $ 995.00
GROUP 8 -- $ 973.00
GROUP 9 -- $1339.00 (New)
GROUP 5 -- $ 717.00
Medicare Covered ASC Pain Management Procedures
| CPT | DESCRIPTION | Group |
| 62311 | Epidural lumbar/sacral/caudal | 1 |
| 62310 | Epidural cervical/thoracic. | 1 |
| 62318 | Inject. Incl.cath placement, continuous cervical/thoracic | 1 |
| 62319 | Inject. Incl. Cath placement, continuous lumbar/sacral | 1 |
| 64410 | Phrenic Nerve | 1 |
| 64415 | Brachial Plexus | 1 |
| 64417 | Axillary Nerve Block | 1 |
| 64420 | Intercostal, single | 1 |
| 64421 | Intercostal, multiple | 1 |
| 64430 | Pudental Nerve | 1 |
| 64479 | Transforaminal, epidural cerv/thor, 1st level | 1 |
| 64480 | Transforaminal, epidural cerv/thor, ea. addt’l. | 1 |
| 64483 | Transforaminal epidural lumbar/sacral, 1st level | 1 |
| 64484 | Transforaminal epidural lumbar/sacral, ea. addt'l | 1 |
| 64475 | Facet, lumbar/sacral single | 1 |
| 64476 | Facet, lumbar/sacral addt’l | 1 |
| 64470 | Facet, cervical/thoracic single | 1 |
| 64472 | Facet, cervical/thoracic additional | 1 |
| 64510 | Stellate Ganglion | 1 |
| 64520 | Lumbar sympathetic | 1 |
| 64530 | Celiac Plexus | 1 |
| 62280 | Subarachnoid | 1 |
| G0260 | Inj for sacroiliac jt anesth * | 1 |
| 62282 | Epidural, lumbar/caudal | 1 |
| 64600 | Trigeminal Nerve, any | 1 |
| 62270 | Spinal puncture lumbar | 1 |
| 64620 | Intercostal: destruct | 1 |
| 64622 | Destruct Paravetebral Facet, lumbar single | 1 |
| 64623 | Destruct Paravetebral Facet, lumbar ea. addt’l | 1 |
| 64626 | Facet joint or facet joint nerve cerv/thor, 1st level | 1 |
| 64627 | Facet joint or facet joint nerve cerv/thor, ea. addt’l | 1 |
| 62263 | Percutaneous lysis of adhesions | 1 |
| 62273 | Blood Patch | 1 |
| 64680 | Celiac Plexus: destruct | 2 |
| 62350 | Implant Catheter | 2 |
| 62355 | Remove implanted catheter | 2* |
Billing spinal injection CPT 64470,64472,64475 AND 77003
Spinal Injections.
Injection procedures are billed in the same manner as all other surgical procedures with the following considerations:
1. For purposes of multiple procedure discounting, each procedure in a bilateral set is considered to be a single procedure.
2. For injection procedures which require the use of flouroscopic localization and guidance, ASCs may no longer bill separately for the technical component of the radiological CPT code (e.g., 77003 –TC ). Payment for these codes is bundled into payment for the primary procedure.
Example: Injection Procedures with flouroscopic guidance, Chicago, IL.
Line item CPT code Maximum Bilateral/Multiple Allowed
on bill modifier payment policies applied amount
1 64470–SG–50 $668.18 $1,002.27 $ 1,002.27(1,2)
2 64472–SG–50 $289.90 $434.85(3,4) $ 434.85
3 64475–SG $600.12 $300.06(5) $ 300.06
4 77003–TC $ 0.00(6) $ 0.00 $ 0.00
Total allowed amount $ 1,737.18(7)
1. Highest valued procedure is paid at 100% of maximum allowed amount.
2. Bilateral payment policy applies 150% multiplier to maximum allowed amount.
3. The multiple procedure payment policy is not applied in this case because 64472 is an add-on code to 64470.
4. When applying the bilateral procedure payment policy to a secondary line item billed with a modifier -50, the bilateral multiple is applied before the multiple procedure reduction if applicable for that line item.
5. When applying the multiple procedure payment policy, the secondary procedure max allowable is reduced by 50%.
6. Flouroscopic guidance is bundled into the primary procdure.
7. Represents total allowable amount
Exception: HCPCS Code G0260 cannot accept modifier -50 or any other multiple procedure modifier.
Injection procedures are billed in the same manner as all other surgical procedures with the following considerations:
1. For purposes of multiple procedure discounting, each procedure in a bilateral set is considered to be a single procedure.
