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Please define "Pass Through" Where can we obtain the pass-through status items list? What is the address of the CMS website that has the 'addedndum AA' and 'addendum BB'? Do these addenda include a list of HCPCs codes ( eg. implants, screws, etc)? Where are the spreadsheets you are referencing? On the package items, can you roll the charge up into the primary CPT cost to capture the dollars? Pass through status means and item we can separately report for additional payment outside the "packaged price". Pass through status is assigned to certain implants, drugs or services and allows us to bill separately for these implants, drugs or service and get payment in addition to the payment for the "packed price" for the surgery. www.cms.gov/ascpayment Yes, these addenda contain a list of the HCPSC codes we would use for screws and inplants (it does not list any brand names, just the code). They can be found on the CMS website under specialty provider type - a link is included in the presentation That is what the packaged price is, CMS uses a formulary to set the price for these surgical procedures and they take into account all factors that are used to perform this procedure and the allowable covers all of these. When you set your price for these procedures, you should also take account everything you use to set fee.
When we bill the secondary for J8 codes and Medicare allowed only on the procedure code, the secondary ins allowe amount does not include th implant cost, so they do not generally pay anything after medicare pays. How can we bill t so the secondary, for example bcbs wil allow for the implanted item? Will you repeat the "V" codes that you add to bill the ACIOL and PCIOL? What's the difference between -52 and -74 if the surgeon decides to stop after anes? Did you bill the code with J8 Status separately to Medicare? You should not, this cost for this should be included in your fee for the actuall surgical procedure. If you price it this way, the secondary insurance carrier should pick up the difference from what Medicare approved and paid. V2787 fpr ACIOL's and V7288 for PCIOL's 52 modifier is used to report a reduced service meaning the provider decided not to do the whole procedure for some reason (usually cancer to advanced, etc). The 74 modifier is used when there are circumstances that effect the health and safety during the procedure, either the patient's blood pressure gets to high or to low, or some other occurance happens and for the well being of the patient, the procedure is stopped. Each note should reflect why the procedure was stopped, how much was done and should be submitted to the carrier with appropriate modifiers. What about bilateral modifier -50? Are finger/toe modifiers allowed for specificity? Not all carriers will accept, go to your intermediaries site and your payer websites to find out Yes, they are allowed by some payers for specificity and can stop denials for duplicate procedures. Check your carriers websites
Is modifier 51 allowable in an ASC? What if surgery is a multiple procedure and one of the procedures was discontinued and the other was completed? Do we still bill the discontinued procedure with mod -74? and the continued procedure as usual? Should the PT modifier be attached to the ASC suite fee in addition to the professional charge? Medicare does not want the 51 modifier added to on any of their claims. Some payers will allow. Yes, you should always bill for all procedures during an operative session even if one was discontinued. Make sure the op note shows completion of one procedure, how far you got on the discontinued procedure, why it was discontinued and use the appropriate modifier when filling for payment. Certainly. If a payer states no co-insurance for a screening procedure for the ASC, they we need to let them know we had to convert this procedure from a screening to a diagnostic so we are paid appropriatley. Check to see what the patients benefits state when this situation occurs.
The secondary often uses their own allowed amount for each code that was paid by Medicare. The secondary allowed amounts do not include the implant cost, they would normally pay the implant separately if the were primary. You may not be paid. You should not file for an implant that is included in the packaged price for Medicare. This is not a clean claim. If you need a denial from Medicare you can try using one of the G modifiers. Either the GZ or the GY - either is perfect as GZ states the item is not reasonable or necessary and you expect to be denied. In truth, the implant is necessary and you ARE getting paid in the packaged price. The GY is to receive a denial for items or services that are statutorily excluded, meaning that do not meet the definition of any Medicare benefits and for non-medicare insurers, it means it is not a covered item. I realize each insurance carrier has their own fee schedule and most only pay all or a portion of what Medicare approved and did not pay. Contact your provider rep for the insurance carrier and make sure you are filing to their requirements. Are you going to go into the quality reporting G-codes? Not in this presentation. Our faciltiy bills implants with L8699, is there a better code to use? Probably, L8699 is a generic inplant code - the HCPCS manual has specific codes for some implants such as L8620 for a metacarpophalangeal joint implant and L8642 for a Hallux implant - find out what the implant is, review the manual and assign the most specific code
Mod 51 does not affect payment (multiple procedure rule would apply no matter what, regardless of mod 51 being added or not) I have seen Medcare put the 51 on the claim when it comes back on the EOB, So, if you are non participating, you cannot find out the commercial policies because they require log on. So much for transparancy :( Should modifier 59 be used in place of modifier 51 if 2 separate procedures were done? Is a provider still allowed to bill with Modifier SG? What about modifier "33" for commerical preventive? would you not use this instead of PT? Does CMS apply multiuple surgical guidleines to bilateral Add on codes specifically? For example 66493-50 and 64494-50 and 64495-50. That is correct and why we don't need to add for Medicare claims Yes, they will assign that code themselves This may or may not be true, if you don't participate with Cigna for example, you may still be able to access information, call the plan and find out the rep for your area. Yes, the 59 may be needed when procedure have an NCCI edit. Double check each plans requirements No, the SG modifier was deleted a few years ago It is possible they want the PT OR the 33. You will need to contact your payers or search the website. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, the bilateral adjustment is applied BEFORE applying any multiple procedure rules.
