Good afternoon. Thanks for joining us. We're going to let everybody have a few minutes to get dialed in. So we'll get started in probably about two minutes. All right, we'll go ahead and get started. Thanks so much for joining us today, everybody. My name is Jamie Quimby, and I'm one of the managers here with our Revenue Cycle Solutions Department. Today, I'm going to cover with you ambulatory surgery coding. We're going to go over some documentation and reimbursement advice. We'll start with a little housekeeping. To access today's slides, you can click on the chat box and there will be a link that you can find there. Please do not use the chat box for anything else. Questions will be submitted through the Q&A box. As always, we ask that you keep your questions on topic, and also know that we will answer as many questions as we can at the end. But we do compile all the questions in a Q&A format, and we do post that on our Academy site later. For claiming CEU credits, you must log into your personal MedAxium Academy account, and then you will locate in your Academy where the registered session is and your history. Then you click on the claim CEU to access the certificate. It will give you the option to either save the PDF copy or you can print it. Now, to get the coding CEU certificates, you do have to individually register and launch the presentation. We do have to keep a transcript of all the names attended as well as submit proof. This is a requirement from the AAPC. It is important that you do launch the presentation to get that full credit. We're going to start with an ASC overview. If you're new to this specialty, you probably know that resources are pretty minimal, especially in our cardiovascular space. For me personally, the best resource that I have found has been the Medicare ASC manual I do list at the end of this presentation. There's a resource page and it has multiple links on that page. Every one of those links, it's very informative and I highly recommend you review those if you do work in this area. CMS does do a good job outlining specific guidance within all of the links that I'm sharing with you at the end. Another recommendation I have is to check with your local Medicare contractor. A lot of them have ASC resource page now and you can find lots of good detail there as well. Another recommendation, of course, is to check with any of your other big payers because they may have their own policies as well. What is an ASC? Medicare defines this as a freestanding facility other than a physician's office where surgical and diagnostic services are provided on an ambulatory basis. These are not emergent procedures. In an ASC setting, all services are going to be pre-planned and scheduled in advance. Some regulation highlights, ASC operations and licensings are generally regulated by that specific state. In most cases, they will require a special certificate of need and or state licensing to operate. There has to be a layout and building requirements also submitted. These vary by state, of course, but most commonly, you'll have to submit the number of beds that you'll have, parking spaces, size of hallways, etc. In order to receive coverage and reimbursement though from Medicare, you will be required to get a Medicare deemed status approval. Again, as I stated a couple of slides ago, check with your local Medicare contractors. As I said, many of them have excellent resources from an ASC perspective. Lots of good detail. A lot of them will also have their fee schedules posted, the allowable services that they reimburse for, and all that detail will be there. Highly recommend you check your local carrier. Now, we'll go over some guidelines. ASC billing is quite different. If you're used to only doing regular professional billing services for your physicians. Unlike with physician reporting, which requires a few highly specialized guidelines that we're all very familiar with, Medicare being number one. ASC billing and coding though aren't centered on a specific specialty. There's certain things like when you're looking at your claims, some carriers may require the normal 1500 claim form that we use as provider reporting, but some may require the facility claim form. Again, it's just going to vary by your carrier. The facility will report for their services and then the providers that are involved that day for that particular patient, they report their services on the professional basis. The place of service code that is used for an ASC is that 24. That is specific to a surgery center. There's multiple modifiers that are commonly used in an ASC setting on the facility side. This is not going to be an all-inclusive list that I cover with you, but we do work with a couple of programs. I just wanted to touch base on the ones that I commonly see. Obviously, the TC will be the highest one. If you do professional billing, you know the 26 modifier well. The TC is the opposite modifier of that 26. The TC covers all the technical components of the service. I'll cover the facility itself and any staffing involved that the facility employs to help render those services to the patients. Modifier 52, that one's used. I commonly use that one personally if I see a cardiac cath done. This is a reduced service. If I have a cardiac cath being done and the provider is performing an IFR, we know with an IFR reporting currently, the full CPT description is not being met. Therefore, we have to reduce the service because there's no medication being administered. In an ASC setting, I use a 52 modifier for that same scenario. Because the full service was performed, it didn't fully meet the CPT description. The 52 in that scenario is what I use. I think there was an AHA article that came out that recommended the 73 or 74. But when you