Good afternoon, everyone, and welcome to our session four on coding and reimbursement for our OBLs, office-based labs, and our ambulatory surgery center, ASCs. I'm Nicole Knight. I'm the Executive Vice President of Revenue Cycle Solutions and Care Transformation, and Jamie is joining me today, who is a Senior Consultant and Manager with Revenue Cycle Solutions. We are excited to present this content. I know it's been a week full of information, and we appreciate all of you that have attended all of our sessions and are attending today. A couple of housekeeping things. In the chat box, you will have a link available to download the handouts. These will be in a PDF format, and you should be able to save those to your computer. For questions, we ask that you type questions in the Q&A section, and they will be responded to throughout the webcast, and if we have some time at the end, which I imagine we will, we will cover some of those questions that we're able to answer. We'll also be compiling all of the questions and providing those as part of the academy, so you'll have a listing of all the questions and answers. It's going to take us a couple of weeks to get that together post-webinar, but we will have that available for you as well. Just a reminder, to claim your academy CEUs, you go to your academy website and log in, and there's a button that says Claim CEUs. These certificates do stay out here. Once you claim them, you can either download it or they're available to print later. We do offer AAPC CEU certificates for this webcast for 1.5 CEUs. If you need BMSC CEUs, please email Jolene Bruder. Effective next year, just a couple of changes to our CEU process. For AAPC CEUs, we will begin offering four to six webinars that will be on demand for you to get CEUs. Currently, all of our webinars are live, and you must attend the live webinar to get your CEUs. Our goal next year is to have four to six that will be recorded, and you'll have to take a test, but we'll be able to receive CEUs on demand. If you watch the webcast live, you do not have to take the quiz. It's only when you view it on demand. We also will be offering AHIMA CEUs for our webcasts that are approved by their vendor requirements, and we'll no longer be offering BMSC CEUs as the number of folks that need those and the process for obtaining them has become cumbersome, so we are going to go with AHIMA and AAPC, which generally most AHIMA and BMSC certification bodies accept the AAPC CEU certificates, but we want to be sure to offer and support our AHIMA credentials as well. All right, so let's dive in on OBLs versus ASCs. In cardiovascular, we've seen that several of our practices that are private may have, or if you've integrated or have a PSA, Physician Service Agreement, with your facility, you may have kept your office-based lab intact. So what is an OBL? This is a location per CMS other than a hospital, a SNF, a military facility, community health center, et cetera, where routinely you provide health exams, diagnosis, treatment of illness, and injury on an ambulatory basis. Basically, this is services that can be performed in the office setting, place of service 11, based on Medicare reimbursement and other carriers, and those are billed in your office practice, and there are certain requirements around that. We've seen a big shift to ambulatory surgery centers with some additions of approval of cardiovascular services, EP services that can be performed in an ASC, and CMS defines these as a freestanding facility, so this is independent of the physician's office where surgical and diagnostic services are provided on an ambulatory basis. We do see where certain centers have gone through the process of being a designated OBL on certain days and a designated ASC on other days. This has regulations, requirements, and a lot that goes into making that happen, but we are seeing that model, and of course, with ASCs, we're seeing many partnerships across many cardiovascular service lines with facilities, physician practices, and entities. From a regulation perspective, office-based surgery anesthesia is regulated by the medical board or the state for your OBLs. It may or may not require a certificate of need. It is specific to your state, so all of those certificate of needs and the regulations around your state, there are requirements. There's really no special regulation for CMS for participation as long as you're a billing provider in practice. However, your location has to be approved as a location for CMS, and there are, of course, state inspections, accreditations, and most OBLs do participate in some accreditation process, but definitely in a state inspection process. For ASCs, they require an operation or licensing that's regulated by the state, also a certificate of need or licensing. There's certain facility requirements that are required, and that's why when you're looking at OBLs and converting them to ASCs, there are different requirements when it comes to facilities. It also requires a Medicare deemed status to receive reimbursement from CMS, so a couple of differences there. If your programs haven't started talking about this or you don't know a lot about these two, here's just a little bit of differences and regulations so you can understand how these are set up, structured, and operated. We talked about place of service, so for your OBL, the services are reported with the place of service 11 for office, and then for ASC, it's place of service 24. Some of the billing differences, OBLs do not bill a separate facility fee, professional non-facility fee on the fee schedule covers both the physician's processional service and that cost of providing the service in the office, so that for lack of a better term, technical piece. Now, I will tell you some billing centers on OBLs bill globally, and I have seen some that have the TC billed one way and the professional billed the other, and then there's all kinds of agreements that can be arranged, but generally in OBLs, we see the global billing there that's reimbursed under that non-facility fee schedule for CMS. Now, for commercial payers, those are based on your individual contracting with those payers and how they're going to cover those services. For ASC, physicians generally bill for their professional services, and the ASC bills separately for the facility services. There may be devices, supplies that go into billing for these service, and it does vary largely depending on the specific payer on how these are billed and how they're managed through the billing and claim process. Some common modifiers used, this isn't all of an inclusive list, but some that you will see in the OBL and the ASC, a