I would advise not to send the G0289 to Medicare--even with the GY modifier...not sure who with Medicare would tell you to go against their own processing manual
100-04 Medicare Claims Processing Manual Section 040
Chapter 14-Amb Surg Ctrs
Subject Ambulatory Surgical Centers - Section 40 - Payment for Ambulatory Surgery
"(Rev. 1514; Issued: 05-23-08; Effective: 01-01-08; Implementation: 06-23-08)
Medicare contractors calculate payment for each separately payable procedure and service based on the lower of 80 percent of actual charges or the ASC payment rate. The charge-to--payment rate comparison occurs at the line-item level.
ASCs should not report separate line-item HCPCS codes or charges for items that are packaged into payment for covered surgical procedures and therefore, are not paid separately (e.g., nonpass-through implantable devices). Instead, it is important that ASCs incorporate charges for packaged services into the charges reported for the separately payable services with which they are provided. Facilities may not be paid appropriately if they unbundle charges and report those charges for packaged codes as separate line-item charges.
The ASC can't report G0289 as CMS has stated that since this is an add-on code it is just physician work at this time.
CMS is very clear that you do not continue to bill when they state it is noncovered or bundled service - it can be considered a false claim
Orthopedic Coder's Pink Sheet
Effective Date 09/01/2004
Publish Date September 2004
Subject It's a no go for ASCs trying to bill code G0289
"If you code for an Ambulatory Surgery Center (ASC) you can forget about Medicare paying for a chondroplasty performed with a meniscectomy, reported using code G0289 (Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee).
An official from the Centers for Medicare & Medicaid Services (CMS) offers this explanation, “When procedures are performed in an ASC that aren't on the ASC list then Medicare does not pay. There are some occasions when procedures that are not on the list are performed such as a lesion removal from the eyelid and one from the back of the patient's hand. [While the eyelid lesion would be more complicated], the one on the back of the hand would be a quick thing that is done in the office. Rather than make the patient come in for two visits, the physician removes both at the ASC. We would not pay a facility fee for the lesion removal from the hand because it can be done in the office and does not require an ASC. The physician could bill for the procedure documenting that he had performed it in an ASC and he would receive the higher fee at the non-facility rate.”
This holds true whether you are performing the procedure in an ASC or in an outpatient setting under [Outpatient Prospective Payment System (OPPS)]. As of 2003, CMS also bundled or ‘packaged' G0289 under OPPS and no additional reimbursement is allowed for facilities.
In the end, CMS advises ASCs to contact them to review the ASC list and any code that may or may not be on the list. “We periodically update the ASC list and this is something that ASCs might want to bring to our attention. We would be happy to review our policy,” says the Medicare official. "
