Otolaryngology Coding Alert

Get to know modifier SG when you bill for an ASC Any otolaryngology coder who has suddenly been led into the world of ambulatory surgery center coding knows that ASCs present unique challenges. If you code for an ambulatory surgical center but you still find yourself puzzled by ASC coding rules, review the following four FAQs to get the lowdown. 1.  Remember to Coordinate Coding With Physician Question: I know that Medicare will deny the ASC's charges for any procedures that aren't on the ASC's list of approved services, but what happens if the physician performs a nonapproved service anyway? How can we collect for the ASC's portion? Answer: Occasionally, the physician will perform a procedure in the ASC that Medicare does not include on its list of approved ASC services. The ASC cannot ask the patient to sign an advance beneficiary notice for a service that is not on the approved list, nor can the ASC bill the Medicare patient for any unpaid balance, says Annette Grady, CPC, CPC-H, CPC-P, OS, director of education at Coding MetriX Inc., and an officer on the AAPC National Advisory Board. 

When the service is not covered in an ASC, Medicare will make no facility payment but the physician can still collect for his portion of the surgery. If the physician chooses to perform a service not on the approved ASC listing, the ASC should make arrangements with that physician for reimbursement since Medicare pays the physician the ASC's portion of the payment. Many ASCs use the difference between the  facility and the nonfacility reimbursement and then bill that amount to the physician.
 
Best practice: If this occurs, you should ask the physician to sign a document stating he understands that the procedure is not on the ASC list and that he will be responsible for reimbursing the ASC the difference between the facility and nonfacility reimbursement, Grady says.

2. You May Not Need Modifiers 78, 79 Question: I code for an ASC, and my payer won't reimburse me for claims with modifiers 78 (Return to the operating room for a related procedure during the postoperative period) and/or 79 (Unrelated procedure or service by the same physician during the postoperative period) on them. Should we appeal? Answer: -An individual payer has the right to deny a claim if it is within their guidelines to do so, and with many self-insured plans out there, the guidelines vary greatly regarding this issue,- says Stephanie Ellis, RN, CPC, owner of Ellis Medical Consulting Inc. in Brentwood, Tenn.
 
Most important issue: -The ASC's global period for all procedures performed in the facility is 24 hours,- Ellis says. -Most of the procedures performed in ASCs have a global period of 10 [...]