Q: I understand that the new Medicare Ambulatory Surgical Center List adds some services and deletes others. How did eye services make out?

A: The new ASC List applies to services provided on or after July 1, 2003. There were no deletions to ophthalmology services. The codes that were added for ASCs are in the table below.

Generally, there are two primary elements in the total cost of performing a surgical procedure: the cost of the physician's professional services for performing the procedure; and the cost of services furnished by the facility (ASC) where the procedure is performed (surgical supplies and equipment, nursing services, etc.).

The ASC payment rate is a standard overhead amount established on the basis of the Center for Medicare & Medicaid Services' estimate of a fair fee that accounts for the costs incurred by ASCs generally in providing facility services in connection with performing a specific procedure.

Because payment for ASC facility services is subject to the usual Medicare Part B deductible and coinsurance requirements, Medicare pays participating ASCs 80 percent of the prospectively-determined rate, adjusted for regional wage variations.

For instance, Section 1833(i)(2)(A) (iii) of the Act requires that payment for insertion of an intraocular lens include an allowance for the IOL that is reasonable and related to the cost of acquiring the class of lens involved. CMS has established $150 as the amount of payment allowed for an IOL inserted during or subsequent to cataract surgery in an ASC.

CMS groups ASC payments based on costs to the ASC. The ASC payment rates for specific groups are: Group 1, $333; Group 2, $446; Group 3, $510; Group 4, $630; Group 5, $717; Group 6, $826 ($676 + $150 for IOLs); Group 7, $995; Group 8, $973 ($823 + $150 for IOLs); and Group 9, $1,339.

Q: Some new codes seem redundant. For example, how does 15822 (revision of upper eyelid) differ from 15823 (revision of upper eyelid)?

A: This is a great example of how important it is to read beyond the short descriptors. 15822 is Blepharoplasty, upper eyelid, while 15823 is Blepharoplasty, upper eyelid, with excessive skin weighting down lid.
During blepharoplasty, it is not uncommon for the surgeon to remove a fold of skin from the upper eyelid that mechanically weights the lid and causes it to droop. The two skin edges are then sutured together. If the surgeon removes this excess fold of skin during blepharoplasty, coding the procedure as 15822 will result in a lower reimbursement ($510) as compared to the rate for 15823 ($717). As long as the removal of the excess fold of skin and suturing the two skin edges is documented in the operative report, the ASC is entitled to the larger reimbursement rate.

Q: How would we use 67334 (revise eye muscle w/suture) vs. 67335 (eye suture during surgery)?

A: Both of these are considered "add-on" procedures during strabismus surgery. They cannot stand alone, and must be listed along with the code for strabismus surgery, 67314. If performed bilaterally, you must also include the modifier 50. You would use 67334,  Strabismus surgery by posterior fixation suture technique, with or without muscle recession.

List 67335 for placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s). Listing these add-on procedures will not change the reimbursement level, but if they are not documented in the operative report, it could lead to rejection of the claim. Be sure everything that is coded is documented in the operative report.
Here is an operative report for a procedure coded as CPT Code(s): 67314-50, 67334-LT, 67311-RT. It is abridged here for space considerations, with key documentation shown in boldface type.

Preoperative Diagnosis: V pattern esotropia with high accommodative convergence/accommodation ratio (AC/A), OU.
Operation:
1. Inferior oblique recessions, OU (14.0 mm).
2. Left medial rectus recession 7.0 mm with posterior fixation suture.
3. Right medial rectus recession 5.0 mm.

Postoperative Diagnosis: V pattern esotropia with high accommodative convergence/accommodation ratio (AC/A), OU.

Indications: This is a 43-year-old man with a history of right esotropia and strabismus surgery at a very young age (medial rectus recession) and dense amblyopia of the right eye.

Operative Course: [Describe preoperative care and prep.] Forced ductions were performed which revealed a mild degree of tightness of the right medial rectus muscle. A lid speculum was placed. Attention was directed first toward the re-recession of the right medial rectus muscle. The eye was rotated into an abducted position, and a partial nasal limbal peritomy was fashioned using Westcott scissors.

Careful dissection was carried out to remove scar tissue anterior and overlying the recessed medial rectus muscle. [Further description of operative procedure.] Next, a single double-armed 6-0 Dexon suture was woven through the width of the muscle with blocking bites in the center and at the superior and inferior poles. The muscle was then disinserted using Aebli scissors. The suture needles were then brought back forward through the original muscle insertion in a crossed sword fashion and then tied together using a cinch knot. The cinch was placed at a position such that the muscle hung back 11.5 mm from the limbus. This arrangement was performed to allow adjustment of the suture the following morning based upon his postoperative ocular alignment measurements.

Next, the 6-0 plain gut sutures that were preplaced through the anterior corners of the conjunctival limbal peritomy were brought back through the limbus and tied in a loop. This allowed sagging of the conjunctiva to facilitate adjustment the following day.

Attention was then directed toward the right superior rectus muscle where a recession of 4.0 mm was performed. [Further description of operative procedure] The position of the recess of the superior rectus muscle was then reexamined and deemed to be secure and in good position. [Describe final suturing, irrigation and patching of eye.]

Note: This information is based on the March 28, 2003 Federal Register: Medicare Program; Update of Ambulatory Surgical Center List of Covered Procedures Effective July 1, 2003; Final Rule. You can download it at: http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/2003/03-7236.htm. 

Ms. Jones, RHIA, CCS is a Maryland-based independent consultant specializing in ASC coding and billing auditing, training and operations assessment. She has written the Clinical Coding Guide: Medicare's 2003 Expansion of the ASC List, and ASC Clinic: Eye and Oculoplastic Surgery. Contact her at LolitaMJ@ aol.com.