look at the definition of those, those are similar to the definition of the modifier 53, which is when a service has to be discontinued due to extenuating circumstances or the service is now threatening the patient's well-being. Modifier 73 is similar to that 53 on the professional side. The 73 though is reported when the service hasn't been started yet, meaning there's been no anesthesia that has been administered. For 74, this is a discontinued service due to extenuating circumstances. But that is after the anesthesia has been performed. Again, 73 versus 74 just depends on how far they got basically to start with. For anatomical modifiers, I commonly obviously would be using these for our cardiac caths when an intervention is involved. Then also, if I'm looking at a peripheral case and they do it, maybe a lower extremity intervention on right or left side of the body, I would report those as well. Then modifier 59, or depending on your carrier requirement with the X modifiers. Again, there's no change with how this is reported. If you code for cardiac caths currently, for example, if you have a patient coming in that has a scheduled just diagnostic service, maybe they had chest pain and abnormal nuclear study, and the provider ordered them to have a diagnostic cath done to see what else could be going on, they end up finding a severe stenosis in one of the vessels and then decide at that time that they're going to put a stent in the vessel. Because of that, the stent along with the angiography would bundle because of the edits that are put in place, but it wasn't a staged intervention. The provider didn't know they were going to do the stent until they got in to do the diagnostic part first. A scenario like that is when you would apply that 59 modifier to the diagnostic portion, so that way it doesn't bundle with the intervention. Under the ASC payment system, these items and services fall within the scope of the ASC facility services. Payment for them is then packaged into the ASC payment for the covered surgical procedure performed. You again can find this level of detail in that Medicare ASC manual. But specifically what they list out here is that any nursing technicians and related services would be included. None of this stuff listed here is separately billable by the facility. The equipment, the surgical dressings, there are some of the implantable devices that are included also. There are some devices that are listed in a pass-through status under the ASC fee schedule. I will be covering that in an upcoming slide, so I'll explain what the difference of that is. But again, any splints, cast, administrative record-keeping, housekeeping, all of that stuff is included in that primary payment for the service you're reporting. Examples of items and services that are not included in that ASC. This would be any provider reporting for their professional services. That provider would report those services separately. They would append any applicable professional modifiers like the 26 and so forth. Then also, certain DME products can be separately reported. Like I said, we'll cover those in an upcoming slide. Certain braces are separately reportable. They'll be reported by the supplier though. Then services furnished by an independent laboratory. Again, that will be the lab that's reporting those services separately. Just to give you an idea. The ASC bills for the primary service and they get paid for their facility services in that claim. Then any other providers involved would bill their services separately to get a separate reimbursement. This list of covered ASC procedures, this link here is very important. I'm going to pull over an example of what it actually looks like. I have it pulled up here on my screen, so I'll drag it over in a second. But beginning January 1st of 2008, CMS started publishing updates to the list of procedures. For which an ASC may be paid for each year. In addition to this, Medicare does publish quarterly updates to this list, which is why I highly recommend you save your local Medicare contractors page, especially if they have an ASC specific resource page, because they do post these quarterly updates there. The complete list though, you can find from CMS from this link. Then I am going to show you on this slide, this is just a snapshot of that list. Again, not all inclusive, but you can see here common cardiology ones that we see. You can see the payment indicators here. I'll cover what the payment indicators mean in the next slide, but N1 status means the service is packaged. It's on the ASC schedule though, so it doesn't mean you would not report it. It just means the payment for this service is going to be packaged in the primary service you're performing. A few things to note here. You can see here, I took a snapshot of the interventions listed for the coronaries. You'll see that the other interventions are not listed. That means they are not even on the fee schedule, so they're not approved to be performed. But let me get the, so this is the actual ASC fee schedule, the 2024, and again, that link in the previous slide will take you directly to this. But you can see down here, there's different tabs. This is an excellent resource. It lists certain things. It'll detail out what all the indicators mean for the payment status. Here, they list certain things that they exclude from ASCs. You can see here are acute MIs, obviously. Acute MI is going to be more of an emergent basis, not a staged, scheduled procedure, which is why that one makes sense that it would not be approved. Let me get this out of our way. Here's just an example of common ASC payment indicators that I see. Everything, the first five you see all have dollar amounts attached to them. It just defines how the service is listed