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A Planning Playbook for Opening a New Orthopedic ASC
The ASC market continues its rapid growth. In 2023, roughly 116 new ASCs opened in the U.S., many of which were orthopedic-specific in nature....
Confusion reigns over when and how to use some of the new and revised codes in the 2003 edition of the Physician's Current Procedural Terminology (CPT) code book and the 2003 HCPCS codes (Healthcare Common Procedure Coding System).
In a classic case of a good intention gone awry, the 2003 CPT codebook attempted to simplify modifier codes by replacing five-digit codes with two-digit codes. For example, rather than using 09950 to report bilateral surgery, you now use a two-digit code (?50) for bilateral procedures.
Not all payers have switched to the two-digit modifiers. If you have third-party payers that require the five-digit modifiers, confirm that they will now accept the two-digit modifiers and that they are aware that five-digit modifiers no longer "officially" exist. This is crucial for making sure your payers continue to reimburse your claims without holdups over the modifiers.
Confusing codes
The "simplified" modifiers aren't the only problem for ASCs. Many specialties have new or revised 2003 codes that are causing confusion.
- Dermatology/plastic surgery. There's a new way to code excision of benign lesions (CPT codes 11400 ? 11446) and excision of malignant lesion (11600 ? 11646). For instance, let's take code 11600. The previous description of the code was, "Excision, malignant lesion, trunk, arms, or legs; lesion diameter 0.5 cm or less." In 2003, the code now reads, "Excision, malignant lesion including margins, trunk, arms, or legs, excised diameter 0.5 cm or less." This means that lesion diameter plus the narrowest margins required to adequately excise the lesion (based on the physician's judgment) equals the "excised diameter" referred to in the code. The measurement of lesion plus margin is made prior to its actual excision. Thus, the excised diameter is the same whether the surgical defect is repaired in a linear fashion or reconstructed (such as by a skin graft).
If a benign lesion of the trunk measures 1.0 cm and the margins required to adequately excise the lesion are 0.5 cm on both sides for a total margin of 1.0 cm, the physician should document 1.0 cm 0.5 cm 0.5 cm = 2.0 cm. Your coder should report the case with CPT code 11402 ("Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 1.1 to 2.0 cm").
- Gastroenterology. The three new codes added to the GI endoscopy codes related to directed submucosal injections are:
43201 Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance.
45335 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance.
45381 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.
Although the vague reference to "any substance" seems to indicate that claims need not identify the substance injected, many payers still want to see the substance documented in support of the claim. According to the AMA, common substances include india ink, saline, botulinum toxin and corticosteroid solutions.
- Urology. CPT code 52001 now refers to the "evacuation of multiple obstructing clots." In 2002, it had meant "cystourethroscopy with irrigation and evacuation of clots." The key terminology here is "multiple obstructing clots." The AMA considers these to be large clots that obstruct the bladder neck and cause urinary retention. Be sure to indicate that the surgeon performed cystoscopy to evacuate multiple clots preventing the patient's normal urinary function.
Code G0289 is an add-on code, not a primary code, to be used in addition to the correct knee arthroscopy CPT code for the main procedure performed. Code G0289 is to be used when a procedure is performed in the lateral, medial or patellar compartments in addition to the main procedure. According to a CMS memorandum issued on Jan. 3, Code G0289 is incidental and will not generate a separate Ambulatory Payment Classification (APC) payment for hospitals. There is no compensation specific to the code because reimbursements for the services described by this code are "packaged" into the arthroscopic knee CPT codes with which G0289 is used.
Report this adjunct code only once per extra knee compartment, even if chondroplasty, loose body removal and foreign body removal are performed at the site. You may report G0289 twice (or with a unit of two) if the surgeon performs procedures in two different compartments in addition to the knee compartment where he performed the main procedure.
Although the code description does not say so, you should only report G0289 when the surgeon spends at least 15 minutes working in the additional knee compartment. You should not report it if the surgeon performs the procedure due to a problem caused by the arthroscopic procedure itself. Lastly, CMS will not allow billing of CPT codes 29874 (arthroscopic removal of loose/foreign body) and 29877 (arthroscopic chondroplasty) along with other arthroscopic procedures on the same knee.
Suppose a Medicare patient has outpatient right knee arthroscopic medial chondroplasty with a right knee arthroscopic lateral meniscectomy. Use G0289-RT along with CPT 29881-RT. If a Medicare outpatient has a left knee arthroscopic foreign body removed from the medial compartment and a left knee arthroscopic anterior cruciate ligament reconstruction, use G0289-LT along with 29888-LT. If a Medicare outpatient has a right knee arthroscopic loose body removed from the lateral compartment, and a right knee arthroscopic medial compartment and suprapatellear pouch synovectomy, use G0289-RT with 29876-RT.
- Pain management. Previously, when hospitals billed for a sacroiliac joint injection for anesthetic/steroid purposes with CPT code 27096 (Injection procedure for sacroiliac joint, arthrography and/or anesthetic steroid), the claim would be denied. The rationale is that the costs for code 27096 are packaged into the arthrography-imaging component APC reimbursement for code 73542.
To facilitate appropriate reporting and payment for the procedures described by CPT code 27096, CMS created the following adjunct codes for hospital outpatient reporting to replace CPT code 27096:
G0259 Injection procedure for sacroiliac joint, arthrography.
G0260 Injection procedure for sacroiliac joint, provision of anesthetic, steroid and/or other therapeutic agent and arthrography.
For Medicare outpatients, report code G0260 for a sacroiliac joint injection with an anesthetic, steroid and/or other therapeutic agent for arthrography. For all other agents, use G0259. CMS has given G0259 an incidental procedure status indicator because an injection for arthrography is still packaged into CPT code 73542; however, code G0260 has been assigned to APC 0204. So if a sacroiliac joint is injected with an anesthetic and/or steroid, hospitals are paid under APC 0204 (national APC payment rate: $105.61; national unadjusted co-payment: $40.13).
- Gastrointestinal endoscopy. The 2003 codebook reveals how CMS will reimburse hospitals for the new "camera in a pill" (M2A capsule endoscopy) devices. When billing these procedures for Medicare patients, assign the new HCPCS Level II code G0262: "Small intestinal imaging, intraluminal, from ligament of treitz to the ileo cecal valve, includes physician interpretation and report."
Code G0262 has been assigned to APC 711, which has a national payment rate of $625, of which $125 is the national co-payment amount (prior to geographical adjustment).
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