Avoid Technical Traps When Billing APCs

By Caral Edelberg, CPC, CCS-P

Now that ambulatory payment classifications (APCs) are actually under way, many nuances of APC billing seem difficult, if not impossible, depending upon the type of software used and the configuration of the coding and billing departments. But a few reminders about some of the technical traps that exist in the billing arena will help you avoid reimbursement problems.

Condition Code G0

Condition codes allow us to bend the rules a bit when appropriate. In the case of G0, it is used when two or more distinct and unrelated patient visits are made within one revenue center on a calendar day, and you want to get paid for each. (Health Care Financing Administration [HCFA] edits prevent payment for multiple, related visits on the same calendar day.)

When multiple visits occur, you are required to enter the number of visits in the Units field on the claim. Units greater than one for the evaluation and management (E/M) visit codes will be rejected without the G0 condition code.

One of the major issues with this code relates to who will be responsible for assigning it in the transition of the claim from coding to billing, as it is foreseeable that the same coder may not code each visit. Although software edits may help, the soft coding (coding performed by an individual and not the charge master) must determine the accurate application of the G0 only after review of each record to ensure that each visit is indeed separate and distinct.

Using Modifier -25

Outpatient areas may bill a nursing/facility assessment level in addition to a procedure only when the E/M level is significant and separately identifiable. At this time, HCFA has provided no clarification of what conditions constitute significant and separately identifiable.

But HCFA edits tell us that without the -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to an E/M level identified in addition to a procedure, no payment for the E/M will be made. Therefore, until more information is obtained, each facility should develop uniform criteria for identifying E/M levels in addition to procedures.

Observation Services

Although no separate payment for outpatient observation will be made under APCs, HCFA requests that this service be reported with revenue code 762 for codes 99217-99220.

After tracking use of this code following implementation of APCs, HCFA has said that it will consider assigning observation its own APC. Therefore, reporting the service will be essential to help HCFA realize the importance of the code, and to get your coders in shape for when Medicare might pay it.

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- Published on 2000-10-01