Maximizing Reimbursements And Compliance

Outlook for ASCs providing cardiology and vascular surgery care

Historically, cardiology and vascular procedures were performed exclusively in a hospital setting. Nearly 20 years ago, however, many of these procedures began migrating to outpatient settings, such as renal dialysis centers, catheterization labs and endovascular labs, otherwise known as office-based vascular interventional laboratories (OBLs). The primary drivers for this movement included convenience, shorter appointment wait times and better outcomes for patients; greater control of technology and staffing, plus improved reimbursement, for physician owners of OBLs; and significant cost savings for payers.

Recently, due heavily to improvements in medical technologies—which now allow for more complex procedures to be performed in an outpatient setting—combined with significant reductions in reimbursement for certain procedures in an OBL, many OBLs have launched ASCs and now operate in a hybrid OBL/ASC model. For example, the severe reductions in OBL-based reimbursement in the dialysis vascular access service arena in 2017 made it difficult for these facilities to survive, let alone thrive. In a hybrid model, the facility operates as an OBL on certain days of the week and as an ASC on the other days of the week. By moving to a hybrid model, these groups are able to take on additional and more complex procedures, thus providing a high-quality and convenient solution for their patients. This, in turn, simultaneously increases the volume and reimbursement for the providers and significantly improves the utilization and efficiency of the OBL/ASC.

While there has been a significant increase in Medicare-approved cardiology and vascular procedures that can be performed in an ASC recently, there still are many procedures that are not yet approved to be performed in an ASC. Thus, the two best options to perform such procedures in an ASC today would either be in a hybrid OBL/ASC, or in an already existing multispecialty ASC that can be tailored to perform such specialized procedures. Due to continued advancements in medical technology, however, it is highly likely that Medicare will approve more complex cardiology and vascular procedures, such as aneurysm repairs and carotid stenting, to be performed in an ASC. When approved. single-specialty cardiology and vascular ASCs will be fully utilized and highly profitable.

If an OBL makes the decision to move to a hybrid OBL/ASC, it will have to tackle numerous issues to make the transition. These issues include, in most states, obtaining a certificate of need; complying with the federal and state fraud and abuse and self-referral laws; obtaining and maintaining an ASC state license; satisfying the Medicare Conditions for Coverage; and focusing on key operational and revenue cycle differences in an ASC as compared to an OBL, such as scheduling, registration, billing, coding and practice management.

Revenue Cycle and Coding Considerations

If an OBL makes the decision to move to a hybrid OBL/ASC, it is critical to place significant emphasis on training, particularly for the scheduling and medical coding functions. Given that the facility will be operating part time as an OBL and part time as an ASC, the scheduling team must be well-versed in the types of procedures that should be scheduled in an OBL as compared to an ASC, and be aware of the dates for each. Handling this correctly or incorrectly has a definite ripple effect on the rest of the revenue cycle and, ultimately, on reimbursement.

When an OBL adds in an ASC, it is critical that the facility has a highly experienced ASC coding team handling the work as ASC coding is significantly different from OBL coding. Ideally, the coders would all be ASC-certified and have significant cardiology and/or vascular experience to fully appreciate and manage the numerous differences.

For example, a procedure performed in an OBL, or place of service 11, would have only one claim coded and submitted for reimbursement. It would be on the professional or physician claim referred to as a CMS 1500 claim form. On the other hand, if a procedure were performed in the ASC, or place of service 24, two claims would need to be coded and submitted, with the professional claim on a CMS 1500 form and the facility claim on either a CMS 1450 form (UB 04) or a CMS 1500 form, depending on the payer’s requirements.

Further, device insertion or replacement codes such as pacemakers, implantable cardioverter-defibrillators (ICD), and event recorders have an ASC payment indicator of J8, which means that the procedure is considered device-intensive. Therefore, for an ASC, Medicare’s payment for the generator/supply is built in to the reimbursement of the procedure code billed by the facility. When used in an OBL, however, the same devices can be reimbursed separately by Medicare.

A few examples of add-on codes and other ancillary services that are often provided in conjunction with the primary procedure codes, which are not reimbursable by Medicare to an ASC since they are bundled in with the primary procedure but are reimbursable in a professional, or OBL setting, include:

1. CPT 33225 – Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (e.g., for upgrade to dual chamber system).
2. CPT 93641 – Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads, including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator.
3. 36907-36909 – Central segment dialysis circuit interventions.
4. CPT 7xxxx series – Codes for imaging and guidance.

In addition, it is critical that the coders stay informed about the cardiology and vascular procedures that are getting approved by Medicare to be performed in an outpatient setting, as the list is increasing rapidly. It is equally important to regularly track the changes in reimbursement. As an example, as mentioned above, one of the drivers for OBLs to move to a hybrid model was the drastic reimbursement reduction that OBLs suffered at the beginning of 2017. Specifically, significant changes in reimbursement for dialysis vascular access care were implemented in 2017 by CMS because of a new payment policy requiring services to be bundled if they are billed together more than 75 percent of the time. These reimbursement changes impacted the most commonly performed interventional services, thus placing enormous financial pressure on OBLs. Examples include a 32 percent reduction in the fee for angiogram of access (CPT 36901), a 40 percent reduction in the fee for angiogram with angioplasty (CPT 36902), a 30 percent reduction in the fee for thrombectomy (CPT 36904), and a 20 percent reduction in the fee for thrombectomy with angioplasty (CPT 36905).

While there are many more examples, these highlight the necessity of having a strong operational team with highly experienced ASC coders, who are regularly tracking newly approved outpatient procedures and aggressively monitoring reimbursement increases and decreases.

This is an exciting time for the cardiology and vascular professions, as many of their procedures will be rapidly transitioning to outpatient settings, be it an OBL, a hybrid OBL/ASC, a multispecialty ASC or even a single-specialty ASC that has sufficient volume to thrive. This is a win-win-win situation for patients, providers and payers alike.

When an OBL adds in an ASC, it is critical that the facility has a highly experienced ASC coding team handling the work as ASC coding is significantly different from OBL coding. —Jessica Edmiston and Wendy Horton

Jessica Edmiston is Senior Vice President, Coding, for National Medical Billing Services in Chesterfield, Missouri.  Wendy Horton is a certified interventional radiology cardiovascular coder for National Medical Billing Services. 

Source: ASCA Focus April 2018 – Maximizing Reimbursements and Compliance

This post was first published April 1, 2018 and was updated July 29, 2020.

Jessica Edmiston, Senior Vice President, Coding

Jessica Edmiston BS, CPC, CASCC AHIMA Senior Vice President, Coding Jessica leads National Medical's outstanding coding team that is comprised of the most experienced and skilled surgical coders in the country. She obtained her Bachelor of Science in Education from the University of Missouri in St. Louis and has been credentialed with the highly acclaimed Certified ASC Coder (CASCC™) Credential. Additionally, Jessica is an approved ICD-10-CM trainer through AHIMA. Nationally renowned for her coding expertise, Jessica is requested by name to speak at large conferences and authors numerous articles in medical trade journals and publications. Working closely with National Medical’s Performance Review department, Jessica identifies coding compliance issues and areas of missed revenue while proposing best practice coding solutions. Jessica also ensures the coding team receives continuing education to remain abreast of the medical coding updates while deepening their coding expertise. In her free time, Jessica enjoys traveling to beaches as well as camping and exploring several of the beautiful national parks of Utah.

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