BILLING FACILITY FEES - Mowles Medical Practice …

1 BILLING FACILITY fees Medicare ASC Payment Groups Once an ASC is approved for Medicare participation, the ASC can only be reimbursed for procedures that are on a list of procedures that Medicare will reimburse to an ASC. Procedures on the list fall into one of 9 groupings with a payment rate assigned to each group. The payment group is determined by the CPT procedure rendered. The groups actually have no clinical coherence but were based on a cost analysis survey last performed by CMS in 1994.

2 Medicare Unadjusted National allowances per group as below were effective October 1, 2002. GROUP 1 -- $ GROUP 2 -- $ GROUP 3 -- $ GROUP 4 -- $ GROUP 6 -- $ GROUP 7 -- $ GROUP 8 -- $ GROUP 9 -- $ (New) GROUP 5 -- $ Medicare Covered ASC Pain Management Procedures CPT 2002 DESCRIPTION Group CPT 2002 DESCRIPTION Group 62311 Epidural lumbar/sacral/caudal 1 62282 Epidural, lumbar/caudal 1 62310 Epidural cervical/thoracic.

3 1 64600 Trigeminal Nerve, any 1 62318 Inject. placement, continuous cervical/thoracic 1 62270 Spinal puncture lumbar 1 62319 Inject. Incl. Cath placement, continuous lumbar/sacral 1 64620 Intercostal: destruct 1 64410 Phrenic Nerve 1 64622 Destruct Paravetebral Facet, lumbar single 1 64415 Brachial Plexus 1 64623 Destruct Paravetebral Facet, lumbar ea. addt l 1 64417 Axillary Nerve Block 1 64626 Facet joint or facet joint nerve cerv/thor, 1st level 1 64420 Intercostal, single 1 64627 Facet joint or facet joint nerve cerv/thor, ea.

4 Addt l 1 64421 Intercostal, multiple 1 62263 Percutaneous lysis of adhesions 1 64430 Pudental Nerve 1 62273 Blood Patch 1 64479 Transforaminal, epidural cerv/thor, 1st level 1 64680 Celiac Plexus: destruct 2 64480 Transforaminal, epidural cerv/thor, ea. addt l. 1 62367 Analysis pump w/o reprogram 2 * 64483 Transforaminal epidural lumbar/sacral, 1st level 1 62368 Analysis pump with reprogram 2 * 64484 Transforaminal epidural lumbar/sacral, ea. addt'l 1 62350 Implant Catheter 2 64475 Facet, lumbar/sacral single 1 62355 Remove implanted catheter 2* 64476 Facet, lumbar/sacral addt l 1 62287 Nucleoplasty 9* 64470 Facet, cervical/thoracic single 1 62361 Non-programmable pump 2 64472 Facet.

5 Cervical/thoracic additional 1 62362 Programmable pump 2 64510 Stellate Ganglion 1 62365 Implanted pump 2 64520 Lumbar sympathetic 1 63650 Implant neurolectrode 2 64530 Celiac Plexus 1 63660 Revision/remove electrode 1 62280 Subarachnoid 1 63685 Implant spinal transmitter 2 G0260 Inj for sacroiliac jt anesth * 1 63688 Remove spinal transmitter 1 * Indicated on the table above has an effective date of addition or deletion from the ASC payment list of July 1, 2003.

6 Most covered Pain Management procedures fall into groups one or two. Some pain procedures are not on Medicare s payment list for ASC FACILITY reimbursement. These procedures then fall under Medicare s site of service differential rule, meaning professional fees are paid at the higher office site of service differential. The place of service on the physician s bill is still ASC -24. It is important to monitor the explanation of benefits for correct site of service payment on these claims.

7 Since a patient cannot be billed for FACILITY fees from procedures not on the approved list, an ASC s only advantage from supporting such off list cases may be to charge non-owner physicians rent for use of the ASC These Medicare FACILITY fees include: y Use of the FACILITY y Nursing and technician services y Drugs y Biologicals y Surgical dressings y Materials for anesthesia y Splints, casts and equipment directly related to the provision of the procedure y Administrative, record-keeping and housekeeping items and services In addition to FACILITY fees in the ASC setting, the following are paid separately.

8 Y Physician services (Professional fees ) y Laboratory expenses (Must be CLIA certified to perform lab tests or CLIA waived to perform minor labs such as glucose or pregnancy testing) y X-Rays y Diagnostic procedures other than those directly related to the surgical procedure y Prosthetic devices y Leg, arm, back and neck braces y Artificial limbs y DME for use in the patients home (typically not applicable in pain management) Implantables such as neuorstimulators and drug infusion pumps are paid by the Part B carrier-not the DME carrier).

9 Managed Care FACILITY Contracts As previously stated, in order to contract with other third party payers, Certification by Medicare as a provider of surgical services is mandatory. Many payers also require accreditation before the FACILITY can obtain a contract with them. This process, however, should be started as soon as the proposed FACILITY has filed a notice on intent as applicable in the State or the CMS applications have been filed. The credentialing process should be started by requesting FACILITY applications and then completed when the FACILITY is found to be in compliance.

10 The contract proposal from the MCO should include a fee schedule for each CPT code that the ASC will be providing. Most Managed Care contracts typically do not send their entire fee schedule that represents all of their approved fees . For procedures that are not listed on their fee schedule, it is important to ascertain how non-covered services will be paid, such as fee for service and at what percentage of billed charges. Negotiations on the FACILITY contract should include exclusions.