Otolaryngology Coding Alert

Get to know modifier SG when you bill for an ASC

Any otolaryngology coder who has suddenly been led into the world of ambulatory surgery center coding knows that ASCs present unique challenges. If you code for an ambulatory surgical center but you still find yourself puzzled by ASC coding rules, review the following four FAQs to get the lowdown.

1.  Remember to Coordinate Coding With Physician

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 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, director of education at Coding MetriX Inc., and an officer on the AAPC National Advisory Board. 

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 since Medicare pays the physician the ASC's portion of the payment. Many ASCs use the difference between the  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 facility and nonfacility reimbursement, Grady says.

2. 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.
 
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 of the unusual cases when you-d 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 surgeon.
 
The surgeon 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.
 
-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.

3. Don't Rely on All Physician Code Selections

Question: Our ASC requires the otolaryngologist 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. But in my experience, I find that our surgeon 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 surgeon must report the same code, it can be unsafe to rely solely on the surgeon's code selection.
 
If the surgeon is knowledgeable about coding, it might be a good idea for him to dictate his codes into the report 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 otolaryngology in Ann Arbor. -But the coder should still read the dictation to make sure the surgeon 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 surgeon 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 are reporting accurate and matching codes.
 
4. 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 surgeon performs in an ASC, you must list modifier SG (ASC facility service) 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.