How ASC Payment Groups Can Affect Reimbursement
CODING Corner
How ASC Payment Groups Can Affect Reimbursement
‘Facilities can’t afford to lose any revenue in the outpatient setting.’
(Editor’s note: ADVANCE will present this new coding column on a monthly basis.)
Leaving codes off a bill or inappropriately assigning codes can have a significant negative impact on your payments. Obviously, facilities can’t afford to lose any revenue in the outpatient setting.
To help ensure that you’re getting the reimbursement you deserve, here’s a quick review of current outpatient payment methods and examples of how improper coding affects your payment.
Two Payment Possibilities
In the current outpatient arena, hospitals can receive payment in one of two possible ways for the services they provide. The CPT codes assigned and billed for the outpatient encounter determine which of the following two methods the Medicare carrier will use:
- If the CPT codes billed appear on the ambulatory surgery center (ASC) code list, the facility receives a blended rate. Specifically, that rate is 58 percent of the ASC payment group amount and 42 percent of the facility costs or charges. Hospitals use their wage index to determine what their ASC payment group rates will be.
- If the CPT codes billed do not appear on the ASC list, the facility receives a percentage of their charges.
The two reimbursement amounts may vary significantly. Therefore, it’s essential that you assign all the possible codes on the UB-92 claim form to get the payment your facility deserves.
Speaking of payment, the base rates of the ASC payment groups for services rendered on or after Oct. 1, 1995, are as follows:
Payment Group 1: $304
Payment Group 2: $408
Payment Group 3: $467
Payment Group 4: $576
Payment Group 5: $657
Payment Group 6: $769
(includes $150 intraocular lens
[IOL] allowance)
Payment Group 7: $911
Payment Group 8: $903
(includes $150 IOL allowance)
The following case studies provide examples of how correct coding affects payment. To make things easier, the examples use only the base rate for the ASC payment group.
Case 1: Hammertoe Repair
A 34-year-old female is admitted to the same-day surgery unit with a diagnosis of second, third and fourth hammertoes of the left foot. The physician brings in the patient to perform a hammertoe repair of the second, third and fourth phalanges of the left foot.
The facility coder assigned 28285, which falls into payment group 3, once for this procedure.
28285 Hammertoe operation, one toe
However, this decision was incorrect because the code should have been assigned three times for the three phalanges repaired. By not assigning the code two more times, the facility received less reimbursement than it deserved.
You can see from the comparison below the difference in reimbursement. Here’s how you would get paid if you assigned only one code.
Code Payment Group Payment Amount
28285 3 $467.00
Total Paid $467.00
If you assigned the code three times—the correct decision—this is what your payment would look like:
Code Payment Group Payment Amount
28285 3 $467.00
28285 3 $233.50
28285 3 $233.50
Total Paid $934.00
The facility receives 100 percent of the ASC payment for the first procedure and 50 percent for each additional procedure.
Case 2: Bilateral Biopsies
A 64-year-old female presented to the same-day surgery unit with a diagnosis of bilateral breast masses. The physician admitted the patient to perform bilateral incisional breast biopsies.
The facility assigned code 19101 (biopsy of breast, incisional), which falls into payment group 2, once. However, the facility should have billed it twice. As the comparison below shows, doing so makes a difference.
Code Payment Group Payment Amount
19101 2 $408.00
Total Paid $408.00
Here’s how this case should have been billed and paid:
Code Payment Group Payment Amount
19101 2 $408.00
19101 2 $204.00
Total Paid $612.00
In this example, the error originated in the business office where the biller assigned the code once and placed a number 2 in the units column on the UB-92 claim form. As already explained, to bill a bilateral procedure, the code should be included twice on the UB-92 claim form.
Make sure that the coders and billers understand the proper way to report codes for bilateral procedures and procedures that state one digit, each digit or some similar terminology.
In addition, check your Medicare bulletins for details on how to report multiple codes, and pass these guidelines on to staff.
* About the author: Peggy M. Hapner is a senior health care consultant and outpatient coding expert at Medical Learning Inc. (MedLearn®), Minneapolis. She develops publications and presents outpatient seminars on diverse topics, such as ambulatory patient groups and medical records coding. Hapner also performs coding assessments and conducts on-site training in CPT, ambulatory surgery center and emergency department coding and comprehensive data quality.