on the fee schedule and how they're going to reimburse for it. On the N1 status, though, again, that one means it's a packaged service or item. No separate payment is made. That's how it's defined. If you go to the Medicare regulations, though, in chapter four, they state specifically, and I'm going to quote it, it says, if a claim contains services that result in an APC payment, but it also contains packaged services, separate payment for the packaged service is not made since the payment is included in the APC. However, charges related to that packaged service are used for outlier and transitional payments, as well as for future rate setting. Therefore, it is extremely important that all HCPCC codes, consistent with their descriptors, CPT and or CMS instructions, and correct coding principles, and all charges for all services they furnish, whether payment for the service is made separately, paid, or is packaged. So what they're saying there is that even though it's an N1 status, it's listed on the fee schedule, it doesn't mean you wouldn't report it still, even though you know you won't get payment for it. Medicare looks at these services annually, and they reevaluate the fee schedule based on the need for these services to be performed. So you do still want to report anything that's listed as N1 status. All right. Device-intensive procedures. These are specific ASC-covered surgical procedures that under the OPS are assigned to certain device-dependent ambulatory payment classification groups, or what we typically will call an APC. Excuse me. Device-dependent APCs are groups of procedures that require the insertion or implantation of expensive devices. So payment for the high-cost devices is packaged into the procedure payments under the OPS fee schedule. So there's just a separate status indicator or payment indicator for these, so you'll know which ones are packaged and which ones aren't. But they do pay those at a higher reimbursement because of how expensive the device is. HCPIC reporting for DME equipment, so some of the DME products can be reported. If they are listed as a pass-through status on the fee schedule, coverage of course is going to vary by payer. When reading through an operative report, you always want to verify when you're coding for a facility that procedure log. I have a couple case examples where I put some of the procedure log. The procedure logs are just a very detailed log from start and finish of the service. You take that log and compare it to what the physician's operative report is, just to make sure everything is captured. When reviewing the procedure log, you're looking for any mention of any device or implant. If there is, then you want to review any reporting that would be applicable to that service. There are some vendors that have resources available on their websites that can assist you in looking up their products as well as crosswalking to any applicable HCPIC service. This is an example of that. This is a vendor, Medtronic. The example here is we had a defibrillator implant. I took the model number from the procedure log and I looked up on Medtronic's site and put in that model number. This is the actual snapshot of what that model number crosswalked to for a C code. The 33249, we know from a physician reporting side, that includes your generator placement for your defibrillator as well as an atrial lead, a right atrial lead, and a right ventricular lead if they did both. Just the generator side of that would be the C1721 from that DME perspective. Common reporting for ASC services. We are working on a coding card right now for the ASC reporting to add to our resources for everybody. We do expect to have that out early next year. It is going to be an extensive card because cardiovascular does do services now on the coronary side as well as the EP side with device implants as well as peripheral. We're most likely going to make this into three separate cards to help people. Like I said, we are working on it. What I'm going to cover with you is just some common services. It's definitely not an all-inclusive list. I wanted to show you how they're listed on the ASC payment indicators as well. All of these are just our standard cardiac paths that we're used to. It just starts with the coronaries only, then adds the LV, right heart cath only, right heart cath with coronaries, and so forth. You can see on the ASC side, you're going to append that modifier TC because they are applicable to those services. These are all listed as a G2 payment indicator, meaning they do have payment associated with them on that surgery center fee schedule. Now, these were new codes that were added last calendar year. These are combination codes. So, from a facility perspective for the ASC, if you have a combination where you're doing a left heart cath, which these are down here, and maybe you're doing the IVs with it, the C7523 is what you would report. That's a combination of our 93458 and our 92978. Now, because these C's codes are specific to the ASC, you do not have to append the TC modifier because these are only reportable by the ASC. But it does combine the two services together to simplify the reporting. These are all listed as the G2 status as well. So, these all do have payment amount associated with them. Again, just to make this simple for everybody, I just tried to list them in order. So, it starts with our coronaries, our coronaries with bypass grafts involvement. You can see it goes from the IVs to the FFR and so forth. Coronary interventions. So, we do have angioplasties. Those are allowable. The additional branches are like they are now for how we report for the professional side. So, no dollar amounts are associated with them. But for the ASC fee schedule, they are listed as that N1 