Orthopedic Coding Alert

You-ve learned the basics, now master ASC Coding

If you code for an ambulatory surgical center but still find yourself puzzled by ASC coding rules, review the following two FAQs to get the lowdown.

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) or 79 (Unrelated procedure or service by the same physician during the postoperative period). 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.
 
Most important issue: -The ASC's global period for all procedures performed in the facility is 24 hours,- Ellis says. -Most of the procedures performed in ASCs have a global period of 10 or 90 days defined, which is the global period for the operating physician's claims -- not the facility's claims.-
 
Therefore, ASC coders will rarely need to use modifiers 78 or 79. One situation when you would use these modifiers is if a patient underwent a procedure in the ASC and then went to the recovery room. While in recovery, the patient started to hemorrhage and the surgeon returned the patient to the OR to stop the hemorrhage on the same day.
 
-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 subsequent 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 use modifiers 78 or 79 on their claim.
 
-If the patient was taken back to the OR at the same ASC for a procedure within the 24-hour period after the first procedure was performed, and the ASC used the 78 or 79 modifier and still had the claim denied, I would advise the ASC to pursue vigorous appeal procedures,- Ellis says.

Don't Rely on All Physician Code Selections

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

Answer: -I don't think this is a good idea for many reasons,- says Lisa Weston, CPC-H, LHRM, director of ambulatory surgery coding services for The Coding Network LLC. -The coder will still have to read the report and assign codes based on what is documented and not by the codes that were dictated.-
 
Because the ASC and the surgeon must report the same code, it can be unsafe to rely solely on the surgeon's code selection.
 
The problem: The surgeon's office might report the code that the surgeon dictates, while the ASC should bill based on a coder's analysis of the documentation. They may be different, which means that the ASC and surgeon's office will each bill different codes for the same operation. In those cases, the insurance carrier may deny payment to the ASC (or the surgeon).
 
Don't give up and change the codes to match just to get paid and avoid a denial. This could inadvertently create either compliance exposure or revenue issues for your ASC and its owners.
 
First, talk to the surgeon or the surgeon's office and explain the reasoning behind your code selection. Second, appeal to the insurance company by submitting the operative report with a detailed explanation of the coding and why it is appropriate, Weston says.
 
Best bet: You must base your codes on the documentation and coding guidelines. Coordinate billing and coding choices between the ASC and the surgeon to ensure that both report accurate and matching codes.