Billing Office Visit in ASC

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erina586

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Hello I recently took over a Pain Management doctor's billing and coding. I realized that the previous biller was coding office visits along with the injections performed. These procedures were performed in an ASC. She was billing 99213 Mod 25 with procedure 62311 and receiving payment. I do not believe you can bill the 99213 when the dr is in an ASC. Is this correct? The doctor does have documentation of systems and chief complaints listed she is definitely getting all the right info from patients and documenting? Please help Thanks
 
Regardless of the place of service, I personally do not bill a follow visit if an injection(s) is performed. Below describes some different guidelines that could be relevant in this question.


Special Consideration for Ambulatory Surgical Centers (Code 24) When a physician/practitioner furnishes services to a patient in a Medicare- participating ASC, the POS code 24 (ASC) will be used. NOTE: Physicians/practitioners who perform services in a Medicare-participating ASC will use POS code 24 (ASC). Physicians are not to use POS code 11 (office) for ASC based services unless the physician has an office at the same physical location of the ASC which meets all other requirements for operating as a physician office at the same physical location as the ASC – including meeting the “distinct entity� criteria defined in the ASC State Operations Manual that precludes the ASC and an adjacent physician office from being open at the same time -- and the physician service was actually performed in the office suite portion of the facility. That information is in Appendix L of that manual which is at http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf on the CMS website.

http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/Downloads/MM7631.pdf

Below Appendix L from State operations manual for ASCs

An ASC does not have to be completely separate and distinct physically from another entity, if, and only if, it is temporally distinct. In other words, the same physical premises may be used by the ASC and other entities, so long as they are separated in their usage by time. For example:
• Adjacent physician office: Some ASCs may be adjacent to the office(s) of the physicians who practice in the ASC. Where permitted under State law, CMS permits certain common, non-clinical spaces, such as a reception area, waiting room, or restrooms to be shared between an ASC and another entity, as long as they are never used by more than one of the entities at any given time, and as long as this practice does not conflict with State licensure or other State law requirements. In other words, if a physician owns an ASC that is located adjacent to the physician‟s office, the physician‟s office may, for example, use the same waiting area, as long as the physician‟s office is closed while the ASC is open and vice- versa. The common space may not be used during concurrent or overlapping hours of operation of the ASC and the physician office. Furthermore, care must be taken when such an arrangement is in use to ensure that the ASC‟s medical and
administrative records are physically separate. During the hours that the ASC is closed its records must be secure and not accessible by non-ASC personnel.
Permitting use of common, non-clinical space by distinct entities separated temporally does not mean that the ASC is relieved of the obligation to comply with the NFPA Life Safety Code standards for ASCs, in accordance with §416.44(b), that require, among other things, a one-hour separation around all physical space that is used by the ASC and fire alarms in the ASC.
It is not permissible for an ASC during its hours of operation to “rent out� or otherwise make available an OR or procedure room, or other clinical space, to another provider or supplier, including a physician with an adjacent office.
 
It is inappropriate in any setting to bill a visit level when the patient is coming in for a scheduled procedure. The medical necessity for the procedure was already determined at a previous visit, any "work" now being performed by the provider is an inherent part of the procedure and cannot be billed separately.
 
Thank you Debra for this information. Im definitely gathering as much information as I can before I give the news to the dr.
 
RRiley, Here is from the NCCI Policy which addresses new patient encounters where a procedure of 0-10 days is performed on the same day as intial encounter.


B. Evaluation and Management (E&M) Services
Medicare Global Surgery Rules define the rules for reporting evaluation and management (E&M) services with procedures covered by these rules. This section summarizes some of the rules. All procedures on the Medicare Physician Fee Schedule are assigned a global period of 000, 010, 090, XXX, YYY, ZZZ, or MMM. The global concept does not apply to XXX procedures. The global period for YYY procedures is defined by the Carrier (A/B MAC processing practitioner service claims). All procedures with a global period of ZZZ are related to another procedure, and the applicable global period for the ZZZ code is determined by the related procedure. Procedures with a global period of MMM are maternity procedures.
Since NCCI edits are applied to same day services by the same provider to the same beneficiary, certain Global Surgery Rules are applicable to NCCI. An E&M service is separately reportable on the same date of service as a procedure with a global period of 000, 010, or 090 under limited circumstances.
If a procedure has a global period of 090 days, it is defined as a major surgical procedure. If an E&M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, the E&M service is separately reportable with modifier 57. Other preoperative E&M services on the same date of service as a major surgical procedure are included in the global payment for the procedure and are not separately reportable. NCCI does not contain edits based on this rule because Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits.
If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. E&M services on the same date of service as the minor surgical procedure are included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles.
Example: If a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable. However, if the physician also performs a medically reasonable and necessary full neurological examination, an E&M service may be separately reportable.
Revision Date (Medicare): 1/1/2013
VIII-4
For major and minor surgical procedures, postoperative E&M services related to recovery from the surgical procedure during the postoperative period are included in the global surgical package as are E&M services related to complications of the surgery that do not require additional trips to the operating room. Postoperative visits unrelated to the diagnosis for which the surgical procedure was performed unless related to a complication of surgery may be reported separately on the same day as a surgical procedure with modifier 24 (“Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period”).
Procedures with a global surgery indicator of “XXX” are not covered by these rules. Many of these “XXX” procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed. This work should never be reported as a separate E&M code. Other “XXX” procedures are not usually performed by a physician and have no physician work relative value units associated with them. A physician should never
report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure. With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. This
E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure. Appending modifier 25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure is correct coding.
 
mitchellde said:
It is inappropriate in any setting to bill a visit level when the patient is coming in for a scheduled procedure. The medical necessity for the procedure was already determined at a previous visit, any "work" now being performed by the provider is an inherent part of the procedure and cannot be billed separately.
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This is semi incorrect as there are tons of scenarios with planned procedures in different settings.

When a patient has other issues not related to the scheduled procedure, if that is discussed a visit level is ALWAYS appropriate to bill out with the use of modifier 24. Any type of labs, imaging orders and prescriptions sent out not related and also related to the procedural diagnosis a visit level is ALWAYS appropriate to bill out with the use of modifier 24. The reading of the reports are included in the encounter visit you sent the orders, so you are missing out for payment as you cannot get the credit on the next visit.

ALSO, any type of encounter with decision for a procedure and it is performed on the same day are billed with Modifier 25 or 57 depending on the global days.

Double check the encounter notes before bypassing to bill a level visit, Dont miss out on lost revenue.
 
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