Under the new Medicare ASC payment system, payments for some covered surgical codes are discounted or packaged. Here's a look at what this means for ENT reimbursement.

• Discounting. Multiple procedure discounting is applied when more than one surgical procedure is performed during a single operative session. The full Medicare payment is made, and the beneficiary pays the full coinsurance amount for the procedure having the highest payment rate. Fifty percent of the Medicare payment amount and the beneficiary coinsurance amount is paid for all other procedures performed during the same operative session, to reflect the savings associated with having to prepare the patient only once and the incremental costs associated with anesthesia, OR and recovery room use, and other services required for the second and subsequent procedures. Notably, ENT procedure code 30300 (removal foreign body, intranasal; office type procedure) is not subject to multiple procedure discounting. This procedure is always paid at 100 percent — even if other procedures are performed during the same session.
• Packaging. Packaged services are those that are recognized as contributing to the cost of the services under the new ASC payment system, but that CMS doesn't pay for separately. Many ENT physicians perform sinus surgery using stereotactic computer-assisted volumetric navigation (code 61795) or three-dimensional rendering with CT scan imaging (codes 76376/76377). Under the new payment system, these services are packaged and don't generate separate payments from Medicare.

Although CMS hasn't addressed ASC reporting of packaged services, in the Nov. 27, 2007, Federal Register (page 66611), CMS stated: "To the extent possible, hospitals may use HCPCS codes to report any packaged services that were performed, consistent with CPT or CMS coding guidelines."

Although separate payments won't be generated, ASCs should strongly consider coding, charging and billing packaged services on the claims submitted to Medicare, just as CMS has advised hospitals.

• Transitional payments. To provide additional time for ASCs to adapt to the new payment system and to facilitate Medicare beneficiary access to ambulatory surgical procedures at those ASCs that may not adjust as quickly as others to the new payment system, CMS has adopted a transition period of four years. The contribution of calendar year (CY) 2007 ASC payment rates to the blended transitional rates will decrease by 25 percentage point increments each year of transitional payment until CY 2011, when CMS will fully implement the ASC payment rates calculated under the final methodology of the new payment system.

Most of the ENT procedures listed in "Commonly Performed ENT Procedures" have a 2008 payment that is higher than the 2007 rate under the former payment system. A few codes, however, now have lower payments, such as release of nasal adhesions (code 30560) and control of nosebleeds (codes 30903 to 30906). Procedures new to ASC payment for CY 2008 or later calendar years aren't subject to the transition policy. New procedures receive payments determined according to the final methodology of the new ASC payment system. For example, removal of nasal foreign body (code 30300) was not covered in 2007, and it is now recognized under APC group 340.

ENT coding tips
Accurate and comprehensive coding is a major factor in ASCs receiving optimal payments under the APC system. Here are some ENT surgery coding guidelines applicable to all healthcare providers.

• It's OK to report CPT codes 31238 (endoscopic control of epistaxis) and 31237 (endoscopic polypectomy) appended with modifier -59 when the epistaxis is unrelated to the polypectomy. However, if subsequent bleeding is caused by the performance of a polypectomy or biopsy and control of bleeding is performed at this time, don't separately report code 31238 for the control of epistaxis in this instance. (Source: CPT 2000 Coding Symposium handout, American Medical Association, Chicago, Ill.)

• When reporting turbinate submucous resection code 30140, documentation in the operative report should reflect that the physician entered or incised the mucosa and, for the most part, preserved it. The simple statement, "excised the turbinate(s)" is often not enough documentation to reflect that the submucous resection of the inferior turbinate was performed. Coders may need to ask the physician for the specific technique performed. (Sources: May 2003 and December 2004 CPT Assistant newsletters, AMA.)
• Don't report turbinate fracture code 30930 with submucous resection code 30140 if the procedures are performed on the same turbinate. (Source: December 2004 CPT Assistant newsletter, AMA.)
• Turbinate injection code 30200 is a bilateral procedure, so bilateral procedure modifier -50 is not needed for this code. (Source: December 2004 CPT Assistant newsletter, AMA.)
• The reference to "tissue" in endoscopic maxillary antrostomy code 31267 can include polyps, mucous membrane, bony partitions or massive fungal concretions/debris. (Source: CPT Assistant newsletter, January 1997, page 6.)
• Report code 31237 (without a modifier) each time you perform a post-op endoscopic debridement (without a biopsy or polypectomy) following functional endoscopic sinus surgery (FESS). (Source: December 2001 CPT Assistant newsletter, AMA.)
• Report code 61795 (stereotactic computer assistance) when performed in conjunction with ENT, head and neck procedures, including FESS. Examples would include those procedures described by codes 31254 to 31256, 31267, 31276, 31287, 31288, 31290 to 31294, and 61548. (Source: October 2001 CPT Assistant newsletter, AMA.)