Are there any Medicare guidelines for NCCI facility edits? Or do the physician NCCI edits apply to facilities for Medicare also? NCCI Edits-Physicians These code pair edits are applied to claims submitted by physicians, non-physician practitioners, and Ambulatory Surgery Centers (ASCs)(provided the code is listed as one of the Medicareapproved ASC procedures). Website to print the how to use manual from MLN (Medicare Learning Network) is: www.cms.gov/outreach-and-education/medicare-learning- Network.MLN/MLNProduct/Downloads/How-to-Use- NCCI-Tools.pdf What about modifier "33" for commerical preventive? would you not use this instead of PT? When multiple procedures are billed is there a CMS guidline that outlines the order in which the procedures should be paid. For example by highest allowed? You might. The 33 modifier is for use with Task force services under A or B rating. Check what services fall under these ratings and you commercial carrier to see which on they prefer. Yes, the highest allowable (or one with the highest RVU's) should be paid at 100% and then each remaining one cut to 50% of the allowable. From experience, Trailblazer will pay correctly regardless of order on the claim form but to be sure, it is always best to rake them correctly We are still discussing Cigna correct? Was there other information in your question or did you ask an earlier question? I may need to review the transcript and answer. I cannot determine which questions was yours. To clarify use of 73 and 74, the patient must be back in OR, not the preop area? Yes, once the patient is in the room and physician makes determination
Does the ASC also bill for 64415 ( intrascalene block) that is adminstered by the Anesthesiologist, during a shoulder arthroscopy? Does Medicare deny bills if we bill with the -SG modifier? It is on the approved procedure list but should be billed by the anesthesiologist Check the drug administered on the addenda to see if it is separatley reportable. Here is an a link to the transmittal regarding the deletion of the SG modifier: www.cms.gov/regulationsandguidance/transmittals/download//rc1638cp.pdf. Read the transmittal, it states: Surgical services billed for dates of service through December 31, 2007, containing the ASC facility service modifier SG must be reported as TOS F. Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services. ASC providers should discontinue applying the SG modifier on ASC facility claims. The indicator F does not appear in the TOS table because its use depends upon claims submitted with POS 24 (ASC Facility) from an ASC (specialty 49). This became effective for dates of service January 1, 2008 and after
If Modifier SG is used can the claim be denied and ask the provider to resubmit? Here is an a link to the transmittal regarding the deletion of the SG modifier: www.cms.gov/regulationsandguidance/transmittals/download//rc1638cp.pdf. Read the transmittal, it states: Surgical services billed for dates of service through December 31, 2007, containing the ASC facility service modifier SG must be reported as TOS F. Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services. ASC providers should discontinue applying the SG modifier on ASC facility claims. The indicator F does not appear in the TOS table because its use depends upon claims submitted with POS 24 (ASC Facility) from an ASC (specialty 49). This became effective for dates of service January 1, 2008 and after
For Medicare claims, our ASC wants the denial on the implant even though we know we won't be paid. Should we put the GY on the HCPCS code? Here is an a link to the transmittal regarding the deletion of the SG modifier: www.cms.gov/regulationsandguidance/transmittals/download//rc1638cp.pdf. Read the transmittal, it states: Surgical services billed for dates of service through December 31, 2007, containing the ASC facility service modifier SG must be reported as TOS F. Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services. ASC providers should discontinue applying the SG modifier on ASC facility claims. The indicator F does not appear in the TOS table because its use depends upon claims submitted with POS 24 (ASC Facility) from an ASC (specialty 49). This became effective for dates of service January 1, 2008 and after
Medicaid of Nebraska is still using the SG, are they in violation for doing this. Here is an a link to the transmittal regarding the deletion of the SG modifier: www.cms.gov/regulationsandguidance/transmittals/download//rc1638cp.pdf. Read the transmittal, it states: Surgical services billed for dates of service through December 31, 2007, containing the ASC facility service modifier SG must be reported as TOS F. Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services. ASC providers should discontinue applying the SG modifier on ASC facility claims. The indicator F does not appear in the TOS table because its use depends upon claims submitted with POS 24 (ASC Facility) from an ASC (specialty 49). This became effective for dates of service January 1, 2008 and after
If you're in the state of Ohio, Paramount still requires the SG modifier Here is an a link to the transmittal regarding the deletion of the SG modifier: www.cms.gov/regulationsandguidance/transmittals/download//rc1638cp.pdf. Read the transmittal, it states: Surgical services billed for dates of service through December 31, 2007, containing the ASC facility service modifier SG must be reported as TOS F. Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services. ASC providers should discontinue applying the SG modifier on ASC facility claims. The indicator F does not appear in the TOS table because its use depends upon claims submitted with POS 24 (ASC Facility) from an ASC (specialty 49). This became effective for dates of service January 1, 2008 and after Does CMS provide a list of surgical procedures that should have a modifier 59? Yes it is the NCCI list found on the CMS website. It doesn't not state "use the 59 modifier for these code pairs" but gives a list of procedure considered to be "bundled" or part of another procedure. If medically necessary to perform on same day, a 59 modifier should be appended.
