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Billing S&I's when surgical portion is done in the O.R.

  1. Default Billing S&I's when surgical portion is done in the O.R.
    Medical Coding Books
    Hi -

    I hope someone can answer this question for me and point me in the right direction for supporting documentation per CMS.

    If a procedure with a corresponding S&I code/charge is done in the OR and the surgical portion of the procedure is captured in the OR time charge and soft-coded, is the S&I portion still billable?

    For instance the pt has a Transcather occlusion/embolization done - CPT 37204 in the OR and OR charges for time in the OR....Can we still bill/report the S&I 75894 with the appropriate modifiers if they are done/documented or is it considered part of the OR time as well?
    My belief has always been that they S&I's are billable, but I have a client insisting they are not. While I can't find anything that says 'NO'....I can't find anything that says 'YES' either.
    Thanks.

  2. #2
    Location
    Salt Lake City
    Posts
    841
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    is your provider doing the embolization?
    Jenifer McPolin CPC, CPMA, RCC

  3. #3
    Default
    Quote Originally Posted by lbarker0828 View Post
    Hi -

    I hope someone can answer this question for me and point me in the right direction for supporting documentation per CMS.

    If a procedure with a corresponding S&I code/charge is done in the OR and the surgical portion of the procedure is captured in the OR time charge and soft-coded, is the S&I portion still billable?

    For instance the pt has a Transcather occlusion/embolization done - CPT 37204 in the OR and OR charges for time in the OR....Can we still bill/report the S&I 75894 with the appropriate modifiers if they are done/documented or is it considered part of the OR time as well?
    My belief has always been that they S&I's are billable, but I have a client insisting they are not. While I can't find anything that says 'NO'....I can't find anything that says 'YES' either.
    Thanks.
    If you can get a copy of Society of Interventional Radiology Coding manual, they describe what is involved with the professional codes and the S&I codes. But anyhow, for your embo example. The 37204 part is what the physician's work and what he can bill for. The 75894 part is the "supervision and interpretation". It involves supplies, room time, and the interpretation of images. As for "who gets what" i.e procedure is done in the OR, I think the OR would get the price for the S&I code, and the doctor would get the professional charge. So yes, you can bill both codes, but make sure the procedure has two codes. The new charge for the IVC filter is a single code which includes everything, and you don't use the old codes to "unbundled" the procedure.
    HTH,
    Jim Pawloski, CIRCC

  4. #4
    Location
    Alexandria, LA
    Posts
    518
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    Are you coding/billing for a physician or for the hosptial?

  5. Default
    I am auditing for an outside source for a hospital. I apologize. I should have mentioned that and the fact that we are working on charge capture for historical data. So we are still working with the 2011 coding guidelines.
    Thank you all for your input.

  6. #6
    Location
    Alexandria, LA
    Posts
    518
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    Quote Originally Posted by lbarker0828 View Post
    I am auditing for an outside source for a hospital. I apologize. I should have mentioned that and the fact that we are working on charge capture for historical data. So we are still working with the 2011 coding guidelines.
    Thank you all for your input.
    Ok, then remember, the hospital is one entity. The hospital should list all the codes included in a procedure (catheterization, procedure, S & I, etc.) They can (and every one I've seen do) put one charge, but all of the codes involved should be listed. Some of them will be packaged (status N). This is similar to bundled on the physician fee schedule side, except that CMS says that packaged codes should still be listed. CMS Claims Processing Manual (100-4), Chapter 4, Section 180.2 talks about coding for surgery procedure. And section 10.4 of the same chapter talks about packaged codes. It is important to list those codes (such as the S & I codes) because packaged codes are used for future rate-setting.

    Now, the problem is how to divide that up so that the radiology department gets their share of the payment for services performed in OR, since the S & I is packaged. This is something that should be discussed between OR administration, Radiology administration, and the overall financial administration of the hospital. Perhaps OR will code the surgical codes (36247, 37204, etc.), and radiology will code the 70000 codes (75894, 75898, etc.) The radiology department's codes will edit against the surgical codes, but the rad department may get "credit" for it. That's something you need to figure out internally.

    The physician/s, of course, are going to be coding the same codes. They are billing for the physician's (professional) work involved. Their coding doesn't impact yours unless they forget to put -26 modifier on the 70000 codes.

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