2. For injection procedures which require the use of flouroscopic localization and guidance, ASCs may no longer bill separately for the technical component of the radiological CPT code (e.g., 77003 –TC ). Payment for these codes is bundled into payment for the primary procedure.
Example: Injection Procedures with flouroscopic guidance, Chicago, IL.
Line item CPT code Maximum Bilateral/Multiple Allowed
on bill modifier payment policies applied amount
1 64470–SG–50 $668.18 $1,002.27 $ 1,002.27(1,2)
2 64472–SG–50 $289.90 $434.85(3,4) $ 434.85
3 64475–SG $600.12 $300.06(5) $ 300.06
4 77003–TC $ 0.00(6) $ 0.00 $ 0.00
Total allowed amount $ 1,737.18(7)
1. Highest valued procedure is paid at 100% of maximum allowed amount.
2. Bilateral payment policy applies 150% multiplier to maximum allowed amount.
3. The multiple procedure payment policy is not applied in this case because 64472 is an add-on code to 64470.
4. When applying the bilateral procedure payment policy to a secondary line item billed with a modifier -50, the bilateral multiple is applied before the multiple procedure reduction if applicable for that line item.
5. When applying the multiple procedure payment policy, the secondary procedure max allowable is reduced by 50%.
6. Flouroscopic guidance is bundled into the primary procdure.
7. Represents total allowable amount
Exception: HCPCS Code G0260 cannot accept modifier -50 or any other multiple procedure modifier.
Billing Implanted Durable Medical Equipment
Implanted Durable Medical Equipment & Prosthetic Implants.
Implants must be billed on a separate line using the appropriate HCPCS code. Many implant items have maximum fees under the OWCP fee schedule and the appropriate HCPCS codes should be used. If no maximum allowable levels are set by the fee schedule, OWCP will pay acquisition cost for implants when the bill is accompanied by a copy of the original invoice clearly showing invoice cost less applicable discounts.
Exception: Intraocular Lenses.
Intraocular lenses, including new technology lenses, are bundled into the fee for the associated procedure. Please include the cost of the lens in the charge for the procedure. It is permissible to include a line on the bill with the HCPCS code for an intraocular lens (e.g., V2630, V2631 and V2632) and its associated cost for information purposes only.
Implants must be billed on a separate line using the appropriate HCPCS code. Many implant items have maximum fees under the OWCP fee schedule and the appropriate HCPCS codes should be used. If no maximum allowable levels are set by the fee schedule, OWCP will pay acquisition cost for implants when the bill is accompanied by a copy of the original invoice clearly showing invoice cost less applicable discounts.
Exception: Intraocular Lenses.
Intraocular lenses, including new technology lenses, are bundled into the fee for the associated procedure. Please include the cost of the lens in the charge for the procedure. It is permissible to include a line on the bill with the HCPCS code for an intraocular lens (e.g., V2630, V2631 and V2632) and its associated cost for information purposes only.
Monday, July 26, 2010
Modifiers required for ASC.
ASC Billing Information for OWCP
Modifiers required for ASC.
Modifier –SG must be appended as the first modifier to all surgical procedure codes (CPT/HCPCS) billed by an Ambulatory Surgery Center.
Modifiers accepted for ASC.
OWCP will accept all valid CPT and HCPCS modifiers, though only a few will affect payment.
Modifiers affecting payment for ASC.
Modifier -50, Bilateral modifier.
Modifier -50 identifies cases where a procedure typically performed on one side of the body is performed on both sides of the body during the same operative session. Providers must bill using a single line item for each procedure performed and append modifier -50 to indicate that a procedure was performed bilaterally. The bilateral procedure will be paid at 150% of the allowed amount for that procedure.
Example: Bilateral Procedure, Modifier -50, Chicago, IL.
Line item CPT code Maximum Bilateral policy Allowed
on bill modifier payment applied amount
1 64721–SG–50 $1,090.08 $1.635.12 $1,635.12
Total allowed amount $1,635.12
1. Bilateral procedure is paid at 150% of maximum allowed amount.
Modifier -51, Multiple surgerical procedures modifier, Chicago, IL.
Modifier -51 identifies when multiple surgeries are performed on the same patient at the same operative session. Providers must bill using separate line items for each procedure performed. Modifier -51 should be applied to the second and subsequent line items. The total payment equals the sum of
100% of the maximum allowable fee for the highest valued procedure according to the fee schedule, plus
50% of the maximum allowable fee for the subsequent procedures with the next highest values according to the fee schedule.
Example: Multiple Procedure, Modifier -51, Chicago, IL.