status. So, you would still report it if you did perform two interventions within that single major vessel. The C code here, this is for an angioplasty where they also have that brachytherapy involved too. And let's see, C1, C2, C3, stenting reporting, it depends. Most what I see in the ASC setting is a drug eluding stent. So, in that case, you would report the C code. The C code does have dollar amounts associated with it. So, you report that instead of the 92928. If you do have a case where it's not a drug eluding stent, but maybe a bare metal stent, that's when you would report the traditional codes we would be used to on the professional side. So, the C9600 is specific to a drug eluding stent. So, if it's not a drug eluding stent, but just like I said, a bare metal stent, you would report the 92928 still. So, we do have a C code specific to the ASC for coronary lithotripsy. This does have a payment indicator of J7, which is a pass-through device that's paid separately. So again, this is on the fee schedule with dollar amounts. And it is listed as a pass-through status all the way through the end of next year. Some lower extremity peripheral interventions. Again, this is just going to depend on what vessel they're in in that lower extremity area. But again, you can see here all the add-on codes. Again, they're all listed as that N1 status. So again, no separate payment will be made, but you still would report it if you're doing multiple services. The C7532 is that combination code. If they do that balloon angioplasty with the IVAS, the lower extremity, or the vascular IVAS code. So, that's just combining the two. Again, you wouldn't put any TC modifier because that C code is specific to the ASC. Again, additional interventional services for our peripherals. Again, here, just to see. These are just common ones I see, like I said. Not an all-inclusive list. Any of the diagnostic services for the lower extremities, those are all listed as an N1 status also. So, that payment for that service will be packaged into any intervention that you do. Iliac artery interventions that are commonly seen. So again, just to list out here, all the add-on codes for this whole section here is going to be N1 status. Here's our FEMPOP interventions. These C codes were also added last year. So again, these are just combination codes which report the intervention with the IVAS ultrasound performed. Again, no TC modifier is applicable to those since they are specific to the ASC. These are the lithotripsy lower extremity reporting options available. These are all listed as that device-intensive procedure. So, again, these are the lithotripsy lower extremity reporting options available. These are all listed as that device-intensive procedure on the fee schedule. So, these all do have reimbursement associated with it. You can see the first four here are just, I think I got them listed in order. You can see some here are for the tibial peroneal and some, like here, it says except. So, it'd be lower extremity arteries except down in these two vessels. All right. And then additional tibial peroneal revascularization. So, whether to do the angioplasty, atherectomy, those services. It's interesting to me that the peripheral atherectomies are allowable in the ASC, but they haven't yet added the coronary atherectomy services. So, again, just something to think about and wonder if Medicare does have that on the radar to get added for a future year. Dialysis circuit reporting. So, some of these codes last year had some C codes added, which I'm going to skip to. So, again, these are all combination codes. And, again, these were added last year at the end of the year for this calendar year. So, if you do have these combo services being performed, you would just report that C code instead. And you can see here they do all have payment indicators associated with them. So, they will have reimbursement. Some embolization reporting is also allowable in the ASC setting. I specifically added this 37244 just because it goes with these codes. But this one specifically is not listed as a payable service on the ASC schedule side. So, that 37244 wouldn't be reportable if it was performed in ASC. Again, that could vary by your carrier, of course, but from a Medicare reporting perspective, it's not allowable. So, thrombectomy reporting is allowed also. You can see that the 37185 and the 186 are both listed as an N1 status. So, for EP device implants, again, common reporting that I see, initial implants, and then, of course, battery changeouts are the two common. So, for this one, this is just our common initial implants that we report. So, pacemaker, our defibrillator, that LV lead, and then the loop implant or the ILR, what we typically see abbreviated. Reporting, though, for the generator side of it from the HCPCS DME side. So, again, these are just common codes. So, single chamber, dual chamber, multi-chamber, and then that loop implant, whether it's a pacemaker or defibrillator. Lead implants, again, these are separately reportable. So, and I do have a case example at the end that has a device service. So, I'll show you what that reporting looks like. But, again, look, going to that vendor's site, and you can look up and crosswalk to the C code, depending on the model information that they give you in the op report. These C codes were also added to the OOP report. So, again, C codes were also added last year. So, if you remember at the end of last year, we had a ton of ASCC codes that were added. These were the last of them. So, these are combination codes for a pacemaker where an LV lead is also implanted. The C7537 is a combination of our right atrial lead and an LV lead. The 7538 is a combination of an RV lead and an LV lead implant. And then the 39 is a combination