CODING


Medicare Internet Only Manual, Pub 100-04, Chapter 14, at http://www. cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/ clm104c14.pdf, acts as the primary resource for ASC claims processing, including national contractor messaging generated when ASCs bill excluded services. Unfortunately, however, not everything is spelled out clearly in the Claims Processing Manual. CMS uses a network of contractors


called Medicare Administrative Con- tractors (MACs) to process Medicare claims, educate providers on Medicare billing requirements, handle appeals and answer beneficiary and provider inquiries. Part B MACs having juris- diction over the geographic area(s) in which these spine procedures would be performed may have local determinations resulting in additional policy or billing instructions and guidance.


An ASC that is performing these procedures, or looking to do so, is advised to reach out directly to its MAC to determine how the ASC might be reimbursed and how the MAC would process claims. The MAC would know, for instance, if there are additional billing instruc- tions in the area. Facilities should review any codes not on the CMS list of approved ASC procedures prior to the procedure and notify the patient, because any reim- bursement for non-covered codes would be the patient’s responsibility. In situations where Medicare pay- ment is expected to be denied, provid- ers issue the Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, to Original Medicare (fee for service) beneficiaries. The Medicare Claims Processing Man- ual, Chapter 30, Section 50, offers the


guidelines for mandatory and volun- tary use of the ABN. While ASCA was happy with the codes added in 2015, it raised concerns with CMS staff earlier this year about confusion within the industry stemming from the inclusion of some codes with- out others that are commonly related. ASCA staff also argued that it would not be economically feasible for many of the approved codes to be performed in the ASC setting until such time as devices and secondary codes used in conjunc- tion with the primary codes are added to the ASC payable list. Medicare’s 2016 ASC payment rule should come out in the next two or three weeks, and ASCA hopes that its advocacy efforts will lead to more spine codes being payable effec- tive January 1, 2016.


Kara Newbury is ASCA’s regulatory counsel. Write her at knewbury@ascassociation.org.


ASC FOCUS OCTOBER 2015


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