Medicare Compliance & Reimbursement

True or false: Modifier SG only applies to the ASC facility side, and not the physician side.

The answer is true -- and if you got that one right, you're on your way to ASC reimbursement bliss.

Last week, CMS issued its quarterly update to the ASC Payment System, which includes HCPCS codes, modifiers, drugs and supplies that are payable for ASCs effective April 1.

With so many changes affecting ASCs this year, it's enough to make your head spin -- but despite all of the changes, some aspects of ASC reimbursement have remained the same.

1. Know where to find ASC-allowed services. CMS maintains a very specific list of codes payable for ASCs, but if you don't know how to access the list, you could be flying blind when it comes to reimbursement.

Resource: You can download the most recent ASC-allowable codes at http://www.cms.hhs.gov/ASCPayment/, which includes not only the current quarter (which began on April 1), but also any previous quarters in case you're battling older claims.

2. Remember the "same-day global" rule. Every procedure the ASC bills has a "same-day" global period. This makes sense because the ASC is not reporting physician work services -- only facility fees. This applies to the coder working for the ASC, but not the physician who performed the service.

For instance, if a patient experiences postoperative bleeding and the physician must return the patient to the ASC for control of bleeding on the same day, both the physician's coder and the ASC's coder should report the appropriate control-of-bleeding code appended with modifier 78 (Return to the operating room for a related procedure during the postoperative period) because the procedure occurred within the "same-day" global period for the ASC.

If, however, the physician returned the patient to the ASC the day after the initial surgery, the ASC coder would report the appropriate control-of-bleeding code with no modifier. For the ASC's purposes, the initial surgery's global period has expired, even though the surgery includes a 90-day global period for physician services.

On the other hand, the surgeon's coder would report the bleeding-control code with modifier 78 appended because the physician's services follow the standard global rule.

Takeaway: The ASC coder should follow the "same-day" global rule, but the physician's coder should follow standard global period rules from the fee schedule, says Annette Grady, CPC, CPC-H, CPC-P, senior orthopedic coder and compliance auditor for the Coding Network.

3. Properly append modifier SG. When the ASC coder bills Medicare for any service performed in the ASC, he must list modifier SG (ASC facility service) as the first modifier on the claim. And if you're an ASC coder, remember to append modifier SG to every code listed on the claim, not just the first code.

For example, the surgeon performs a modified McBride bunionectomy (28292) on the left great toe and performs a hammertoe correction (28285) on the left fourth toe in the ASC.

The ASC coder should report 28285-SG-T3 as the first procedure (because the hammertoe correction is an ASC grouper of "3," which pays more), and the bunionectomy second (with a grouper of "2") as 28292-SG-TA-59 (Distinct procedural service).

The surgical coder will report 28292-TA as the primary code (due to 28292's higher relative value), followed by 28285-T3-59.

4. Discontinued coding modifiers may differ. ASC coders may occasionally use modifier 52 (Reduced services) but won't use modifier 53 (Discontinued procedure). Instead, insurers usually require ASC coders to use modifiers 73 (Discontinued outpatient procedure prior to anesthesia administration) or 74 (Discontinued outpatient procedure after anesthesia administration), as appropriate.

5. Keep in contact with the ASC. One mistake that can kill your reimbursement is when the physician and the ASC report different codes for the same procedure. Because the physician and ASC should report the same codes for each surgery, any coding discrepancies should be ironed out before the claim is submitted, says Allison Tangieleski with Tangieleski Billing in Deer Park, NY.