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September 2005

Savvy Coder: Coding & Reimbursement

How to Code for Services in the ASC: Part 3
By John M. Haley, MD, Evelyn Kelly, OCS, F. Hampton Roy, MD
Sue Vicchrilli, COT, OCS, and Trexler M. Topping, MD

What if an ophthalmologist performs a service that is not covered when performed in an ambulatory surgery center? An ASC should code what is documented in the operative report. If the procedure performed is not payable in an ASC, the ASC cannot change the code to an ASC-payable procedure. The ASC is responsible for discussing this issue with the surgeon to ensure that the procedure codes that are used describe the actual procedure performed.

When the service is not covered in an ASC, no facility payment is made and only the physician receives payment at the nonfacility higher rate. The physician—not the patient—is responsible for the ASC fee. An Advance Beneficiary Notice should not be used.

If a physician opts to perform a service that is not on the approved ASC list, the ASC should make arrangements with the physician for payment since the practice portion (or nonfacility higher rate) is paid to the physician. This can be negotiated in a variety of ways: The ASC might charge the difference between facility and nonfacility, charge fair market value or charge the amount that the hospital would receive. The ASC may ask the physician to sign a document acknowledging that he or she understands that the procedure is not on the ASC list and will be responsible for payment to the ASC. 

ASC Modifiers
Useful CPT and HCPC modifiers are as follows:

–25 Significant identifiable E&M service by the same physician on the same day of the procedure or other service.
–27 Multiple outpatient hospital E&M encounters on the same day.
–50 Bilateral procedure. Not recommended. Bilateral procedures performed during the same operative session should be reported as a two-line item with –RT and –LT modifiers. Payment for a bilateral procedure is 150 percent, typically.
–52 Reduced services.
–58 Staged or related procedure or service by the same physician during the postoperative period.
–59 Distinct procedural service. This modifier unbundles CCI edits. It also distinguishes a different session, procedure or surgery, site or organ system; a separate incision or excision; and/or a separate injury.
–73 Discontinued outpatient hospital/ ambulatory surgery center procedure prior to the administration of anesthesia. This modifier is not to be used for elective cancellations. Diagnosis codes to consider are V64.1 surgical or other procedure not carried out because of contraindication; or V64.3 procedure not carried out for other reasons. The physician appends modifier –53 discontinued service to the surgical code. 
–74 Discontinued outpatient hospital/ ambulatory surgery center procedure after administration of anesthesia. This does not include conscious sedation. If only conscious sedation is used, append modifier –52. The physician appends modifier –53 to the surgical code for the discontinued procedure.
–76 Repeat procedure by same physician.
–77 Repeat procedure by another physician.
–78 Return to the OR for a related procedure during the postop period. 
–79 Unrelated procedure or service by the same physician during the postop period.
–LT Left side.
–RT Right side.
–E1 Upper left eyelid.
–E2 Lower left eyelid.
–E3 Upper right eyelid.
–E4 Lower right eyelid.

–E modifiers, which are typically recognized only by Medicare payers, prevent claims from being rejected as duplicates.