Wiki Medicare guidelines for POS and ASC

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mgutirob

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I work for a Pain Management Center and we also have a ASC right next door. My provider performs Kyphoplasty (22514) in the ASC POS (24). He asked if he could bill it out as POS (11) because the rep. from the company told him that we could because the reimbursement rate is higher. The Administrator asked me if that is permitted and I told him that we can't do that because it would be considered Fraudulent Billing. If the service is performed in the ASC, that is how the claim should be processed both ASC and Physician's Component. If there is a seasoned Pain Management Coder with ASC experience, could you please respond so that we may either speak or email. Your assistants with this would be greatly appreciated.
 
I am sometimes amazed at what these company reps will tell providers. You are correct - if the procedure was performed in the ASC, then it needs to be billed with the appropriate place of service. The office POS 11 does indeed pay a higher rate, but that is because it would include the office's expenses for the supplies, equipment, and use of staff time and office space. If the ASC is providing and billing for these separately, then your provider is not entitled to that extra reimbursement. Payers are very much aware of this (it is called a 'site of service differential' in the reimbursement language) and overpayment recovery auditors routinely review payer claims to search for mismatches between the place of service billed by providers when a facility claim is also on file, so it is unlikely that any provider would even be able get away with this for very long. But even if they did, you are also correct that if done intentionally this would constitute fraud.
 
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Thank you so very much for responding to my question. Like yourself, I have been in the industry for 20+ years and I am not at all surprised at what some of the reps will tell provider's in order to get business. I am very glad that I work for a provider who is not willing to risk his practice and who is all about trusting me as his coder to give him accurate information. I am not willing to risk my certification either and I always do my best to provide my doctor's with the guideline's so if there is ever a doubt, they have it in black and white. It can never be said that I didn't provide them with the most accurate and current information when it comes to coding.
 
Just posting to give you support. I once educated a rep from a urine drug screening company that what his company was doing amounted to kickbacks and I was having none of it. He quit and came back later to say thank you and to tell me he was working for someone else.
 
SharonCollachi said:
Just posting to give you support. I once educated a rep from a urine drug screening company that what his company was doing amounted to kickbacks and I was having none of it. He quit and came back later to say thank you and to tell me he was working for someone else.
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Thank you so very much for your support Sharon. I was telling another colleague that what makes it even harder for us is the fact that those who don't do what we do and understand our language tend to interrupt the Guidelines (Medicare, etc.) to benefit what they are looking for and they fail to read them in their entirety which is where the confusion and/or misleading information comes from.

Regards, Carla M. Rivera, CPC
 
My 2 cents here.
Do not over look the Hybrid ASC/OBL model which is a new trend among providers.
Read here. https://oeisociety.com/wp-content/uploads/2019/04/1030-AHN-ASC-vs.-Office-vs.-Hybrid.pdf

We operate under this model, However, We have clearly define ASC days and clearly defined OBL days.
On ASC days the signage changes among other things. It is done in the same offices and procedure rooms. This has been approved bu the AAAHC. When we bill on an ASC day we bill for the ASC Facility POS 24 fee and the ASC Physician charge POS11 (note this fee schedule is different then the regular physician fee schedule indicated by #) 2 different tax ids.
This model does not allow for, "oh this procedure pays more here so just say it was done in POS 24".
Patients are scheduled, benefits obtained and preauths if necessary under the scheduled date POS.

That being said, I hope this makes sense. There is a lot of information out there on this and again this is new and not many states have clinics doing this.
 
I'm surprised that the OIG allows this sort of thing. The only clear difference that I can see is, we will schedule these procedures on our OBL days to make more money, and these procedures on our ASC days to make more money. Sounds alot like the hospital-affiliated office visits that I ranted about on another thread. As a healthcare consumer, who pays a percentage of the allowed charges myself (as do the majority of people with commercial insurance), I find this practice abhorrent.
 
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