Otolaryngology Coding Alert

Your practice might be able to benefit financially from moving certain office or hospital procedures to an ambulatory surgical center (ASC).

Although most otolaryngology coders mainly deal with outpatient and inpatient services, you might sometimes code for ENT surgeries performed in an ASC, making this location's unique coding rules important to you. For instance, "Action Medical bills for three surgery centers," says one of its billing specialists in Irvine, Calif. And while BergerHenry ENT Specialty Group's five-physician, five-office, five-facility practice performs the majority of its procedures in the outpatient setting, it uses one ASC, says Ginny McManus, billing manager for the New Jersey practice.

News: 2008 marks a world of change to the ASC coding and payment system. CMS added 790 procedures to the ASC-approved list. Identify your top relocation candidates after getting acquainted with these basics.

CMS used to indicate which surgeries it would pay for performing in an ASC (place-of-service code 24) with a list of included codes. In 2008, the payment system is instead exclusionary-based.

Medicare chose specific criteria for which it will exclude a procedure from eligibility for ASC performance, says Susan Garrison, PCS, FCS, CCS-P, CHC, CPC, CPC-H, CPAR, executive vice president of Magnus Confidential Inc. in Atlanta. "CMS will exclude a procedure from the ASC list if the procedure:

- poses a significant safety risk to the beneficiary

- would result in the patient usually requiring active medical monitoring and care after midnight following the procedure

- is on the inpatient-only list

- directly involves major blood vessels

- requires major or prolonged invasion of body cavities

- generally results in extensive blood loss

- is emergent in nature

- is life-threatening in nature

- commonly requires thrombolytic therapy

- can only be reported using an unlisted surgical procedure code."

The hospital Outpatient Prospective Payment System (OPPS) will serve as the basis for the new ASC reimbursement system. Both outpatient hospitals (POS 22) and ASCs "will be paid under Ambulatory Payment Classifications (APC), but with different allowed amounts than hospital outpatients," Garrison says. CMS will pay an ASC-performed surgical procedure about 67 percent of the OPPS rate.

The reduction makes sense. Hospital outpatient departments have higher operating costs than ASCs, says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, executive officer of the American Academy of Professional Coder's National Advisory Board. Hospital outpatient facilities have to incur additional costs, such as providing 24-hour operations and enduring more intense monitoring with certification issues. Plus, "they have more acute type care available and are required to treat patients that do not have insurance," she says.

You can easily spot a code that's new to the ASC- allowed list using the ASC fee schedule. Look at the column marked "CY 2007 ASC Payment Rate" on the ASC fee schedule. "This column will show all approved ASC procedures during the calendar year 2007," Garrison says. Codes that don't have a figure in this box are newly eligible for ASC performance.

Scan the list for empty boxes. "It's useful to compare which codes are added for 2008," Garrison says. You can identify procedures that your otolaryngologist can now perform and receive carrier payment for in an ASC.

The final three boxes of the fee schedule show estimated weights and payments. The new payment system rates will be phased in over four years. So to find out how much a code will pay in the ASC in 2008, look at the final column, "Estimated CY 2008 First Transition Year Payment."

The change to an exclusionary list opens the door to physicians performing numerous office-based procedures in ASCs. About two-thirds of the added ASC-approved procedures were excluded prior to Jan. 1, 2008, because CMS allowed physicians to perform them only in the office (POS 11). "It's kind of a positive," Grady says. The move "will bring back some of the minor procedures again to that ASC setting."

Case: Nasal incision and excision procedures 30000-30110 would normally be completed in an office setting, so CMS would previously deny payment for these procedures in an ASC. But in 2008, carriers will allow payment for these codes in POS 24.

Payment, however, will remain higher for these procedures in the office. Code 30110 (Excision, nasal polyp[s], simple) pays about $213 in the office compared to an ASC national rate of $118.

Your evaluation won't be accurate unless you look at one final factor: the payment indicator (fourth column).

Some to watch for:

- K2 -- drugs and biologicals paid separately -

- N1 -- not paid separately and included in another procedure.

Example 1: You can bill for stereotactic computer use in an ASC in 2008, just as you could in 2007. Code +61795 (Stereotactic computer-assisted volumetric [navigational] procedure, intracranial, extracranial, or spinal [list separately in addition to code for primary procedure]) has a payment indicator of A2 (Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight). CMS also won't subject the code to a multiple- procedure reduction (column 1), which follows the AMA's designation of 61795 an add-on code.

Example 2: In an ASC, you will never be able to bill microsurgery. CMS assigned +69990 (Microsurgical techniques ...) a payment indicator of N1 (Packaged service/item; no separate payment made), meaning the surgical procedure always includes the microdissection.

This isn't much of a surprise. Code 69990 tends to be bundled into most ENT codes, regardless of location.

But the payment rate isn't the end of the equation. You have to consider other factors to determine if moving an office procedure to an ASC is in your financial interest.

Here's how: Zoom in on 37 common office-based ENT codes that CMS just made ASC eligible. "Look at the cost of performing these in the office versus the ASC," Garrison says. To make the decision for appropriate place of service, ask questions such as, "Is there overhead that wouldn't be necessary if the ENTs didn't perform these?"

It's easy: Check out Garrison's list including the details you need to get started: