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Coding Cues: Answers to your questions about...


ASC payment changes; low reimbursement for injectables; document before you submit

Key Points

Changes to the ASC payment system

Our group owns an ambulatory surgery center. We heard that Medicare changed the ASC payment system effective Jan. 1, as well as the list of ASC-approved procedures. Will these changes affect our bottom line?

Probably. The ASC facility payment will be equal to about 65 percent of what Medicare pays a hospital for the same procedure performed in its outpatient department. And now, just as in the hospital, CCI edits and multiple procedure reductions will apply to ASC services. So the order of the procedures submitted on the claim form will affect your overall compensation; you'll receive 100 percent of the allowable charges for the first procedure and 50 percent for every one thereafter.

Numerous other issues affect the reimbursement process, so it's best to evaluate each procedure you plan to do and weigh the costs associated with providing it in an ASC setting against the revenue generated. Monitor your specialty societies for reimbursement information concerning the procedures you typically perform.

Low reimbursement for injectables

Much as I don't wish to, I may have to stop providing my patients with injections. The reimbursement doesn't cover the cost of the drug, much less the cost to administer it. Any tips on how to deal with this problem?

First, make certain you're reporting the correct units of service for the drugs you administer. J codes-used to identify the medicine you inject-come in units, and you may need to charge for more than one unit to fully cover an injection. For instance, one unit may equate to 10 mg, but you or your nurse administers 20 mg. In this case, you should submit two units on the claim form.

Another option is to give the patient a prescription for the injectable. He can then fill it at the pharmacy, and return to you to administer the shot. Inconvenient? Perhaps. But you'll avoid the cost of buying the drugs yourself.

Document before you submit

We perform diagnostic testing in our office. One member of our group looks at the results while the patient's still in the office, uses that information to help determine the plan of care, but doesn't dictate the results until weeks later. We submit the claim for the testing immediately after we see the patient, but should we hold all claims until the findings are documented?

Yes. Although your colleague may indicate a preliminary impression in a chart note that documents the plan of care, you're billing for the complete procedure before the professional component has been rendered. Technically, that's a no-no. Encourage your associate to dictate promptly. You might consider penalizing doctors financially for their tardiness, which is what some practices have decided to do to encourage timeliness.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.

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Jennifer N. Lee, MD, FAAFP
© National Institute for Occupational Safety and Health
© National Institute for Occupational Safety and Health