of a dual chamber. So, that's our RA and our RV lead, along with that LV lead. And then the C7540, it was interesting that they only added one code for this. So, this is when they do a battery change out on a dual lead system, but they're upgrading it to that BioVita device. So, this would be a 33228 and a 33225 reported together. All right. So, now we're going to cover some case examples. So, this first patient, our indications are symptomatic sick sinus syndrome, showing pauses three seconds while awake. So, you can see here just in the highlighted portion, this top portion is just all the general information that you would see in a report, the consent, you know, given and all that detail. Then they go in and this patient had a loop implant. So, you can see here that that was removed. And then down here is where they start doing the placement of the lead. So, you can see we got our ventricular lead here and our atrial lead. Down here, they list, you know, all the different parts and specific numbers there. And then here's where our generator was attached to the leads and then inserted into that new pocket. What I pay most attention to when I'm coding for an ASC is the devices that were taken out and the devices that were put in. So, here we know the loop recorder was removed and then we also had a generator. And you can see we have the manufacturer was Boston. We have our model number here and then same with our two leads. Here's our model number and our other model number. So, with our reporting, we have a 33208 with the KX because of the sick sinus syndrome. We also have the 33286 for the removal of that loop. Then on your HCPCS reporting side, you have the C1785, which when I go to Boston's page and I search for the model number, that L311, it crosswalks and tells you what the appropriate C code is for that model. And then same here with the lead placements. Remember on this last slide here, we had our two leads here, the 7841 and the 7840. So, you can see here, here's our 40 and our 41. And it did, I must have snipped the C code off of that, but it does crosswalk to the C1898. And you report that twice because you had two leads implanted. So, here's an ILR implant. I see a lot of these done in an ASC setting. These are pretty simple procedures. So, again, they typically get, they'll get the consent. This one's being placed for syncope. They did the incision. And then they did the implant without complication. And then here, you can see here's our model number right here. And then when you go to Medtronic's page, it's similar to how Boston's is. It will also crosswalk you. But this is just a snippet of what a procedure log would say. Again, the procedure logs are very, very detailed and there are multiple pages. So, this is just a short snapshot of what this one looked like for this patient. But you can see it gives you timestamps of everything that's done. So, the physician arrived, incision was made, the device was implanted, and here's our closure. And then again, when you put that model number into Medtronic's site, it will also crosswalk you here. So, you would report 33285 for that loop implant for that syncope. And then the HCPCS code for the DME would be the C1764. All right, now we have an ICD generator change for a multi-lead system. So, here in our indications, this device is at its end of life. They have the hypertrophic cardiomyopathy. They also have chronic combined heart failure. And then they have that ventricular tachycardia. Again here's our prepped and draped, consent, all that stuff. You can see here this report is pretty short and sweet but with ASC reporting you always want to take the provider report and the procedure log report from the the lab and kind of compare. So here we have our generator was attached to the leads and inserted into the pocket after the old device was removed. It was then sutured in place so pretty straightforward and simple. Down here you can see the the X-planted device and the model. This was the model number of the one they took out and then this is the one they implanted and the new model number. Again just a snapshot of the procedure log itself. So physician page, they then arrived, device pocket was open, generator was removed, the new generator was attached to the leads and inserted into the pocket and of course closure was complete. So for CPT reporting as well as the HCPCS reporting we'll have a 3-3-2-6-4 since it was a multi-lead system and then when you go to the vendors page and type in that model number it will crosswalk you to the C-1882. I typed that wrong I'm sorry that's not for a single chamber that is for a multi-chamber that's just a multi right there. And you can see down here it it clarifies what it's defined as. So defibrillator that's other than single or dual chamber so this would be your multi. All right now we have a cardiac cath with an intervention. You can see in our indications we have shortness of breath, dyspnea on exertion, weight gain and lower extremity edema. Their chest x-ray was clear. Stress testing did show ischemia so that's why they're bringing the patient into the cath lab. Here you can see access was obtained through the right femoral, left coronary, selective angiography was then performed. Then they did the LV gram and then they pulled over to the right side and did the right coronary angiography. Here further description based on the findings you can see they decided to insert a balloon catheter. They then did that inflated that balloon in the vessel. Then they put that drug eluting stent and here down here is where you can see where they actually were. They were in that left circumflex vessel so the drug eluting stent was advanced across that lesion to the circumflex. And then at the end here they did a contrast