lot of these are common on both sides. You will see some anesthesia modifiers that are on that ASC side that may be a little different, but overall, there are approved modifiers for OBLs and ASCs that are applicable. Procedures allow for both office-based and ASCs. It's only elective non-emergency procedures. There is an approved CMS list for ASC procedures, and then also for office-based, it's included within the Medicare physician fee schedule. If it designates, it can be performed at that site. Generally, these procedures have low risk of complications, no overnight stay, and transfer is unlikely. Most of your centers, whether it's an OBL or ASC, will have transfer services set up as part of their policies and their standards, but really, when identifying these cases, the providers largely come together and develop a standard around which cases will be done and performed in the ASC or the OBL, and what does that look like for your organization. When we look at the OBL, I will tell you a large amount of the OBLs across our membership do perform peripheral vascular, endovascular procedures and diagnostic caths, peripheral angiograms interventions. You do see some dialysis work, even in those coronary OBLs that we have established throughout our membership. One thing to mention, coronary interventions are not approved by CMS to be performed in an OBL, but from commercial contracts, we do have folks who've negotiated that some interventions may be performed in their OBL, but from a CMS perspective, no coronary interventions may be performed, but peripheral interventions may be performed. For your ASC, this was the expansion of ASC services as we see the continuum for services to move into the outpatient setting. Diagnostic heart caths and interventions, and remember, we said non-emergent interventions, so again, there's an ASC approved procedure list, hemodialysis, thrombectomy, AVF creation, and device procedures, such as pacemaker and defibrillator implants. We are seeing some of those done in ASCs. Largely, it's been a lot of the end-of-life pacemakers, battery changes, but they do do new implants in several ASCs, but this is something I know we'll continue to see from a cardiovascular standpoint as the services grow and that list grows from a perspective of what can be performed in that ASC setting. When you look at the reimbursements, and this is rates from this year, and it's national rates, and you look at an ASC rate versus an OBL rate, and the last column is a professional service, so that would be if we're just billing for the physician's professional service that's performed, for an example, in a hospital setting, such as inpatient or an outpatient. If we look at a left heart cath, we see, for instance, our 93458 ASC is $1,400 and some change, office OBL is around $1,100, and this will vary, of course, by your payers, by your Medicare contractors, and then in the professional fees, around $300. You can see on the angioplasty stent codes, you can see the ASC payment rates and the professional service, again, that's when it's performed in our hospital, inpatient, outpatient facilities, and you'll see under OBLs for CMS, it says NA because those are not applicable within that setting, and that is why there is not a fee assigned to the stent angioplasty procedures in the OBL. So, we're going to go through one case example before I turn it over to Jamie to go over our ASC services, so I'm not going to read the case in detail. Basically, this is a procedure of a right transfemoral selective catheterization into the left superficial femoral artery vein graft with a diagnostic ART angiogram and left lower extremity runoff, intravascular ultrasound assessment of that left leg vein graft, and an atherectomy balloon angioplasty. So, if we look at the description of the procedure, the provider goes into detail about the catheter placement, the imaging, and then goes into the vein graft and the actual interventional procedure. So, it talks about that they performed an atherectomy with multiple passes, IVUS at this point, and what the IVUS showed. They used a balloon and achieved some flow there, and then they redid the atherectomy with multiple passes and multiple balloons, and then it was a successful procedure. They repeated that IVUS. We removed the sheath and proceeded with some intraoperative findings from this. So, we wanted to just provide you this to just overall show. In billing for the OBL, it will look exactly like you would normally bill your CPT codes with your modifiers, and this would be one that would be billed globally. So, you're going to globally bill your 37225 for the left. You're going to bill your IVUS. You're going to bill your angiography of the extremity, the 75710, with your 59, and then you'll see on moderate sedation, the moderate sedation code, you would bill both the professional and the facility service for that moderate sedation because you're billing globally in this case. So, this is an example of what that could look like from an OBL perspective. I'm going to turn it over to Jamie now. While she gets her slides up, I think it's an interesting tidbit. Jamie actually took the ASC course through AAPC this year, and we were all looking for her to become a genius in the ASC space because we've all been learning as much as we possibly could about ASCs. There's not a lot of information out there, and I'll tell you the course was very basic from what I understand, but of course, Jamie passed and has more initials behind her name and has really spent a lot of time in this area learning about it and teaching us about it. So, I'm excited for her to share what she's learned so far, and I'll kick it over to you, Jamie. Thanks, Nicole. Yeah, as Nicole said, it's been a lot of hands-on learning with this specialty. The AAPC course was very basic, unfortunately, so just went through basic diagnosis reporting and CPT reporting only. So, I'm going to share with you everything I have learned. I have learned a lot, and as we go through the slides, I'll point out certain things. One area to highlight, though, is your Medicare contractors, they have excellent resources directly on their websites. Most of them have a separate link that will take you directly to an ambulatory surgery center resource guide, and they have a ton of information there. So, that's how I have learned a lot that I know now. So, just want to share that in case you are new to this area. Definitely check out your Medicare contractor. And again, this is just touching up on that. So, again, consult with your local contractors. I don't think I found one that didn't have a separate resource link within their actual website. So, looking