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The following was written by Cristina Bentin, CCS-P, CPC-H, CMA, principal of Coding Compliance Management.
It is recommended that providers — whether ambulatory surgery centers or physicians — review the Office of Inspector General's 2011 Work Plan to proactively identify any areas that may need to be internally audited to ensure compliance. Here are three areas of interest for ASCs in the Work Plan.
1. ASC Payment System. The OIG will continue to review the appropriateness of the rate-setting methodology used to calculate ASC payment rates under the revised ASC payment system. Recall, section 626(b) of the Medicare Modernization Act requires the Secretary to implement a revised payment system for payment of surgical services furnished in ASC facilities.
2. Claims deemed not reasonable and necessary. The OIG will review Medicare payments for Part B claims that providers indicate, via application of the -GA or -GZ modifier, as not reasonable and necessary. Recall, the CMS Claims Processing Manual states that providers may use -GA or -GZ modifiers on claims they expect Medicare to deny as not reasonable and necessary with the difference in modifier selection determined by whether an ABN is on file. The OIG will determine the extent to which Medicare inappropriately paid for Part B claims with these modifiers, as well as the types of providers and the types of services associated with these claims. A recent OIG study estimates over $4 million dollars in inappropriate payments.
3. Medicare billings with modifier -GY. The OIG will review the appropriateness of providers' application of modifier -GY on claims for services that are not covered by Medicare. Modifier -GY is to be used for coding services that are statutorily excluded or do not meet the definition of a covered service. Beneficiaries are responsible, either personally or through other insurance, for all charges associated with the provision of these services, and providers are not required to give beneficiaries advance notice of charges for services that are excluded from Medicare by statute. According to the OIG, "beneficiaries may unknowingly acquire large medical bills for which they are responsible." While the OIG may be focusing on physician and supplier applications of this modifier, ASC facilities should beware.
ASC facilities should keep in mind, the -GY modifier should not be appended to HCPCS codes found on Medicare's ASC list of approved procedures/supplies that are listed with a payment indicator N1 since reimbursement is "packaged" into the primary procedure performed and not deemed "statutorily excluded."
To contact Cristina Bentin and learn more about Coding Compliance Management, visit www.ccmpro.com.
The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Read more insight from Cristina Bentin:
- 10 ASC Coding Challenges and Guidelines That May Impact Your ASC's Bottom Line
- 10 Best Practices for Establishing Internal Coding Audits
- ICD-10 Implementation for ASCs: What You Must Do Now