Wiki Ambulatory Surgery Center "N1" codes

Create Wiki
F

FBCGREGGIE

New
Messages
6
Best answers
0
Why are add-on codes considered as status "N1" for an ASC? Example: Code 22551 is reimbursable, however code 22552 (add-on) code is "N1" - Packaged service/item; no separate payment made?
 
A complete answer to this question is complex, but the short answer is that it's because OPPS, as the name indicates, is a 'prospective payment system'. Unlike a fee-for-service system, which is how physicians are reimbursed and which makes a payment based on the specific service that was performed, prospective payments are estimated payments based on historical data about facility costs. Similar services, rather than having specific fee, are grouped together in classes and are paid at the estimated average cost that the facility incurs for those types of services. So CMS has made the decision that the reimbursement for an add-on code will be incorporated into the calculation of the fee for the base code's group and not handled as a separate group. As with any service in OPPS, the payment is for that class of services won't vary from claim to claim. So some claims will seem underpaid, but others will be overpaid, but over time, the expectation is that the facility is being reimbursed correctly in aggregate.

I've explained this to a lot of people and it's a difficult concept for someone who's used to physician coding and reimbursement. 'Packaged' does not mean the service is denied, bundled, or otherwise not paid, and definitely does not mean that the service should not be reported on the claim. It just means that it's not paid as a separate line item. The cost that the facility incurs will still count towards the calculations of future prospective payments, so it's important to report all services correctly even if it doesn't make a difference in the amount that is paid to the facility for a specific claim. Hope that helps some.
 
Last edited:
CodingGirl1327 said:
Should codes that are packaged in N1 status be billed for reporting purposes, or should they be omitted from the claim entirely? Thank you!
Click to expand...
The codes should be billed for reporting purposes. Status code N1 is a payment indicator, not a coding guideline - it tells you how the payment is calculated. It doesn't mean that the code is denied or that it shouldn't have been billed. It also doesn't apply to non-Medicare claims. You should code all of the procedures accurately and completely per coding guidelines.
 
thomas7331 said:
The codes should be billed for reporting purposes. Status code N1 is a payment indicator, not a coding guideline - it tells you how the payment is calculated. It doesn't mean that the code is denied or that it shouldn't have been billed. It also doesn't apply to non-Medicare claims. You should code all of the procedures accurately and completely per coding guidelines.
Click to expand...
I know this is true...however i don't have source information and a recent audited gave errors on every CPT codes issued that had a N1 indicator...
I am in desperate need to find documentation from CMS or other coding authority to show I issued the codes correctly....I tried explaining to my BOM and Admin that N1 is a reimbursement policy indicator not a coding rule, but they said I have to show them documentation or the errors stand....
Thomas do you have any source links or can you steer me to where I can find actual documentation that will help me prove I issued my codes correct? I issued 22551, 22552, 22853, 22853, and 20930. the auditor says 22853 x2, and 20930 are all errors as they have a N1 indicator and should not have been reported. Any source documentation regarding reporting codes with N1 would be greatly appreciated. Is there any?
 
SimpleCodingGirl said:
I know this is true...however i don't have source information and a recent audited gave errors on every CPT codes issued that had a N1 indicator...
I am in desperate need to find documentation from CMS or other coding authority to show I issued the codes correctly....I tried explaining to my BOM and Admin that N1 is a reimbursement policy indicator not a coding rule, but they said I have to show them documentation or the errors stand....
Thomas do you have any source links or can you steer me to where I can find actual documentation that will help me prove I issued my codes correct? I issued 22551, 22552, 22853, 22853, and 20930. the auditor says 22853 x2, and 20930 are all errors as they have a N1 indicator and should not have been reported. Any source documentation regarding reporting codes with N1 would be greatly appreciated. Is there any?
Click to expand...
Sorry to hear of your predicament. I think your superiors have things backwards here. When auditors cite errors, they are the ones who need to provide you with the documentation to show you what guidelines you failed to follow - not the other way around. Otherwise, they are making you 'guilty until proven innocent', which is not the way things should work. Do you have an appeal process when you question or disagree with or don't understand the rationale of an auditor's findings? Does your facility have a written policy that they can show you that says you are not to report codes that have particular status indicators? If not, the auditors have no business citing and error for that. Auditors must audit according to coding guidelines and/or documented policies and they should be able to back up their findings, it's part of their job to do so - they can't just make up their own rules and walk away from it.

It's entirely possible that there is a guideline out there that I'm not aware of that says Medicare does not want you to report these codes (my experience is mainly with hospital outpatient coding and not ASCs, and so the billing rules for an ASC may be different from what I've said above), and if that is the case, they should be able to provide it to you. But if in fact CMS does not want these codes reported, then it really should be the facility's responsibility to roll those costs together into a single code for purposes of Medicare claims only (and payers that follow Medicare's OPPS payment rules) - for other payers, you'd still want to report those codes or otherwise you could be losing out on revenue. So, in my opinion, it shouldn't be up to the coder to code differently from payer to payer, but ultimately each facility needs to work out its own process for how it's going to handle these individual situations and communicate that to the coders. Ultimately, right or wrong, it's up to your management to decide what they want to do, but I hope that they can be fair to you and address your concerns in the process.
 
Last edited:
You must log in or register to reply here.
Top