Line item CPT code Maximum Multiple procedures Allowed
on bill modifier payment policy applied amount
1 29881–SG $1,712.95 $1,712.95
2 64721–SG–51 $1,090.08 $545.04 $ 545.04
Total allowed amount $2,257.99
1. Highest valued procedure is paid at 100% of maximum allowed amount.
2. When applying the multiple procedure payment policy the secondary procedure billed with a modifier -51 is paid at 50% of the maximum allowed amount for that line item.
3. Represents sum of allowed amounts for line 1 + line 2.
If the same procedure is performed on multiple levels the provider must bill using the proper number of units to indicate the number of levels.
Modifier -73, Discontinued procedure prior to the administration of anesthesia.
Modifier -73 is used when a physician cancels a surgical procedure due to the onset of medical complications subsequent to the patient’s preparation, but prior to the administration of anesthesia. Payment will be at 50% of the maximum allowable fee. Multiple and bilateral procedure pricing will not apply.
Modifier -74, Discontinued procedure after administration of anesthesia.
Modifier -74 is used when a physician terminates a surgical procedure due to the onset of medical complications after the administration of anesthesia or after the procedure was started. Payment will be at 85% of the maximum allowable fee. Multiple and bilateral procedure pricing may apply to this if appropriate to the circumstances.
Modifiers required for ASC.
Modifier –SG must be appended as the first modifier to all surgical procedure codes (CPT/HCPCS) billed by an Ambulatory Surgery Center.
Modifiers accepted for ASC.
OWCP will accept all valid CPT and HCPCS modifiers, though only a few will affect payment.
Modifiers affecting payment for ASC.
Modifier -50, Bilateral modifier.
Modifier -50 identifies cases where a procedure typically performed on one side of the body is performed on both sides of the body during the same operative session. Providers must bill using a single line item for each procedure performed and append modifier -50 to indicate that a procedure was performed bilaterally. The bilateral procedure will be paid at 150% of the allowed amount for that procedure.
Example: Bilateral Procedure, Modifier -50, Chicago, IL.
Line item CPT code Maximum Bilateral policy Allowed
on bill modifier payment applied amount
1 64721–SG–50 $1,090.08 $1.635.12 $1,635.12
Total allowed amount $1,635.12
1. Bilateral procedure is paid at 150% of maximum allowed amount.
Modifier -51, Multiple surgerical procedures modifier, Chicago, IL.
Modifier -51 identifies when multiple surgeries are performed on the same patient at the same operative session. Providers must bill using separate line items for each procedure performed. Modifier -51 should be applied to the second and subsequent line items. The total payment equals the sum of
100% of the maximum allowable fee for the highest valued procedure according to the fee schedule, plus
50% of the maximum allowable fee for the subsequent procedures with the next highest values according to the fee schedule.
Example: Multiple Procedure, Modifier -51, Chicago, IL.
Line item CPT code Maximum Multiple procedures Allowed
on bill modifier payment policy applied amount
1 29881–SG $1,712.95 $1,712.95
2 64721–SG–51 $1,090.08 $545.04 $ 545.04
Total allowed amount $2,257.99
1. Highest valued procedure is paid at 100% of maximum allowed amount.
2. When applying the multiple procedure payment policy the secondary procedure billed with a modifier -51 is paid at 50% of the maximum allowed amount for that line item.
3. Represents sum of allowed amounts for line 1 + line 2.
If the same procedure is performed on multiple levels the provider must bill using the proper number of units to indicate the number of levels.
Modifier -73, Discontinued procedure prior to the administration of anesthesia.
Modifier -73 is used when a physician cancels a surgical procedure due to the onset of medical complications subsequent to the patient’s preparation, but prior to the administration of anesthesia. Payment will be at 50% of the maximum allowable fee. Multiple and bilateral procedure pricing will not apply.
Modifier -74, Discontinued procedure after administration of anesthesia.
Modifier -74 is used when a physician terminates a surgical procedure due to the onset of medical complications after the administration of anesthesia or after the procedure was started. Payment will be at 85% of the maximum allowable fee. Multiple and bilateral procedure pricing may apply to this if appropriate to the circumstances.
ASC Procedures Covered for Payment.
ASC Procedure Covered and Non covered payment in DOL (OWCP)
ASC Procedures Covered for Payment.
All procedures covered by OWCP in an ASC are listed in the list of surgical procedures allowable for facility fee payment to Ambulatory Surgical Center (file name: fs09asc_pymt_grp.xls) available online at:
http://www.dol.gov/esa/OWCP/regs/feeschedule/fee.htm
Note that inclusion in this list does not mean that a procedure is automatically payable. Prior authorization for elective procedures, appropriateness to the accepted condition and other program requirements must also be met.
