A significant number of ASCs are overlooking a potential billing opportunity that may be leaving hundreds of thousands of dollars on the table, says John Poisson, executive vice president and strategic partnerships officer at Physicians Endoscopy.
"In the ASC environment, when you perform multiple, separate maneuvers, if both are properly documented, those are two billable events," he says.
For example, if, during a colonoscopy, in one part of the colon you perform a polypectomy and then in another part of the colon, that is separate and distinct, you do a biopsy, these are two separately billable maneuvers. Medicare, and many of the payors who emulate the Medicare rules, will reimburse this second maneuver at 50 percent of the first one.
"I can't tell you how many times I've had pushback over the years from doctors saying 'you can't bill for that second one or we never do that,'" he says. "There is so much money left on the table. We're not talking about cheating the system or doing anything wrong; we're talking about coding correctly per the Medicare rules." (View section 40.5 on payment for multiple procedures in the "Medicare Claims Processing Manual" by clicking here (pdf))
ASCs losing thousands of dollars
Failing to bill for this maneuver can add up to significant lost reimbursement very fast. If you're in the average U.S. market where you're getting $425 for a colonoscopy, then that secondary maneuver is reimbursed at $212.50. "Do that a thousand times a year, and that's real money," Mr. Poisson says.
Physicians, he says, typically understand they can bill for a second procedure at 50 percent when they do a flip, such as an upper endoscopy and a colonoscopy in the same day. But when it comes to billing for a second maneuver, this concept is more foreign to them.
The reason, Mr. Poisson says, it might be foreign is billing for the second maneuver works very differently on the professional fee side. "Generally for that secondary maneuver all they get is a delta between the reimbursement of those two CPT codes. Let's say they get paid $220 for one CPT, they get $200 for the other. They end up getting $20 [for the second maneuver]."
Getting paid is simple
So how should ASCs not billing for this second maneuver capture the reimbursement they are losing? "The key is it has to properly documented," he says. "They have to be separate and distinct maneuvers. It's not like you can do a biopsy over here and a biopsy over there; those are similar maneuvers even if they are in different parts of the colon."
If the second maneuver is document properly, Mr. Poisson says clinical report writing software typically have internal coding engines which are very good at making sure that documented maneuver receives a secondary CPT code for billing purposes.
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