The beginning of a new year in the ambulatory surgery center industry is rapidly approaching. Along with a new year, comes a series of changes impacting ASC workflow and reimbursement. Three industry experts outline five of the biggest coding and billing changes to anticipate for 2015.
1. ICD-10. When signed into law in April, the Protecting Access to Medicare Act of 2014 effectively delayed ICD-10 implementation until Oct. 1, 2015. Though the switch to the new code set will take place 10 months into the year, the ramifications make it one of the biggest changes to anticipate — the shift from approximately 14,000 ICD-9-CM codes to 68,000 ICD-10-CM codes is no small step to take. "It could take [ASCs] six months to a year to get up to speed," says Michael Orseno, revenue cycle director with Regent Surgical Health.
In addition to preparing all software and staff internally, ASCs will need to form closer ties with physician office coding staff. "We will see an increasing collaboration between provider facilities and physician offices," says Mr. Orseno. "Submitting a claim with different codes from the physician's office and the ASC may delay payment."
"The overall impact of ICD-10 on revenue is still not known, other than there will be the usual sort of factors that cause cash to decrease in the short term, i.e., errors in implementing systems, learning curve for coders, payers' internal systems not working as expected, etc.," says Francisco Silva, operations manager with abeo.
2. CPT code updates. The American Medical Association is set to release 2015 updates for its Current Procedural Terminology code set on Nov. 1. Last year, upper GI/endoscopy codes were reviewed and nearly 25 percent of the CPT code changes affected the field of gastroenterology. This year, lower GI codes, including those for colonoscopy, are up for review. Radiology and pain management will also be affected by the CPT code changes, says Ladonna Schaad, coding compliance manager with abeo.
3. Modifier -59 change. CMS is creating four new HCPCS modifiers to define subsets of modifier -59, which denotes a "distinct procedural service." The four new HCPCS included:
• XE Separate Encounter:
• XS Separate Structure
• XP Separate Practitioner
• XU Unusual Non-Overlapping Service
"We can still use modifier -59, but CMS has the right to insist there is a more specific modifier needed," says Ms. Schaad. "Column 1 and column 2 CPT codes will the most impacted."
4. Bundled codes. ASC leaders can expect to see the bundling of multi-level pain procedures in 2015. "CMS is no longer allowing more than one level of pain procedure. They are not paying on more than one code," says Mr. Orseno. "We can expect to see other major payers follow this lead." The bundling of codes will lead to a decrease in reimbursement for a number of pain procedures performed in ASCs.
Radiology is also being impacted by bundled codes. "We are seeing ever increasing bundling with radiology and ultrasound codes," says Ms. Schaad. "Three new joint arthrocentesis codes for 2015 will include ultrasonic guidance, which will impact reimbursement."
5. Increase in MNRPs. Mr. Silva forecasts that more payers will begin to increasingly offer Maximum Non-Network Reimbursement Plans, or Medicare-based plans, which have lower rates of reimbursement. "With the increasing volume of MNRPs, payers are opting to reimburse at the lower Medicare rate than historic reimbursement rates, i.e., PPO or commercial-based plans," says Mr. Silva. "An analysis should be done comparing the CYTD and PYTD payer and case mixes and based on the results of that analysis, the ASC directors need to be educated on how the cash flow will be impacted."
6. Payer demand for specificity. Payers will not only expect providers to adhere to the increased specificity of ICD-10, but many are also calling for complete medical records prior to claim adjudication. Failure to supply complete medical records for these payers can lead to claim denial and loss of appeal rights. Perform an analysis of payer mix to determine which payers are calling for information. "The revenue cycle management office could then be proactive by dropping the claims to paper for those particular payers/procedures and including the complete medical records on the first submission," says Mr. Silva. "The ASC's RCM office needs to respond to the issue quickly and efficiently."
More articles on coding and billing:
Does Medicare reimbursement favor surgeons?
ICD-10 update: 40% of providers have yet to perform impact assessment
When negotiating contracts, look to the future
1. ICD-10. When signed into law in April, the Protecting Access to Medicare Act of 2014 effectively delayed ICD-10 implementation until Oct. 1, 2015. Though the switch to the new code set will take place 10 months into the year, the ramifications make it one of the biggest changes to anticipate — the shift from approximately 14,000 ICD-9-CM codes to 68,000 ICD-10-CM codes is no small step to take. "It could take [ASCs] six months to a year to get up to speed," says Michael Orseno, revenue cycle director with Regent Surgical Health. In addition to preparing all software and staff internally, ASCs will need to form closer ties with physician office coding staff. "We will see an increasing collaboration between provider facilities and physician offices," says Mr. Orseno. "Submitting a claim with different codes from the physician's office and the ASC may delay payment."
"The overall impact of ICD-10 on revenue is still not known, other than there will be the usual sort of factors that cause cash to decrease in the short term, i.e., errors in implementing systems, learning curve for coders, payers' internal systems not working as expected, etc.," says Francisco Silva, operations manager with abeo.
2. CPT code updates. The American Medical Association is set to release 2015 updates for its Current Procedural Terminology code set on Nov. 1. Last year, upper GI/endoscopy codes were reviewed and nearly 25 percent of the CPT code changes affected the field of gastroenterology. This year, lower GI codes, including those for colonoscopy, are up for review. Radiology and pain management will also be affected by the CPT code changes, says Ladonna Schaad, coding compliance manager with abeo.
3. Modifier -59 change. CMS is creating four new HCPCS modifiers to define subsets of modifier -59, which denotes a "distinct procedural service." The four new HCPCS included:
• XE Separate Encounter:
• XS Separate Structure
• XP Separate Practitioner
• XU Unusual Non-Overlapping Service
"We can still use modifier -59, but CMS has the right to insist there is a more specific modifier needed," says Ms. Schaad. "Column 1 and column 2 CPT codes will the most impacted."
4. Bundled codes. ASC leaders can expect to see the bundling of multi-level pain procedures in 2015. "CMS is no longer allowing more than one level of pain procedure. They are not paying on more than one code," says Mr. Orseno. "We can expect to see other major payers follow this lead." The bundling of codes will lead to a decrease in reimbursement for a number of pain procedures performed in ASCs.
Radiology is also being impacted by bundled codes. "We are seeing ever increasing bundling with radiology and ultrasound codes," says Ms. Schaad. "Three new joint arthrocentesis codes for 2015 will include ultrasonic guidance, which will impact reimbursement."
5. Increase in MNRPs. Mr. Silva forecasts that more payers will begin to increasingly offer Maximum Non-Network Reimbursement Plans, or Medicare-based plans, which have lower rates of reimbursement. "With the increasing volume of MNRPs, payers are opting to reimburse at the lower Medicare rate than historic reimbursement rates, i.e., PPO or commercial-based plans," says Mr. Silva. "An analysis should be done comparing the CYTD and PYTD payer and case mixes and based on the results of that analysis, the ASC directors need to be educated on how the cash flow will be impacted."
6. Payer demand for specificity. Payers will not only expect providers to adhere to the increased specificity of ICD-10, but many are also calling for complete medical records prior to claim adjudication. Failure to supply complete medical records for these payers can lead to claim denial and loss of appeal rights. Perform an analysis of payer mix to determine which payers are calling for information. "The revenue cycle management office could then be proactive by dropping the claims to paper for those particular payers/procedures and including the complete medical records on the first submission," says Mr. Silva. "The ASC's RCM office needs to respond to the issue quickly and efficiently."
More articles on coding and billing:
Does Medicare reimbursement favor surgeons?
ICD-10 update: 40% of providers have yet to perform impact assessment
When negotiating contracts, look to the future