1. Introduction to ASC: Coding and Billing
AAPC Martinez – December 2016
Christopher Lam, CPC, CASCC

2. Presentation Outline Speaker Introduction ASC Introduction
Billing Format: CMS1500 vs UB04
Billing Format: Revenue Codes
Brief Popular ASC Specialty Coding and Billing Topics
Cataract Surgery
Pain Management: Epidural Injections
Colonoscopy
Conclusion: Importance of ASC Coders

3. Speaker Introduction
Graduated from UC Davis with BS in Clinical Nutrition
Work experience:
ASC Support/Scrub Tech
ASC Revenue Cycle Management Assistant
ASC Coder and Biller
Second professional coding presentation!
Ask questions!
Give feedback!!
Today’s Goal: Introduce the foundation and role of ASC in patient care.

4. ASC (Ambulatory Surgery Center) Introduction
ASCA Definition:
“(Outpatient) Health care facilities that offer patients the convenience of having surgeries and procedures performed safely outside the hospital settings.”

5. ASC Introduction Continued
2015 Benchmarks by Becker’s ASC Review
23 million procedures performed successfully and safely
5,464 Medicare certified ASC (versus 5,868 registered hospitals)
Top common services include:
Cataract surgery and after cataract laser surgery (17% & 4%, total 21%)
Upper GI endoscopy (7.8%)
Diagnostic and therapeutic colonoscopy (5.6% and 6%, total 11.6%)
Epidural lumbar spine injections (3.9%)

6. Billing Formats

7. Billing Format UB-04 (CMS-1450)
In 2005, the National Uniform Billing Committee (NUBC) drafted and approved a new revision to UB-92.
In 2007, CMS approved and implemented the UB04 for all institutional providers.
The UB04 is much more complex form to accommodate all institutional providers needs.
Resources on completing a UB04 Form:
CMS Manual System: PUB , Transmittal 1104
Detailed Guides for each field box:

8. Billing Format: Revenue Codes
Revenue codes are used in UB04; FL-42 to simplify medical coding and billing for insurance claims.
It provides information on either where the patient was when they received treatment, or what type of item a patient might have received.
The typical revenue code used for ASC are:
ASC General Procedures: 0490
Other Implants: 0278
Intraocular Lens Implant: 0276
Pacemaker Implant: 0275
General Radiology Diagnostic: 0320
Complete list:

9. Cataract Surgery

10. Cataract Surgery
Medical condition which the lens of the eye becomes progressively opaque.
It is not contagious nor spreads into opposite eyes. But regularly developed together.
In early development, it does not clearly disturb eye sight until it eventually blurs vision.
It can cause “clouded vision” which complicates vision.
Early stages can be address by more lighting or eyeglasses, but can develop into surgery to replace the natural lens with an implant.

11. Cataract Surgery: CPT 66982 vs 66984
CPT (Simple):
Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification).
CPT (Complex):
Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage

12. Cataract Surgery: CPT 66982 vs 66984
The surgeon performs:
Capsulorhexis
Hydrodissection
Hydrodelination
Phacoemusification
Irrigation and aspiration
Remove Cataract Lens
Replace with intraocular lens (IOL)
Cataract Surgery:
Complex
Simple
CPT Code:
__________________ ü
66984

13. Cataract Surgery: CPT 66982 vs 66984
What qualifies a complex cataract surgery?
The American Academy of Ophthalmology (AAO) identified any of the following as a complex cataract surgery:
Is it a miotic pupil that will not dilate sufficiently thus requiring the use of special instruments?
Does the IOL need additional support, such as a capsular tension ring or intraocular sutures?
Is this a pediatrics case that includes the implantation of the IOL?
Is the cataract considered mature, requiring the use of dye?

14. Cataract Surgery CMS and Premium IOLs
IOLs are posterior chamber FDA approved implants (V2632).
CMS reimburses regular IOLs through ASC reimbursement if performed in an ASC.
But does not reimburse Premium IOLs
Cataract surgery does not give you 20/20 vision.
Premium IOLs gives additional benefits than normal IOLs:
Aspheric IOLs: correct presbyopia (farsightedness) with sharper images, better low-light conditions (V2788)
Toric IOLs: correct astigmatism and nearsightedness (V2787)
NOTE: Even though these premium IOLs require additional attention during the implantation, it alone does not justify a complex cataract surgery (CPT 66982).

15. Cataract Surgery CMS and Premium IOLs
Premium IOLs described in the previous slide are patient’s choice and are also patient’s financial responsibility.
CMS highly recommends an Advance Beneficiary Notice (ABN) filled by the patient.
ABN informs the patients of the specific non-covered charges, and gives the patient the options to request or deny these non-covered charges.

