Coding & Billing

Financial Management

By: Cristina Bentin

Published: 10/10/2007

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Ready for the ASC Rollback?


Cristina Bentin, CCS-P, CPC-H, CMA Ambulatory surgery center owners and operators are no doubt looking forward to 2008, when ASCs likely will be reimbursed at 75 percent of the hospital outpatient department rate. But a year before Medicare brings ambulatory payment rates into parity with hospital outpatient rates, it will reduce the rates on 280 procedures whose current ASC payments are higher than hospital payments for the same procedures to the hospital rate.

Cristina Bentin, CCS-P, CPC-H, CMA The rollback takes effect Jan. 1 and amounts to $300 million over five years, according to Congressional Budget Office figures. Which specialties are impacted? If an Office of Inspector General study is any prediction of future savings and reimbursement, a large portion of the Medicare savings would be derived from ophthalmic (cataract, after-cataract) and endoscopic (GI, colonoscopy, arthroscopy, cystoscopy, laryngoscopy) procedures. OIG estimated a potential savings for Medicare expenditures of about $466 million for eye procedures and $233 million for endoscopic procedures if a uniform payment rate for both hospitals and ambulatory surgical centers is established.

Procedures that will have their reimbursement capped include prostate biopsy (CPT 55700), which will go from $446 to the projected hospital rate of $273, a drop of 39 percent, and YAG laser capsulotomy (CPT 66821), which will go from $446 to the projected hospital rate of $309, a drop of 31 percent.

Although the procedures likely to be cut are in 11 different specialties, the impact is disproportionate, according to an analysis by FASA, with orthopedics having the largest number of procedures likely to be cut (106), followed by dermatology (63), pain management/neurology (23) and otolaryngology (21). Ophthalmology is expected to bear the brunt of the total cut in payments (69 percent), followed by dermatology (16 percent) and urology (10 percent), according to FASA.

While 280 procedures have a higher reimbursement in an ASC setting than in an HOPD setting, more than 2,200 procedures have a higher reimbursement rate in the HOPD than in an ASC. According to the OIG, comparable payment rates for HOPD and ASCs could potentially reduce Medicare expenditures by more than $1 billion annually.

2006 CPT Code Revisions Affect Routine Turbinate Procedures

Outfracturing of a medially displaced inferior turbinate might further improve the patency of the nasal airway, but how do you code for it? There's often uncertainty when determining whether to report CPT code 30930, fracture of nasal inferior turbinate(s), therapeutic, when you perform it at the same operative session as CPT code 30140, submucous resection inferior turbinate, partial or complete.

According to the AMA, if you perform both procedures on the inferior turbinate, you'd only report the most extensive procedure, the submucous resection, using CPT code 30140. CPT codes 30140 and 30930 are unilateral codes with three turbinates in the left and three turbinates in the right nasal cavity (inferior, middle and superior turbinates).

Outfracturing is performed on the inferior turbinates to allow airflow into the nose by displacing or changing the original position of the turbinate due to conditions such as nasal airway obstruction or hypertrophy. The middle turbinate may be fractured inward as a surgical approach to the sinus cavities during an endoscopic sinus procedure. In this instance, the fracturing as a surgical approach would be incidental to the endoscopic sinus surgery.

A submucous resection involves the removal of the bony turbinate, not the mucous membrane. Once you remove the turbinate, the mucosa falls downward and laterally which ultimately opens the airway and reduces the airway obstruction.

Now, let's say you perform a fracturing of the middle turbinate(s) and a submucous resection of the superior turbinate. Instead of reporting CPT 30140 or CPT 30930, you'd report CPT 30999, unlisted nasal procedure.

Beginning January 2006, CPT code 30140 and CPT code 30930 specify work performed on the inferior turbinate. CPT cross-references direct us to report the unlisted code 30999 for a submucous resection of middle/superior turbinate or for the fracturing of middle/superior turbinate(s) if clinically indicated. If you performed both of these unlisted procedures during the same session, you'd only report CPT code 30999 once unless carrier guidelines specify otherwise. - Cristina Bentin, CCS-P, CPC-H, CMA

Cristina Bentin, CCS-P, CPC-H, CM\A Now for the good news. The Ambulatory Surgical Center Medicare Payment Modernization Act of 2005 (HR 4042 and S 1884), if passed, would base reimbursement on the service performed and not on the setting. It would take effect in 2008 and be phased in over a four-year period.

ASCs would be reimbursed at 75 percent of the hospital rate for the same procedure. ASCs would also receive adjustments and comparable annual updates for drugs, biologicals and devices. Rather than being confined to list of covered procedures, ASCs could host all cases except those Medicare officials consider unsafe to be performed in an ASC or those requiring an overnight stay.

AMA Clarifies Fluoroscopy Reporting

Pain management coding always seems to present a challenge, even to the most seasoned coders. One such challenge revolves around the number of times you can report fluoroscopy for an injection performed at the L5-S1 (the lumbosacral joint, where the lumbar spine meets the sacrum). Should you report fluoroscopy per spinal region or per level?

In August 2005, a question arose as to whether to report CPT code 76005, fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint), including neurolytic agent destruction, once or twice when you use guidance at the L5-S1 level.

According to the AMA, it would be inappropriate to report CPT code 76005 twice, even though CPT code 76005 typically is intended to be reported per spinal region (cervical or lumbar, for example), and not per level. If you perform a single puncture at the transition of L5-S1, you should report CPT code 76005 once. This directive supercedes the AMA's initial August 2005 directive to report fluoroscopy code 76005 twice.

- Cristina Bentin, CCS-P, CPC-H, CMA

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