Ophthalmology and Optometry Coding Alert

This year is a year of change when it comes to ASC coding, but some coding rules have stayed the same. Reinforce your ASC knowledge with these five tips.

CMS will pay for an additional 790 procedures performed in ASCs in 2008, including more than 60 that apply to ophthalmology. For example, in 2008 you'll be able to bill Medicare when your surgeon removes a foreign body from the eye (65205-65222), performs strabismus surgery (67345), or excises or destroys a conjunctival lesion (68110, 68135) in an ASC.

Go online: To review the full list of surgeries added to the ASC list, visit the Federated Ambulatory Surgery Association (FASA) Web site http://www.fasa.org/additions.pdf.

Medicare also keeps the full list of allowable ASC procedures on its Web site, according to the year that the physician performed the service. Visit the CMS site http://www.cms.hhs.gov/ASCPayment/ for the full list of ASC-allowed procedures.

Every procedure billed by the ASC 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 assigning codes for the ASC, but not the coder who assigns codes for the physician who performed the service.

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

But if 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 attached. 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 ophthalmologist's coder would report the bleeding-control code with modifier 78 appended because the physician's services still fall within the global period.

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.

If you're coding for the ASC, you must list modifier SG (ASC facility service) as the first modifier on the claim when reporting to Medicare for any service performed in the ASC. And remember to append modifier SG to every code listed on the claim, not just the first code.

ASC coders may occasionally use modifier 52 (Reduced services) but won't use modifier 53 (Discontinued procedure). Instead, insurers usually require ASC coders to call on modifiers 73 (Discontinued outpatient procedure prior to anesthesia administration) or 74 (Discontinued outpatient procedure after anesthesia administration), as appropriate, says Becky Kincher, coder for Eye Center of North Colorado in Fort Collins.

Although CMS' recent announcement of proposed 2008 ASC changes has shaken ASC coders across the country, the jury is still out on whether the new rules will harm ophthalmology coders.

"I am somewhat unsure at this point" whether this will be a good or bad change for ophthalmologists, Kincher says. "The phase-in periods for the increases in reimbursement are slow, so we will see decreases before we see increases."

"The chatter in the coding community is back and forth on this," says Chris Felthauser, CPC, CPC-H, ACS-OH, ACS-OR, an independent coding consultant in Eugene, Ore. Whether the changes will affect your bottom line depends on your case mix, he says. "The best thing to do is to look at each practice. I've been taking the surgeon's case mixes and dropping them into a spreadsheet and then loading the fees, current grouper rates, new grouper rates, etc., into that sheet." But it may be too soon to tell how strongly this will affect physicians, he says.