16. Cataract Surgery CMS and Premium IOLs
If a patient agrees to these premium IOLs, ASCA and ASC Becker recommends the legal amount you may charge the patient:
$ CMS covered reimbursement
up to $50.00 surcharge/handling
PT Responsibility of Premium IOLs
Cost of Premium IOL - = +
Example: $895.00
- $ = $745.00
+ $50.00 = $795.00

17. Pain Management: Epidural Injection

18. Pain Management: Epidural Injection
Evaluation, diagnosis, and treatment of various combination of acute and/or chronic pain.
Caused from many reasons such as trauma or degeneration.
We are only going to touch a small portion of Pain Management; Epidural Injection (EI) and Transforminal Epidural Injection (TFEI).
Goal of injection is to provide pain relief.
EI and TFEI effects vary from case to case and person to person.
The relief can last up to days, weeks or even years from single injection.
The injection can be used a therapeutic relief or step in progress of PT

19. Pain Management: Epidural Injection

20. Pain Management: Epidural Injection
Techniques to identify/approach the epidural space:
Imaging guidance (Fluroscopy/CT)
Contrast injection
Force resistance
Diagnostic or therapeutic injection
NEW CODES FOR 2017!!!
62310 and 6211 has been deleted!
Look at new codes:
62320/62321
62322/62323
Codes has been expanded from 2 to 4 to address procedure with or without imaging.

21. Pain Management: Epidural Injection
Without Imaging
With Imaging
Cervical or Thoracic
62320
62321
Lumbar or Sacral
62322
62323
CPT 62320: Injection(s), of diagnostic or therapeutic substance, not including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance.
CPT 62321; with imaging guidance
----
CPT 62322: Injection(s), of diagnostic or therapeutic substance, not including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar and sacral; without imaging guidance.
CPT 62323; with imaging guidance

22. Colonoscopy

23. Colonoscopy
Colonoscopy, exam into the entire large intestine (rectum and colon) with a flexible colonoscope.
Diagnostic or therapeutic to find and treat ulcers, colon polyps, tumors and areas of inflammation or bleeding.
Sigmoidoscopy, alternatively, is the exam of a portion of the large intestine and rectum.
Determining the scope placement will help determining the difference between a colonoscopy or a sigmoidoscopy.
Reaching and examining the terminal cecum or ileocecal valve = colonoscopy
Inability or difficult reaching the terminal cecum or ileocecal valve = sigmoidoscopy
There’s a great Colonoscopy Decision Tree on page 301 of the 2017 CPT Book

24. Colonoscopy: Decision Tree

25. Colonoscopy Diagnostic:
45378, Colonosocopy, flexible; diagnostic including collection of specimen(s) by brushing or washing when performed (separate procedure)
Therapeutic/removal techniques:
CPT 45379: Colonoscopy, flexible; with removal of foreign body(s)
CPT 45380; with biopsy, single or multiple
“Cold biopsy forceps”
CPT 45388; with ablation of tumor(s), polyp(s), or other lesion(s)
Ablation = Destruction
CPT 45384; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
CPT 45385; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
Can be either “Hot” or “Cold” Snare

26. Colonoscopy Multiple techniques may be used to remove a single polyp.
Only the most comprehensive or complex code that accurately identifies the polyp removed should be reported.
Example: Polyp was removed with Hot Snare and cold forceps.
Answer: Code for Hot Snare.
Multiple different techniques may be reported if performed on different polyps.
Example: Cold Snare (45385) and Ablation (45388) was performed on separate polyps on separate sites.
Each technique may be reported once per session.
Example: Cold forceps (45380) was performed on 3 different polyps should be reported once.
CPT 45381: Colonoscopy, flexible; with directed submucosal injection(s), any substance
Saline injection with removal; can be reported with a polypectomy code.

27. Colonoscopy Screening:
Different than diagnostic because it’s preventive measures.
Diagnostic is because you have a problem.
Procedure is a screening if no gastrointestinal symptoms prior to surgery.
But procedure becomes therapeutic once a lesion is addressed.
Modifiers for screening:
PT (For Medicare claims)
33 (Commercial and Medicaid claims)
Screening codes uses G-codes in HCPCS
G0105: Colorectal cancer screening; colonoscopy on individual at high risk
G0121: Colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk
High risk is classified as personal/family history of polyps, colorectal cancer or inflammatory bowl diseases (i.e. Crohn’s or Ulcerative Colitis)
Family is define as parent, sibling, child or first degree relative.

28. Colonoscopy
Medicare PT do not need to pay a deductible for a screening.
But once the procedure becomes therapeutic, PT is responsible for Part B Deductible.
Screening codes uses G-codes in HCPCS for Medicare, while commercial uses the diagnostic.
Appropriate modifiers must be applied.
Determine and document correctly if PT has symptoms prior to surgery date.
Good idea for PT education regarding the difference between screening, diagnostic and therapeutic and how PT responsibility is involved.
Insurance companies are quick to blame incorrectly coding/audits
Code correctly! Though you have positive motive or care for your PT’s responsibility, you are legally required to code and report the right CPTs.

29. CEUs will be rewarded at the end of the meeting.
Thank you everyone!