injection through the sheath. Sometimes you see providers that try to report that service from a professional perspective. From a professional side you can't report anything for the closure. Part of the procedure and getting reimbursed is opening and closing that patient up. From a facility perspective you wouldn't bill anything for the the contrast that was injected but you can report the actual closure device if there is one applicable for that depending on what type of device they use. For an angiocele that does crosswalk to a C code reporting so we'll look at what that looks like. These are the cardiac findings. This will show all the degree of the stenosis. You can see here with the circumflex they did have an 80 percent and then that OM1 vessel they do have 50 to 60. And then right here in our conclusions we have that 80 percent mid circumflex stenosis successful PCI with that drug eluting stent to that mid circumflex and then there's our LV gram readings. For reporting purposes we had that C9600 because we have a drug eluting stent to our left circumflex vessel. The 93458 because we did have a full left heart cath performed. We're going to apply that TC modifier along with the 59. This was not a staged intervention so therefore we can report the diagnostic portion as well. And then the C1760 would be for the angiocele closure device. All right so now we have a peripheral intervention. This one says a shockwave lithotripsy was performed in the left SFA. So right here we have a patient with resting pain lower extremity in their left lower extremity. This patient's well established with this provider when I was going through the list here in the hip area. So we have a patient with when I was going through the list here in the history. So the 73 year old who they've been taking care of for several years. They have a history of external iliac stents placed at another hospital. They also have bilateral SFA and infrapopatial disease bilaterally. They've had a left femoral endarterectomy and then they have recently developed severe ischemic rest pain going into that left foot. They recommended angiogram with a possible intervention again because of the new developing severe pain down to the foot which is why they're coming back in for that diagnostic piece. So again here you can see the normal consent. Moderate sedation was given here but from an ASC perspective we won't be billing anything for that. Then you can see the bilateral groins were prepped and draped. They entered through the right common femoral artery. Got into the access. They then down here did our lower extremity runoff shot and then they talk about the findings from that. From those findings right here they decided to intervene on that SFA disease once more to help them resolve that severe rest pain. So again down here they start placing the catheters and then they get they had some difficulty getting the catheters in but after several tries they finally did get in. You can see they predilated the lesion with the balloon angioplasty and then they did that shock wave intravascular lithotripsy. Now a balloon the balloon angioplasty is included with that lithotripsy for the facility side because there's a special C code that we report. And then at the end you can see a star closed device was then deployed for that closure. So for our reporting for this we have the C9764 which is for that shock wave lithotripsy. That does also include that angioplasty performed because it's within the same vessel. We had our LT modifier since it was done on the left leg. Then we had our 75710 with that TC and the 59. Remember though from the ASC facility reporting side the 75710 is listed as an N1 status. So they're going to bundle the payment for that service into the intervention anyways but you would not report it because it was performed it was truly a diagnostic service. It wasn't staged so and then we get the C1760 for that star closed closure device that was placed. This is that resource page I was referring to at the beginning. Every one of these links is very very helpful. Again if you're new to coding for an ASC or you're the group you're with is thanking you for that resource page. You can go to that the group you're with is thinking about opening up their own ASC. These are excellent resources to get started on you know just looking at the ins and outs of how to report these services. So tomorrow as we continue our boot camp series Jolene and Tammy will be covering coding for peripheral angiography and interventions. This is always a highly requested topic so we do look forward to their information tomorrow and their expertise. And then next Monday Nicole and Linda will be covering and taking a deep dive into the E&M complexity coding and documentation. And with that we are at the end. I know I got through that a lot quicker than I thought so let me go through some of the questions. So an example of when you would use an XE modifier. So again you would have to check with your payers specifically on if they report the X's or not. I can't even off the top of my head I know there's four different X modifiers so I would probably need a case to look at specifically to answer that in greater detail. Would you append a modifier to anything marked on an N1 status? Yes just like that case example I just covered with the lithotripsy intervention. That 75710 is listed as an N1 status on the ASC fee schedule but we're still going to report it as appropriate so because the 26 and the TC modifiers are applicable to that code we would report the TC and of course it wasn't a staged procedure or staged intervention so I would also report that 59 on there as well. They are going to package that payment for that service into the lithotripsy payment. Reporting C codes for implants