ASC and you shall receive (2014 Fee Schedule Increase)?

The implementation date for the Ambulatory Surgical Center Quality Reporting (ASCQR) Program Payment Reduction is right around the corner as well as the updated ASC Fee Schedule (ASCFS) for 2014. 

ASCQR Any ASC that did not meet the program requirements for quality reporting will be subject to an ASCFS 2% payment reduction for their services provided to Medicare beneficiaries.  This applies to Railroad Medicare, Primary Medicare and as of Jan. 1, 2013 Medicare Secondary beneficiaries.  The payment reduction effects only the ASCFS, not the ASCDRUG file, ASCPI file code assignments or the ASC Code Pair file.

For example, a service with a $100 allowed amount would produce a provider payment of $78.40 and a patient responsibility of $19.60 for a total of $98.00.  A $2.00 loss in revenue per $100 in service rendered.

The adjustment codes found on the Medicare remittance advices that will be applied to reflect the reductions are:

Claim Adjustment Reason Code (CARC) 237 – Legislated/Regulatory penalty.  (This will be accompanied by a remark code.)

Remittance Advice Remark Code (RARC) N551 – Payment adjusted based on the Ambulatory Surgical Center (ASC) Quality Reporting Program.


QDCs Evaluation of ASC reporting compliance affecting payments for CY 2014 will be performed based upon claims data processed by the MAC by April 30, 2013 covering dates of service Oct. 1, 2012 to Dec. 31, 2012. 

ASCs report their Claims Based Measures with Quality Data Codes (QDCs) on Medicare Part B HCFA-1500 or in electronically formatted claims.  The claims will be analyzed at the supplier level and tied to the billing NPI.

The 5 QDC’s listed below used for ASC reporting during the third quarter of 2012 are also required for reporting period January 1, 2013 – December 31, 2013.  Claims Based Measures reported for service dates in 2013 will count towards meeting requirements for the CY2015 ASCFS.

ASC Quality Measures   G-code                 Descriptor                                                                                           ASC PI

ASC – 1through 4            G8907                   Patient documented not to have experienced                                      M5

   any of the following events: a burn prior to

   discharge, a fall within the facility, wrong

   site/side/patient/procedure/implant event,

   a hospital transfer or hospital admission upon

   discharge from the facility.

ASC – 1 Patient burn       G8908                   Patient documented to have received a burn prior                             M5

   to discharge.

ASC – 1 Patient burn       G8909                   Patient documented not to have received a burn                              M5

   prior to discharge.M5

ASC – 2 Patient fall in      G8910                   Patient documented to have experienced a fall                                M5

ASC facility                                        within ASC facility.

ASC – 2 Patient fall in      G8911                   Patient documented not to have experienced a fall                         M5

ASC facility                                        within ASC facility.

ASC – 3 Wrong site,         G8912                   Patient documented to have experienced a wrong                          M5

wrong side, wrong patient,                   site, wrong side, wrong patient, wrong procedure or

wrong procedure,                                wrong implant event.

wrong implant

ASC – 3 Wrong site,         G8913                   Patient documented to not have experienced a wrong                  M5

wrong side, wrong patient,                   site, wrong side, wrong patient, wrong procedure or

wrong procedure,                                wrong implant event.

wrong implant

ASC – 4 Hospital                G8914                   Patient documented to have experienced a                                M5

transfer/Admission                                hospital transfer or hospital admission upon

                         discharge from ASC.

ASC – 4 Hospital                G8915                   Patient documented to not have experienced a                          M5

transfer/Admission                                hospital transfer or hospital admission upon

                         discharge from ASC.

ASC – 5 Timing of             G8916                   Patient with preoperative order for IV antibiotic                           M5

Prophylactic  Antibiotic                          surgical site infection

administration for

SSI prevention                                     (SSI) prophylaxis, antibiotic initiated on time

ASC – 5 Timing of             G8917                   Patient with preoperative order for IV antibiotic                           M5

Prophylactic  Antibiotic                          surgical site infection

administration for

SSI prevention                                     (SSI) prophylaxis, antibiotic not initiated on time

ASC – 5 Timing of             G8918                   Patient without preoperative order for IV                                  M5

Prophylactic Antibiotic                           antibiotic surgical site infection

administration for

SSI prevention

medical billing software        Need help to remember to add your Charge Based Measures?

With Iridium Suite Practice Management System from Medical Business Systems, a custom claim scrubber rule can be created for your practice.  This would alert the user that additional codes should be entered when a “qualifying” service is being charged to Medicare.

 

In addition to the Claim Based Measures, there are two Structural Measures that are reported to QualityNet via their website.  Besides being the reporting agent for Structural Measures the QualityNet website has a wealth of information on the ASCQR.

Annual data submission period for these measures wasJuly 1, 2013 – August 15, 2013 covering the performance period January 1, 2012- December 31, 2012.

ASC – 6: Measure ascertains response to the following question(s):

• Does/did your facility use a safe surgery checklist based on accepted standards of practice during the designated period? Yes/No

 

ASC – 7: Measure ascertains response to the following question(s):

• What was the aggregate count of selected surgical procedures per category?

There are eight categories: Cardiovascular, Eye, Gastrointestinal, Genitourinary, Musculoskeletal, Nervous System, Respiratory, and Skin each with designated HCPCS for measurement.  For more details, access the Specifications Manual.

 

medical billing software        Need help to remember to submit your Structural Measures?

With Iridium Suite Practice Management System from Medical Business Systems, a CPT Code report template can be created and scheduled to generate automatically when needed.  The report should show up in your email inbox with all the data required for reporting to QualityNet.

reconsideration If you are notified that you are subject to this reduction, but believe it is an error, you can ask for a reconsideration of the claim reporting review.  You would submit a CMS Reconsideration Request form by March 17th of the payment year.

If CMS determines the reduction penalty was an error, they will notify the MAC to remove the penalty for future claims processing and instruct them to reprocess all previously processed claims containing the incorrect reduced payment amount.

The remittance advice containing claims that have been reprocessed with the corrected allowed amount will indicate this correction with Remittance Advice Remark Code (RARC) N552 – Payment adjusted to reverse a previous withhold amount.


 Unfortunately, you cannot turn back time if you did not comply with the previous reporting requirements, but you should do everything possible now to “get with the program” and begin reporting the applicable measures to your local Medicare contractor.


CMS  Additional helpful information can be found at:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/index.html

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ASC-Quality-Reporting/