Orthopedic Coding Alert

If you-re new to surgery center coding, make modifier SG your friend Any orthopedic coder who has suddenly been led into the world of ambulatory surgery center coding knows that ASCs present unique challenges. The answers to your ASC coding questions can be hard to find, but you can increase your coding accuracy if you break down  ASC coding into a few simple rules. Rule: Find Out What Qualifies as an ASC An ASC is a freestanding facility, other than a physician's office, in which surgical and diagnostic services are provided on an ambulatory basis. Most physicians today work out of a -freestanding- ASC facility, and many have partial or complete ownership. ASCs are very advantageous to patients and generally provide a great cost-effective and quality service.  Typically, an ASC procedure will not exceed 90 minutes and does not require more than four hours of recovery or convalescent time.
 
Insurance payment methodologies vary greatly in the ASC setting, and some basic differences are these:
 
Medicare (CMS) bases its payment on nine payment groups for the ASC, whereas it bases payment to the outpatient hospital surgery center on the Ambulatory Payment Classification (APC). Payment can differ dramatically depending on where the physician performs the surgery.
 
Historically, the payment data come from different sources. Outpatient hospital payment is based on utilization of resources and costs, and it generally costs the outpatient hospital more to provide a service than an ASC freestanding center. The Paperwork Shuffle Another difference is that CMS requires ASCs to submit a CMS-1500 form, but CMS requires outpatient hospitals to use the UB92. Be aware that many commercial payers request the UB92 claim form for ASCs, so you need to have knowledge and a software system that can handle both types of claims.
 
CMS reimburses ASCs using nine national payment rates, which are then adjusted using a local carrier wage index. For information on the nine payment rates and the wage indexes, visit the CMS Web site at www.cms.hhs.gov/Transmittals/Downloads/AB03116.pdf.

Rule: List Modifier SG First When the ASC bills Medicare, the ASC coder should list the place of service (POS) as -24- on the CMS-1500 form. The ASC must submit the claim as -assigned,- and CMS will deny any services that are not on Medicare's approved list of payable ASC services.
 
Physicians may submit their professional services as either assigned or unassigned, but the ASC must submit assigned claims only.
 
Remember: 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. When the service is not covered in an ASC, Medicare will make no facility payment, but the physician [...]