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Topic: Billing rules for devices can be different for each payer

Ambulatory Surgery Reimbursement Update, November 25, 2008

Medicare significantly changed the way it pays ASCs in 2008, but not all insurers changed. This leaves a lot of confusion, especially when it comes to billing for device-intensive procedures—and getting it wrong can cost you. Most insurers use one of three systems to pay ASCs:

  • By groupers (the way Medicare paid in 2007)
  • ASC payment system (the way Medicare pays ASCs currently)
  • Hospital outpatient prospective payment system (OPPS) (the way Medicare pays hospitals currently)

Each system has different rules for how to code services. Knowing which set of rules your payer follows is critical to getting paid correctly.

For spinal cord stimulators and infusion pumps, Medicare now bundles the device payment into the reimbursement under the ambulatory payment classification (APC) system.

“A common mistake that people make under the new ASC payment system is reporting the device code,” says Linda Van Horn, MBA, president and CEO of 21st Century Edge in Kansas City, MO. “This usually results in the claim being denied.”

For example, when ASCs bill for a spinal cord stimulator lead placement, Medicare wants the ASCs to bill for the procedure only. ASCs should bill CPT code 63650, but not the device code. In addition, if a physician places more than one lead, Medicare does not discount for multiple lead placement. Be sure to bill for each additional lead using the -51 modifier (e.g., code 63650-51.) It’s also a good idea to make sure other insurers who follow Medicare guidelines don’t discount for multiple lead placement.

Payers who use the old grouper system still want ASCs to report the L8680 device code with the CPT code 63650 when billing for spinal cord stimulators lead placement. However, other payers who use the HOPD OPPS require ASCs to report code C1778 with CPT code 63650 for the spinal cord stimulator lead placement.

“This is why there is often confusion about not knowing whether or not to code the device or which HCPCS Level II code to use to report the device,” Van Horn says. “The key is to know which system the payer is using and then report the service under those rules.”

Editor’s note: This topic is from the December 2008 issue of Ambulatory Surgery Coding and Reimbursement Insider.

 

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