Gastroenterology Coding Alert

Learn whether to place modifier SG first -- or last

If you're a gastroenterology coder and dipping your toe into ambulatory surgery center (ASC) coding, then you know that ASCs present unique challenges. You've got questions -- and we've got expert answers to help make certain your claims are picture perfect.

1.  Watch Out for Non-Approved ASC Services

Question: I know that Medicare 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 the ASC's portion?

Answer: 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, says Annette Grady, CPC, CPC-H, CPC-P, OS, an independent healthcare consultant  and American Academy of Professional Coders professional medical coding curriculum instructor and workshop educator.

When the service is not covered in an ASC, Medicare will make no facility payment, but the physician can still collect for his portion of the surgery. If the physician chooses to perform a service not on the approved ASC listing, the ASC should make arrangements with that physician for reimbursement because Medicare pays the physician the ASC's portion of the payment. Many ASCs use the difference between the hospital facility and the nonfacility reimbursement and then bill that amount to the physician. 

Best practice: If this occurs, you should ask the physician to sign a document stating he understands that the procedure is not on the ASC list and that he will be responsible for reimbursing the ASC the difference between the hospital facility and nonfacility reimbursement, Grady says.

2. Coordinate Joint ASC and Practice Codes

Question: When a physician owns both the ASC and practice in the same building and performs a colonoscopy, I have to bill for his services and also for the facility services. We also bill for the anesthesia times and medications. We use a CMS-1500 form for the physician's service and anesthesia and UB92 claim form for the facility, but should I use the same codes for all?

Answer: You would use the same codes for both the physician and the ASC, says Margaret Fischer, CCS-P, ACS-GI, business office manager for Tacoma Digestive Disease Center in Wash. This includes both CPT and ICD-9 codes.

Keep in mind: You should remember that almost all GI procedure codes include anesthesia services, and all the ASC facility claims include the cost of medications. "We put modifier SG (ASC facility service) on our ASC claims, so the carrier knows they are facility. Only one of our payers requires us to use a UB92; we bill all the rest on a CMS," Fisher adds.

3. You May Not Need Modifiers 78, 79

Question: 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) on them. Should we appeal?

Answer: "An individual payer has the right to deny a claim if it is within their guidelines to do so, and with many self-insured plans out there, the guidelines vary greatly regarding this issue," says Stephanie Ellis, RN, CPC, owner of Ellis Medical Consulting Inc. in Brentwood, Tenn.

For gastroenterologists, almost all the codes billed have zero global days for the professional portion. Therefore, ASC coders will rarely need to use modifiers 78 or 79. One of the unusual cases when you would 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 the physician. 

The physician returned the patient to the OR to stop the hemorrhage. "That is usually the only time that one of these modifiers would be needed," Ellis says. "If the patient goes back into the OR at the same ASC for a procedure the following day and it is past 24 hours since the ending of the first procedure performed the day before, the ASC does not need to append modifiers 78 or 79 to their claim.
 
4. Don't Rely on All Physician Code Selections

Question: Our ASC requires the gastroenterologist to dictate his CPT codes directly into the operative report. They tell us that this way, the physician and the ASC are sure to report the same code as one another. But in my experience, I find that our physician doesn't always select the correct code, so I'm uneasy about this. Should we follow the ASC's advice?

Answer: The coder shouldn't blindly trust the physician's coding recommendations without also reading the note to confirm the code choices. 

"The coder will still have to read the report and assign codes based on what is documented, and not what codes are dictated," says Lisa Weston, CPC-H, LHRM, director of ambulatory surgery coding services for The Coding Network LLC. 

Because the ASC and the physician must report the same code, relying solely on the physician's code selection can be unsafe. 

If the physician is knowledgeable about coding, having him dictate his codes into the report might be a good idea because only he knows exactly what he performed, says Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of gastroenterology in Ann Arbor. "But the coder should still read the dictation to make sure the physician coded properly, almost like an informal internal audit," he says. 

"If there is a difference of opinion, the coder should contact the physician to discuss the code choice. The physician should never make the coder feel uncomfortable if the coder wants to discuss the appropriateness of the code submitted," Koopmann says.

Tip: Coordinate your billing and coding choices to ensure that both the ASC and physician report accurate and matching codes.

5. Properly Append Modifier SG

Question: I know that when I bill from the ASC side, I must append modifier SG. But does this go on the first code, second code, last code, etc.?

Answer: When you bill Medicare for any service that your physician performs in an ASC, you must list modifier SG as the first modifier on the claim, Grady says. For instance, if the code should have modifier 22 (Unusual procedural services) attached to it, you should first append modifier SG, followed by modifier 22.

And remember to append modifier SG to every code listed on the claim, not just the first code.