Question private-owned, physician-owned, hospital-owned ASC & hospital-based outpatient facility: is there a list of items CMS bundles into CPT codes?

drronline

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Is there a url that lists which items CMS/private payers include/bundle in physician office procedures, ASCs (private-owned, physician-owned, hospital-owned) & hospital-based outpatient facilities (e.g. medical supplies, anesthesia, recovery, injectables, implants)?
 

thomas7331

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For bundling, you can refer to the PTP coding edits tables on the NCCI page of the CMS web site, link below. These are updated quarterly, and there are separate tables for physicians and for facilities. These will tell you which codes (column 2) bundle into which primary procedures (column 1), with indicators to tell you whether or not that edit can be bypassed with a modifier.


But if you're looking for ASC/facility rules for which items (supplies, implants, anesthesia, etc.) are considered 'packaged' into the case rates paid for surgical procedures - that is a separate thing because these are not considered bundled, although they are often confused as that because they don't receive separate payment. For this information, you'll need to look at that OPPS policy files and addenda which detail this (links below for both ASC and Hospital Outpatient). This is quite a bit more complex than just looking up a code to see if it is packaged or not because the payment methodology looks at the entire claim and not just individual codes - for example, there are codes that are 'conditionally packaged' depending on what other codes or charges are present on the claim. If you are working in facility payment and need this information, rather than trying to work with these files I would recommend purchasing an encoder that has this capability because trying to do this manually is very cumbersome.


 

drronline

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How are these items treated (modifier or paid separately) under Medicare:
Scenario 1) ASC - facility bills for 54360 @$12K and 54405@$12K (no modifier), also sterile supply @$3k, anesthesia @$2k, Recovery @$3k, drugs/fluids @$5k, labs @$1k....
Scenario 2) Hospital Outpatient - (same as above)
Scenario 3) Hospital Inpatient - (same as above)
 

thomas7331

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How are these items treated (modifier or paid separately) under Medicare:
Scenario 1) ASC - facility bills for 54360 @$12K and 54405@$12K (no modifier), also sterile supply @$3k, anesthesia @$2k, Recovery @$3k, drugs/fluids @$5k, labs @$1k....
Scenario 2) Hospital Outpatient - (same as above)
Scenario 3) Hospital Inpatient - (same as above)
Scenario 1) My current encoder does not have ASC capability and this facility type isn't my experise, but it would be similar to how the outpatient hospital claim works. For ASC in 2019, 54360 is status A2 (surgical procedure on ASC list; payment based on OPPS relative payment weight) and 54405 is status J8 (device-intensive procedure; paid at adjusted rate) and is not subject to multiple procedure reduction. I believe that any remaining codes would package unless any ASC covered ancillary codes are billed in addition.

Scenario 2) Under 2019 OPPS, 54405 classifies to APC 5377 which is a J1 device-dependent comprehensive APC (HCPCS code would be required for the associated implanted device). All other codes on the claim will package to this APC. The payment will be the APC case rate, adjusted for the hospital's wage index with any outliers taken into consideration.

Scenario 3) CPT codes are not submitted on inpatient hospital claims so you would not encounter this scenario on an inpatient. As an inpatient claim, this would be paid under the DRG rate based on the diagnosis and ICD-10-PCS codes submitted for the services.
 
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