Q What can you tell me about random, unannounced Joint Commission on-site surveys?

A By 2006, all JCAHO regular surveys will be unannounced. It's important to emphasize, though, that initial surveys, even after 2006, will be on an announced basis. Some other facts about random, unannounced surveys:

• For 2004 and 2005, while JCAHO pilot-tests unannounced surveys in volunteer organizations, you'll receive no advanced notice of a random re-survey.
• Re-surveys can be conducted from nine to 30 months after your triennial survey. Starting in 2006, unannounced surveys will occur within the calendar year that your re-survey is scheduled. The JCAHO Board may expand this window.
• JCAHO will randomly select 5 percent of organizations accredited through the end of 2003 for unannounced one-day, one-surveyor re-surveys. Starting in 2006, 100 percent of re-surveys will be unannounced.
• Surveyors who are specially trained in the use of the random, unannounced survey protocols will conduct the unannounced surveys.
• Per current policy, re-survey results may lead to new Type I recommendations and may even cause a change in the organization's accreditation status.
• Per current policy and continuing for 2004 and 2005, there will be no cost for an unannounced re-survey.

Q How many times can I bill for an adjustable suture in one eye (67335)?

A Although there are indications for billing the code more than once, CPT coding instructions state that it's only billed once per eye no matter how many sutures are used since it's the post-op adjustment that is actually being paid (regardless of whether it is performed).

Q I am the administrator of a hospital-physician joint-ventured ASC. The hospital CFO has requested benchmarking information. Any suggestions?

A Benchmarking involves comparing financial data from your center to other surgery centers (external benchmarking). It also involves comparing financial data within your own center, usually on a monthly basis (internal benchmarking). External benchmarking gives you an idea how your center is performing compared to other centers your size. Monthly internal benchmarking of your center lets you pinpoint and correct problems quickly.

Examples of data (indicators) to benchmark are the average charge and average reimbursement per case. Contractual adjustments are also very important. Certainly, you want to benchmark such key expenses as salaries, medical supplies, contracted services, linen/laundry/uniforms and office supplies. Notice that all of these are volume-driven. Other benchmarking indicators include net collection percentage, overhead percentage, profit percentage and number of days in A/R.

The information you'll need to compute indicators for internal benchmarking comes mainly from your accounting records and ASC software system. Your accounting records will supply such figures as payroll amounts, medical-supply costs, profit margins and overhead expenses. Your ASC software system will supply such figures as case information, charges, adjustments and collections.

Information for external benchmarking to compare your center to others like yours will come from services such as Medical Group Management Association, your state ASC organization and vendors. Your ASC-management company will also be able to provide this type of service based on data from other centers it manages.

Q What does Medicare and Blue Cross require as far as medical documentation and predetermination for blepharoplasty procedures in ASCs?

A Blepharoplasty is a Medicare-covered procedure when medically necessary (to improve impaired vision, for example). Each Medicare carrier has different requirements for coverage, so check the requirements for your state's plan. The Florida Medicare carrier, for example, looks for a chief complaint from the patient indicating the medical problems he experiences are from his eyelids, such as interference with vision, difficulty reading due to upper-lid drooping, looking through the eyelashes, seeing the upper eyelid skin or chronic blepharitis (inflammation). Visual-field testing demonstrating the carrier's required amount of constriction of the superior visual field and a series of external photos for subjective evaluation are necessary to demonstrate medical necessity.

You should pre-determine benefits routinely before performing any surgical procedure, especially if the procedure can be considered cosmetic. Documentation requirements to support medical necessity for reimbursement include

• history and physical,
• operative report,
• two visual-field studies (with and without lid elevation) and
• photographs (prints must be frontal, canthus to canthus, to demonstrate a skin rash or position of the true-lid margin or the pseudo-lid margin).

If you perform a blepharoplasty and a ptosis repair, you must submit individual documentation. Each procedure should stand alone in your documentation. This includes photographs.