ASC Procedures Not Covered for Payment.
Surgical procedures that are not included in the list of surgical procedures allowable for facility fee payment to Ambulatory Surgical Center are not covered in an ASC setting. This list does not include procedures that are currently performed on an ambulatory basis in a physician’s office and that do not generally require the more elaborate facilities of an ASC. Neither does the list include procedures that are appropriately performed in an inpatient hospital setting but would not be safely performed in an ASC. We recognize that there are some procedures that might be appropriately performed in ASC for the younger patient who is generally healthy. But for the larger number of OWCP beneficiaries whose health is more likely to be compromised by disability and age, an ASC may be a questionable setting for those same procedures. Therefore, we are including in the list only those procedures that can be safely performed in an ASC on the general OWCP population in at least a significant number of cases. The resulting list of procedures allows ASCs to furnish OWCP beneficiaries with a broad range of surgical services that reflect the practice of contemporary surgery without compromising patient safety.
ASC Procedures Covered for Payment.
All procedures covered by OWCP in an ASC are listed in the list of surgical procedures allowable for facility fee payment to Ambulatory Surgical Center (file name: fs09asc_pymt_grp.xls) available online at:
http://www.dol.gov/esa/OWCP/regs/feeschedule/fee.htm
Note that inclusion in this list does not mean that a procedure is automatically payable. Prior authorization for elective procedures, appropriateness to the accepted condition and other program requirements must also be met.
ASC Procedures Not Covered for Payment.
Surgical procedures that are not included in the list of surgical procedures allowable for facility fee payment to Ambulatory Surgical Center are not covered in an ASC setting. This list does not include procedures that are currently performed on an ambulatory basis in a physician’s office and that do not generally require the more elaborate facilities of an ASC. Neither does the list include procedures that are appropriately performed in an inpatient hospital setting but would not be safely performed in an ASC. We recognize that there are some procedures that might be appropriately performed in ASC for the younger patient who is generally healthy. But for the larger number of OWCP beneficiaries whose health is more likely to be compromised by disability and age, an ASC may be a questionable setting for those same procedures. Therefore, we are including in the list only those procedures that can be safely performed in an ASC on the general OWCP population in at least a significant number of cases. The resulting list of procedures allows ASCs to furnish OWCP beneficiaries with a broad range of surgical services that reflect the practice of contemporary surgery without compromising patient safety.
ASC Services Not Included in the Facility Payment.
Facility payments for ASCs do not include the following services which may be paid separately:
• Professional services including physicians;
• Laboratory services;
• X-ray or diagnostic procedures other than those directly related to the performance of the surgical procedure;
• Prosthetics and implants except intraocular lenses;
• Ambulance services;
• Leg, arm, back and neck braces;
• Artificial limbs; and
• DME for use in the patient’s home.
ASC SERVICE LIST INCLUDED IN FACILITY PAYMENT
ASC services included and non included in Facility payment- DOL
ASC Services Included in the Facility Payment.
Facility payments for ASCs include the following services which are not paid separately:
• Nursing services, services of technical personnel, and other related services;
• Use by the patient of ASC facilities including the operating room and the recovery room;
• Drugs, including take-home medications, biologicals, surgical dressings, supplies, splints, casts, appliances and equipment directly related to the surgical procedure;
• Diagnostic or therapeutic items and services directly related to the surgical procedure (including simple preoperative laboratory tests, e.g., urinalysis, blood hemoglobin or hematocrit);
• Administrative, record keeping and housekeeping items and services;
• Blood, blood plasma, platelets, etc.;
• Materials for anesthesia; and
• Intraocular lenses (IOLs).
ASC Services Included in the Facility Payment.
Facility payments for ASCs include the following services which are not paid separately:
• Nursing services, services of technical personnel, and other related services;
• Use by the patient of ASC facilities including the operating room and the recovery room;
• Drugs, including take-home medications, biologicals, surgical dressings, supplies, splints, casts, appliances and equipment directly related to the surgical procedure;
• Diagnostic or therapeutic items and services directly related to the surgical procedure (including simple preoperative laboratory tests, e.g., urinalysis, blood hemoglobin or hematocrit);
• Administrative, record keeping and housekeeping items and services;
• Blood, blood plasma, platelets, etc.;
• Materials for anesthesia; and
• Intraocular lenses (IOLs).
OWCP ASC payment
Payment Policy for ASC Services in the Facility Payment.
