ambulatory surgical center (asc) billing practices ... · o for billing information refer to...

WYASC Conference

Ambulatory Surgical Center (ASC)

Billing Practices

September 26, 2014

Presenters: Sheree Nall, Provider Services Manager, Division of Healthcare Financing

Amy Buxton, Field Representative, Xerox State Healthcare

Why the change?

September 29, 2014 2

Wyoming Medicaid implemented the new reimbursement methodology for Ambulatory Surgical Centers (ASCs) effective July 1, 2014 to better align its reimbursement for services provided by ASCs with those for services provided in other in other outpatient settings. The new payment system is based on Wyoming Medicaid’s Outpatient Prospective Payment System (OPPS) and uses Medicare’s relative weights and the Wyoming Medicaid method of payment for each service (this is referred to in the OPPS system as the status indicator) for each procedure code. Wyoming Medicaid adopted Medicare’s OPPS status indicators for most services, with some adjustments for Wyoming Medicaid policies.

Ambulatory Surgical Center

Ambulatory Surgical Center (ASC) services are services provided in a licensed, freestanding ambulatory surgical center. Surgical center services do not include practitioner or anesthesiologist services. ASC services must be provided by or under the direction of a licensed practitioner.


Covered Services

• Facility services include items and services furnished by an ASC in connection with a procedure normally covered on an outpatient basis in a hospital.

• No inpatient services are allowed to be performed at an ASC.


Billing Claims with Dates of Service Prior to July 1, 2014

• Billed on CMS-1500 Claim Form • Must bill the same procedure codes as the practitioner • Procedure Code Range 10021-69990 • Reimbursed off ASC Grouping • Modifiers 51 (multiple procedures) and 50 (bilateral procedures)

allowed • CMS-1500 Provider Manual

o Refer to Chapter 6 for information regarding completing the CMS-1500 Claim Form

o Refer to Chapter 10, Section 10.6 for Ambulatory Surgical Center billing information

• Claim adjustments for these dates of service must be completed on CMS-1500 Claim Form

NOTE: When Medicare is the primary payer on a claim, the claim must be submitted to Wyoming Medicaid the same as it was submitted to Medicare (claim form, coding, etc.).


Billing Claims with Dates of Service On and After July 1, 2014

• Billed on UB-04 Claim Form • Must bill the same procedure codes as the practitioner • Use Bill Type 831 • Use Revenue Code 0490 • Procedure Code Range 10000-69999 • Reimbursed using OPPS (Outpatient Prospective Payment System) • Must use appropriate OPPS modifiers • Modifier 51 (multiple procedures) is not allowed • Institutional/UB Manual

o Refer to Chapter 6 for information regarding completing the UB-04 Claim Form o For billing information refer to Chapter 11, Section 11.1.1 (Ambulatory Surgical

Centers), 11.11 (Sterilizations), 11.12 (Surgical Services), 11.15 (Outpatient Non-Covered Services), and 11.16 (OPPS Reimbursement, Definitions, Billing Tips and Guidelines)

o Claim adjustments for these dates of service must be completed on UB-04 Claim Form

NOTE: When Medicare is the primary payer on a claim, the claim must be submitted to Wyoming Medicaid the same as it was submitted to Medicare (claim form, coding, etc.).


UB Billing

• ASCs must bill using the same procedure codes as the practitioner.

• All services should be coded using the standard coding guidelines and rules established by the American Medical Association.


UB04 Claim Form


Reimbursement Methodologies With the new Methodology, services are reimbursed based on one of the following three approaches, based on the status indicator. • An Ambulatory Payment Classification (APC) fee schedule

– For the ASC reimbursement methodology, an ASC specific conversion factor for APC-paid services. The effective Wyoming Medicaid ASC conversion factor for CY 2014 is $40.00.

• A separate Wyoming Medicaid fee schedule • A percent of charges

– These services will be reimbursed using the average general hospital Medicaid cost-to-charge ratio calculated annually for Wyoming Medicaid’s inpatient level of care participating providers.


Bill Type, Revenue Codes and Procedure Codes


• Claims must be billed using Bill Type 831, with Revenue Code 0490, and the procedure code range of 10000-69999

• Under OPPS Pricing, payment calculations are dependent on CPT/HCPCS procedure codes at the line level.

• ASCs are advised to ensure the accuracy of the procedure codes, accompanying units, and appropriateness of the accompanying revenue code.

UB Field

42 – Rev Code

44 – Procedure Code

45 – Date of Service

46 – Units

47 – Total Charges

Payment Method

Payment Amount

0490 48102 7/14/14 1 $616.00 APC $417.08

APC Fee Schedule Refer to the APC fee schedule appropriate for the date of service to

determine the payment when paid under the APC (Ambulatory Payment Classification) method.


APC Fee Schedule


Status Indicators The status indicator directs payment of the line item. Each procedure code’s specific status indicator can be reviewed by using the APC or Wyoming Medicaid Fee Schedule. The status indicators used by the Division of Healthcare Financing (DHCF) are based on the indicators used by Medicare with DHCF specific indicators:



Fee Calculation – In its simplest form, the calculation of an APC assigned procedure code is: (relative weight) x (conversion factor) = payment

40.3317 (relative weight) x $40.00 (ASC conversion factor) = $1613.27 (payment)

Modifiers


• Modifiers add clarification and specificity to procedures. Failure to use modifiers or use of an incorrect modifier may adversely affect the payment for some outpatient services.

• OPPS does not accept the use of the 51 modifier.

Level I (CPT) Modifiers Level II (HCPCS) Modifiers 25 50 63 73 91 BL CA EA FA GA J1 KG LC Q0 P1 RC TA

27 52 74 CR EB F1 GG J2 KK LD Q1 P2 RT T1

33 58 76 EC F2 GH J3 KL LT P3 T2

59 77 E1 F3 GR KT P4 T3

78 E2 F4 GS KU P5 T4

79 E3 F5 GZ KV P6 T5

E4 F6 KW T6

F7 KY T7

F8 T8

F9 T9

Bilateral Procedures


When billing bilateral procedures, bill the procedure code on one line and one unit and bill with modifier 50.

OPPS Quarterly Updates


For all updates, Medicaid will make the following specific, targeted updates to the OPPS system: • Implement the IOCE for outpatient hospital claims processing each

quarter • Annually implement adjusted OPPS conversion factors for ASCs and

the three hospital types (general hospitals, critical access hospitals and children’s hospitals)

• Delete procedure codes that Medicare deletes • The allowed modifiers can also change

In addition, Medicaid will continue to implement the quarterly changes one quarter after the information is received from CMS. However, to address providers’ concerns regarding the implementation and effective date of procedure codes, quarterly updates will have the same effective date for Medicaid as for Medicare. Therefore, to be paid in accordance with the most recent quarterly update, providers must resubmit/adjust (as applicable) their claims after Medicaid’s implementation of the quarterly changes.

Resources

Important Phone Numbers • Provider Relations

800-251-1268 press 1, 5, 0 (to speak with an agent)

o Claims Questions o Procedure Codes o Eligibility o Payments o Verify Client Information o Remittance Advices

• EDI Services 800-672-4959, press 3

o Electronic Billing Questions o Web Portal Troubleshooting o Web Portal Password Resets

Important Web Resources • Wyoming Medicaid http://wymedicaid.acs-inc.com

o Provider Manuals o APC Fee Schedule o Wyoming Medicaid Fee Schedule o Secure Provider Web Portal o Electronic Billing


Questions?


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