Does CMS have a list of procedures that are not subject to multiple surgery payment reductions? Yes, it can be found on the CMS website (www.cms.gov) under the payment section - RVU files (also referred to as the MPFSDB or Medicare Fee Schedule Database). It list global days, if a code is subject to multiple procedure reductions, if it can be billed bilaterally, etc. Where can I find an updated version of the payer matrix that shows if implants can be billed and how much and lists fee pricing groups for different carriers? I think that the NCCI for OOPS is used for ASC You won't find one for all insurance carriers, you can access the one from CMS on the CMS website at www.cms.gov/ascpayment. For other payers, you will have to check you comment and put together a matrix for your payer mix. NCCI Edits-Physicians These code pair edits are applied to claims submitted by physicians, non-physician practitioners, and Ambulatory Surgery Centers (ASCs)(provided the code is listed as one of the Medicareapproved ASC procedures). Website to print the how to use manual from MLN (Medicare Learning Network) is: www.cms.gov/outreach-and-education/medicare-learning- Network.MLN/MLNProduct/Downloads/How-to-Use- NCCI-Tools.pdf 33 modifier for commerical for colonoscopy in ASC? scheduled screening turned to polpyectomy? use of 33 modifier covered? I'm wondering if any of these big insurance companies actually have accounts for students? You will need to check with your payers. They could require either one or none. You would need to contact the insurance carriers.
If billed for 64493 with Mod 50 as primary, reimbursement would be 150%, if 64494 with Mod 50 is billed as secondary how would you reminburse this bilateral? WOuld it be 50% of the LT and 25% of the RT or 50% oif the RT and 50% of the LT? Where can I get access to the Medicare groupers and their fees? just a comment - I have some payers that still require the - SG modifer (from above question) If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, the bilateral adjustment is applied BEFORE applying any multiple procedure rules. From the CMS website: www.cms.gov Here is an a link to the transmittal regarding the deletion of the SG modifier: www.cms.gov/regulationsandguidance/transmittals/download//rc1638cp.pdf. Read the transmittal, it states: Surgical services billed for dates of service through December 31, 2007, containing the ASC facility service modifier SG must be reported as TOS F. Effective for services on or after January 1, 2008, the SG modifier is no longer applicable for Medicare services. ASC providers should discontinue applying the SG modifier on ASC facility claims. The indicator F does not appear in the TOS table because its use depends upon claims submitted with POS 24 (ASC Facility) from an ASC (specialty 49). This became effective for dates of service January 1, 2008 and after
In an ASC setting, are we able to bill a diagnostic arthroscopy (29870) with 29881? CCI Edits say it is bundled but our doctor states it is allowed. Are providers allowed to bill for DMEs used in the ASC? You can NEVER bill the 29870 with another scope code within the knee. CPT states 29870 is a separate procedure code meaning it is the only service performed. A diagnostic scope is included in a surgical scope including the 29881. You could bill the 28970 with an ankle or shoulder scope code. Read the definition of separate procedures in the CPT manual, under the surgery guidelines section. Only for items that are designated as pass-through or separately reportable from the list of approved procedures. I am still a little confused about the multiple procedure If Medicare patient, you don't need the 51. If third party with a mod -74...Would I still bill a multiple procedure and -payer, I would attach the 51 just to be sure. I would first 74 for the discontined procedure? use the 74 modifier, then the 51.