CODING


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Department of Health & Human Services


Centers for Medicare & Medicaid Services


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42 Code of Federal Regulations Parts 405, 410, 412, 414, 416, 419 and 486


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CMS-1717-FC Hospital Outpa- tient Prospective Payment— Notice of Final Rulemaking with Comment


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RIN 0938-AT74 CY 2020 Hos- pital Outpatient PPS Policy Changes and Payment Rates and Ambulatory Surgical Center Payment System Policy Changes and Payment Rates


might be possible to buy attach- ments for general, multi-func- tional OR tables to make them compatible, thus adhering to bud- getary constraints.


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Include your business office team— coder/biller/denials/insurance—prior to the implementation of new proce- dures or new payer contracts. Afterall, they are in the trenches daily, know the contracts, see the denials, and perform the write-offs. Don’t exclude them.


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Be aware of the relative time each procedure takes and maximize use of the facility.


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Research specific payer reporting direc- tives and reimbursement(s). Determine profitability per insurance payer.


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Start negotiations with the payer early since the process can be time-consum- ing. Do your research prior to contract negotiations. Be armed with the cost analyses for your case mix. Under- stand other payer reimbursements/ comparisons based on cost per CPT so you know whether the case is prof- itable or whether you need to fight for a rate increase. Have reimburse-


ment comparables from local hospi- tals to show the payer that your facil- ity can provide a more cost-effective, higher quality service while provid- ing excellent patient care. Invoke your inner Annie Oakley and re-affirm to the payer “anything a hospital outpa- tient department (HOPD) can do, your ASC can do better, your ASC can do anything better than them.”


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Negotiate carveouts, when neces- sary, if additional implant reim- bursement is not factored into the payer’s reimbursement for the pro- cedure in which the implant is used.


Vendor Reimbursement Advice Do not rely on vendor reimbursement information/coding tips without doing your own research. Your business team is the expert and has direct access to your current payers. Involve your team in researching insurance payers, Medi- care and specialty societies. Do not assume the information from a product/ instrumentation vendor is correct with- out research. Remember, CPT codes provided by vendors might not always


16 ASC FOCUS FEBRUARY 2020 | ascfocus.org


describe the documented procedure performed. Ultimately, it is the facility’s responsibility to verify and ensure cor- rect reporting of its surgical procedures based on payer-specific directives, not vendor recommendations.


Training and Education Physician. The very fact that the sur- geon is bringing a TKA to your facil- ity is based on their critical judgment that the TKA to be performed on this particular Medicare beneficiary does not require resources only available in a hospital inpatient setting. Surgeons performing the TKA in your facil- ity should be well-trained and well- versed in the performance of the TKA prior to bringing it to your facility.


Staff. Hold an in-service before bring- ing a new procedure to the facility so the staff will understand the different aspects of the surgery from both a clin- ical and a reimbursement perspective. From a business staff aspect, ensure your entire business office is aware of the reimbursement aspects of the new procedure(s). A few considerations:


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