OWCP pays the lesser of the billed charge (the ASC’s usual and customary fee) or the maximum allowed rate. The base maximum allowable rate for any ASC surgical procedure is 200% of the maximum allowable rate for physician’s professional charge as determined from RVU and conversion factor values associated with each HCPCS code, and from GPCI values associated with site of service.
State waiver: Ambulatory surgery services provided in a hospital-based ambulatory surgical center in Maryland are exempt from this section. The Maryland Health Services Cost Review Commission establishes rates for hospital-based ambulatory surgery services in Maryland. Since Maryland hospitals are required to bill these rates, reimbursement for ambulatory services is to be based on the billed charge. Freestanding non-hospital based ambulatory surgical centers in the state of Maryland are not covered under the Maryland state waiver for hospital inpatient, hospital outpatient and hospital-based ambulatory surgical centers.
Monday, July 19, 2010
Revenue Code List 0254 to 0400
| REVENUE CODE | DESCRIPTION |
| 0254 | DRUGS/OTHER DX |
| 0255 | DRUGS INCIDENT/RADIOLOGY |
| 0260 | IV THERAPY |
| 0261 | IV THER/INFSN PUMP |
| 0262 | IV THERAPY/PHARMACY SVCS |
| 0263 | IV THERAPY/RX/SUPPLY DEL |
| 0264 | IV THERAPY/SUPPLIES |
| 0269 | IV THERAPY/OTHER |
| 0273 | TAKEHOME SUPPLY |
| 0274 | PROSTHETIC DEV |
| 0276 | INTRAOCULAR LENS |
| 0290 | MED EQUIP/DURAB |
| 0291 | MED EQUIP/RENT |
| 0292 | MED EQUIP/NEW |
| 0293 | MED EQUIP/USED |
| 0294 | SUPPLIES EFFECTIVE (HHA) |
| 0299 | MED EQUIP/OTHER |
| 0300 | LABORATORY OR LAB |
| 0301 | LAB/CHEMISTRY |
| 0302 | LAB/IMMUNOLOGY |
| 0303 | LAB/RENAL HOME |
| 0304 | LAB/NR DIALYSIS |
| 0305 | LAB/HEMOTOLOGY |
| 0306 | LAB/BACT-MICRO |
| 0307 | LAB/UROLOGY |
| 0309 | LAB/OTHER |
| 0310 | PATHOLOGY LAB OR PATH LA |
| 0311 | PATHOL/CYTOLOGY |
| 0312 | PATHOL/HYSTOL |
| 0314 | PATHOL/BIOPSY |
| 0319 | PATHOL/OTHER |
| 0320 | DX X-RAY |
| 0321 | DX X-RAY/ANGIO |
| 0322 | ARTHROGRAPHY |
| 0323 | ARTERIOGRAPHY |
| 0324 | DX X-RAY/CHEST |
| 0329 | DX X-RAY/OTHER |
| 0330 | RX X-RAY |
| 0331 | CHEMOTHER/INJ |
| 0332 | CHEMOTHER/ORAL |
| 0333 | RADIATION/RX |
| 0335 | CHEMOTHERP-IV |
| 0339 | RX X-RAY/OTHER |
| 0340 | NUCLEAR MED OR (NUC MED) |
| 0341 | NUC MED/DX |
| 0342 | NUC MED/RX |
| 0343 | NUC MED/DX RADIOPHARM |
| 0344 | NUC MED /RX RADIOPHARM |
| 0349 | NUC MED/OTHER |
| 0350 | CT SCAN |
| 0351 | CT SCAN/HEAD |
| 0352 | CT SCAN/BODY |
| 0359 | CT SCAN/OTHER |
| 0360 | OR SERVICES |
| 0361 | OR/MINOR |
| 0362 | OR/ORGAN TRANS |
| 0367 | OR/KIDNEY TRANS |
| 0369 | OR/OTHER |
| 0380 | BLOOD |
| 0381 | BLOOD/PKD RED |
| 0382 | BLOOD/WHOLE |
| 0383 | BLOOD/PLASMA |
| 0384 | BLOOD/PLATELETS |
| 0385 | BLOOD/LEUCOCYTES |
| 0386 | BLOOD/COMPONENTS |
| 0387 | BLOOD/DERIVATIVES |
| 0389 | BLOOD/OTHER |
| 0390 | BLOOD/STOR-PROC |
| 0391 | BLOOD/ADMIN |
| 0399 | BLOOD/OTHER STOR |
| 0400 | IMAGE SERVICE |
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