Wiki Pain Management ASC facility billing for Medicare

[heatherirene19]

Question:

We just opened an ASC and started billing. Learned the hard way that modifier 50's are not allowed in ASC billing on the facility side, and resent all of those claims. For Medicare however, they are only paying first level facet injections, ie 64493 and not 64494 or 5, as they are add on codes, I thought it wrong to add mod 59's to them. Does anyone know why they wouldn't pay them. They are denying as inclusive in another procedure.

Thanks in advance.

 

[thomas7331]

Medicare reimburses ASCs under a prospective payment methodology - you get a flat fee for which includes any add-on codes. It differs from physician reimbursement in that you're not getting a fee per procedure but rather a payment that is calculated to be an average for a variety of similar types of procedure that are done. The add-on codes are not being denied, it's just that the payment is packaged into the rate you're getting - you won't be able to get additional payment by adding modifiers or changing your billing. But you still need to report the add-on code because the you'll want to represent accurately the services that are being performed as that will figure into the new prospective rate that is calculated each year.

 

[shari1264]

Medicare Replacement Plans

Medicare reimburses ASCs under a prospective payment methodology - you get a flat fee for which includes any add-on codes. It differs from physician reimbursement in that you're not getting a fee per procedure but rather a payment that is calculated to be an average for a variety of similar types of procedure that are done. The add-on codes are not being denied, it's just that the payment is packaged into the rate you're getting - you won't be able to get additional payment by adding modifiers or changing your billing. But you still need to report the add-on code because the you'll want to represent accurately the services that are being performed as that will figure into the new prospective rate that is calculated each year.

Does this apply to Medicare Replacement plans as well?

 

[thomas7331]

The Medicare Advantage plans should pay the same rates as standard Medicare unless your facility or practice has negotiated and contracted for a different payment rate or different payment methodology.

 

[shari1264]

Medicare Replacement Plans

The Medicare Advantage plans should pay the same rates as standard Medicare unless your facility or practice has negotiated and contracted for a different payment rate or different payment methodology.

Thank you for your prompt reply!