Are you a gold-star ASC coder?
Some practices code for services performed in ambulatory surgery centers (ASCs) every day, while others are just getting started. To determine how much you know about coding and billing for ASC procedures, take this quick quiz. Then, click the ‘Full Article’ button to find out how you fared.
Question 1: Physician Performed A Non-Approved Service?
We recently learned that our Medicare payer will deny the ASC’s charges for any procedures that aren’t on the ASC’s list of approved services, but what happens if the physician performs a nonapproved service anyway? How can we collect for our portion of the charges?
Hint: For a list of CMS-approved ASC procedures, visit here.
Question 2: Do You Need Modifiers 78, 79?
I code for an ASC, and my payer won’t reimburse me for claims with modifiers 78 (Return to the operating room for a related procedure during the postoperative period) and/or 79 (Unrelated procedure or service by the same physician during the postoperative period) appended to them. Should we appeal?
Question 3: Should You Rely on All Physician Code Selections?
Our ASC requires the physician to dictate his CPT codes directly into the operative report. They tell us that this way, the surgeon and the ASC are sure to report the same code as one another.
But in my experience, I find that our surgeon doesn’t always select the correct code, so I’m uneasy about this. Should we follow the ASC’s advice and have the physician select the codes, or is there another way that our codes can match the ASC-billed codes?
Question 4: How Do We Append Modifier SG?
I know that when I bill services performed in an ASC, I must append modifier SG (ASC facility service) to the CPT code. But does this go on the first code, second code, last code, etc.?
Ready to check your work? Press ‘full article’ & tally your score.
Question 1: Physician Performed A Non- Approved Service?
Answer 1: Occasionally, the physician will perform a procedure in the ASC that Medicare does not include on its list of approved ASC services. The ASC cannot ask the patient to sign an advance beneficiary notice (ABN) for a service that is not on the approved list, nor can the ASC bill the Medicare patient for any unpaid balance. However, the physician can still collect.
“When physicians perform procedures not on the Medicare-approved ASC list, they are reimbursed at the higher – practice expense RVU rate,” says Deb Bridges, CPC-H, with University Suburban Health Center in South Euclid, Ohio. “CMS stated in Transmittal B-01-43 that any ASC-performed procedure is payable.
Under those circumstances, physicians are paid at a higher rate and the ASC is deemed as the physician’s office,” she advises.
Good news: “Since the transition to the new payment system, it is hard to find a procedure that isn’t allowed in the ASC,” Bridges says. “We rarely, if ever, have that problem anymore.”
Question 2: Do You Need Modifiers 78, 79?
Answer 2: The ASC’s global period for all procedures performed in the facility is 24 hours. Most of the procedures performed in ASCs have a global period of 10 or 90 days, but that global period applies to the operating physician’s claims — not the facility’s claims.
Therefore, ASC coders will rarely need to use modifiers 78 or 79. One of the unusual cases when you’d use these modifiers would be if a patient underwent a procedure in the ASC and went home to rest. While recovering that afternoon, the patient started to hemorrhage and called thesurgeon.
The surgeon returned the patient to the OR to stop the hemorrhage. If the patient went back into the OR at the same ASC for a procedure thefollowing day and it was past 24 hours since the ending of the first procedure performed the day before, the ASC does not need to appendmodifiers 78 or 79 to their claim.
Question 3: Should You Rely on All Physician Code Selections?
Answer 3: The coder shouldn’t blindly trust the physician’s coding recommendations without also reading the note to confirm the code choices.
“We do have one dictation system that allows the physicians to dictate the CPT codes, but we ignore the physician codes and code based onwhat is actually documented in the operative record,” says Margaret T. Atkinson, BS, CPC, RMC, business manager with Centennial SurgeryCenter in Vorhees, N.J. “As coders, we know that the actual body of the note must support the CPT codes and most surgeons are not savvy or up to date on coding rules and guidelines.”
Tip: “Our ASC receives the operative note a bit earlier than the physician’s offices,” Atkinson says. “Therefore, we code the note for them (including physician modifiers) and fax it back to them for billing. It is a perk for them to schedule the cases here since the coding is done for them. It saves their staff time and money in the long run. As for the benefit to the ASC, we are assured that there will be no reason for the payer to delay payment for coding issues since we will all be on the same page.”
Question 4: How Do We Append Modifier SG?
Answer 4: When you bill Medicare for any service that your surgeon performs in an ASC, you no longer need to append modifier SG (ASC facility service) on the claim.
“Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services,” according to CMS Transmittal 1410.
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