does that depend on the Medicare payer? Yeah it's going to depend again check with that your local. Most like I said most of the Medicare contractors they have excellent resource pages. Some have a specific link that does nothing but ASC coverage within their site. An example of one I can give you off the top of my head is First Coast Service Options they're the Medicare contractor here in Florida. They have a really good ASC resources page so a lot of the others have also really good resource pages so again just check with that carrier. Some of your commercial carriers too you're going to want to check with them on reporting for C codes as well just to see what their policies are. Somebody asked if we are providing facility billing information mixed in with professional so as we were talking through some of the cases kind of just we're doing a comparison of how the facility side of things look versus how we are if you do the professional side billing only and you've been doing that for years you know how I'm reporting for that services go so it's kind of showing you a mix of the difference between the two. Let's see so are the C codes specifically the combination codes are those supposed to be reported for all insurance companies or just Medicare? Again that is something you should check with your carrier policies on specifically. Those C codes were created specifically for the ASC and they are listed on the ASC fee schedule. Some of your Medicare replacement plans may recognize them some of your just standard commercial payers may recognize them so again just check with those policies specifically. Somebody says I didn't know facilities were able to report for the angiocele device. Yeah it is listed as an N1 status though so no separate payment is going to be made but again at the beginning when we covered the Medicare manual policies and how Medicare specifically references reporting those N1 status services are still important so no separate payment will be made for the device the closure device but again they're going to package the payment for that in the primary procedure being performed. On that cath report do you not report modifier 51? So the 51 modifier is carrier specific so we typically don't add those to our webcasts so again just check with that payer and if they require that modifier then you would report it. Again somebody commented we were always told we cannot close for the closure device again check with that payer specifically but they are listed on the ASC fee schedule with that N1 status and they are listed on the ASC fee schedule. The N1 status of course means they're going to be packaged in with the payment but you still would want to report it. Let's see for the facility side should we only use the C codes? It depends on what's being performed and if there's a C code applicable to that procedure like for the coronary example that we went over where they had the drug eluding stint we obviously we're going to report that C code versus the 92928. You wouldn't report both because the C9600 does it is on the ASC fee schedule and it does have dollars associated with it so you would only report that. Let's see somebody asked me this is Nicole I was just going to add a statement about this. I think for the questions that I see coming through and just listening to you give this presentation and just being exposed minimally to ASC coding you know in our world in cardiovascular I think this is only going to get more complex and more services added to it as we move to the outpatient and I think many of you will hear us say you have to confirm with your payers. We've experienced from coding these ASC cases that some want CPTs and C codes some want one some want the other someone so it's very hard for us to provide a blanket statement and then I think the other thing is is that when you think about hospital outpatient and facility services ASCs are facilities but they have their own fee schedule and their own reimbursement. They have different ownership models different management and different costs so it's very important as you establish these and you're building billing for these services that you understand all those services that you understand all those caveats because it's very hard for us to provide just that blanket statement. You're doing a great job but I just wanted to mention to everyone because I know sometimes when we say contact your carrier it's carrier specific or it's regional that just means we don't have all of that information and would not want you to start doing something that your payers would not accept. Correct and as I stated earlier too some carriers may want that CMS 1500 form some may want the the UB form so it's it's just really ASC reporting is very carrier driven again that's why if you're new to coding this I the resources page that I put on here I highly recommend you go through the manual. They're not very extensive as far as like there's hundreds of pages to read it's it's not that it's very detailed and very Medicare outlines it very well but again you're also going to want to check with your local Medicare contractors you're going to want to check with your other big commercial payers because the coverage does vary. Definitely a good point. All right so I think we got through most of the questions. Anything else we'll look at in detail and again we'll compile that Q&A into a PDF form later and add that to our web page. Again we look forward to seeing everybody tomorrow if you're registered for the peripheral angiography and intervention webcast with Jolene and Tammy. With that though I give you guys back some extra time today and I hope you enjoyed the presentation and we will see you tomorrow hopefully. Thank you.

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