at the overall ASC payment system, because there is a separate payment system for them. So, some of these items that you see here on the slide, these actually fall within the scope of the ASC facility services. Therefore, the payment for any of these would be packaged into your primary service that you're reporting that is paid. So, there's no separate reporting for a lot of this information here. So, any nursing or your technician staff that you have on file, there will be any separate reporting for their services. The use of the actual facility, there's nothing there, because you're going to append the modifier TC on your services if that modifier is applicable. If there is no applicable modifier TC or 26, then you just report the CPT code itself. Any lab testing under a CLIA waiver are also exempt. Any drugs and biologicals that a separate payment is not allowed under the fee schedule, you would not separately report. There are some that are allowed, so we'll kind of go through what their structure looks like in an upcoming slide. Also, there's some medical supplies and DME or implanted devices. Some are actually listed on a pass-through status. We'll cover that in an upcoming slide also. If they are listed on a pass-through status, then you can report the service. So, again, we'll touch up on that in a few minutes. Again, touching up on that equipment, surgical dressings, splints, casts, all that would not be separately reportable by the ASC. Any radiology services or diagnostic testing where a separate payment is not allowed again under that fee schedule, you would not be able to report. Any administrative services that are provided, again, that's all gonna be bundled into the primary service reported. And again, materials, supplies, equipment for the administration of any anesthesia. And that would also include supervision of those services. Some examples of items and services that would not be part of an ASC. So obviously your physician services, they would separately report their portion. So typically when you're looking at a note from an ASC perspective, you're gonna have that cath lab log notes, kind of what we call, or the facility log. You'll have that separately. And that's a detailed log that has timestamps on it. The RN's filling it out. So they list in detail what's happening from start to finish. But then you're gonna have that separate physician documentation like you're used to looking at from a professional perspective. You always wanna compare the two. So you want the physician's documentation, but you also want that log from the facility. That way you're making sure nothing is missed and everything's being captured. So obviously the physician's going to report their services. They'll append their modifier 26 if it's applicable to that service being reported. But also any DME supplier, they can report any separate services. And then they have their own guidelines and policies. They have to follow ambulance services, braces, that kind of stuff. Services furnished by an independent lab, that lab could report their services. So all that kind of stuff. Now, facility services for surgical procedures that are excluded from the ASC list. So there would have to be an agreement. And obviously the patient would have to know that that service would not be covered. And then if that is agreed upon between the ASC and the patient, then the ASC would just then bill the patient directly. But an agreement again would have to be put in place. They couldn't just have the patient show up, do a procedure and then say, oh yeah, this procedure we did is excluded from the allowable and your insurance isn't going to pay it. So definitely would have to notify the patient. So a list of covered ASC procedures. This is updated yearly by Medicare. And there's a link here where that will take you directly to the entire document. There's multiple addendums on that document and they go through everything from all the codes that are approved on the list for that year. Excuse me. They also have like your status indicators. So there's payment status indicators, which we'll cover. Each one has a different meaning. So again, we'll cover those. There's the pass-through device codes that are allowable are also on the list. So there's multiple tabs within this link that will give you all that information. This is just a snapshot. So this is the addendum AA. This is everything that is approved for calendar year 2023. So I just took a little snapshot of some of the cardiac areas that I see done commonly in the ASC. A lot of device procedures. So you could do your pacemaker implants, your defibrillator implants, that includes your right atrium lead, your left and right ventricle leads, all that can be performed. It could be as simple as just a battery change out. Maybe their system's at the end of its life and they just need to replace the battery for the type of device they have. Loop implants, that's another common one we see done in the ASC setting. So yeah, this is just a snapshot. You can see how it's listed out. It'll list the CPT code or the HCPCS code. It'll give that description. Over here, it'll give the payment indicator. So this is an important area to pay attention to. Sorry, I just skipped. And we'll cover what some of these mean. I will highlight the N1 status indicator because this is a big one that I get a lot of questions on. But then you can also see the details of what the payment weight is for the current calendar year. So looking at the device intensive procedures, so Medicare has a fee scheduled structure for ASCs that does closely mimic the OPS fee schedule structure. Certain devices or implants are listed as a pass-through device. So what that means is the pass-through status is determined for newly FDA approved drugs or device products on an individual basis. That pass-through status is then granted and then CMS will either designate a HCPCS code for it and then they will allow it for reporting. Some of the drugs and devices, they are updated quarterly. So some of them may be removed through that pass-through status and they could be assigned a permanent status or they may be taken out and expired essentially. And then therefore it would then become packaged into the primary service being reported. And these are just examples of what some of those HCPCS codes will look like on that device intensive procedures. A lot of what I see is falling in this category with our device implants. So I have a case example that we'll actually cover later in the presentation. So again, when looking at reporting any DME products, this can include certain equipment, prosthetics, orthotics, and supplies. If listed on the ASC fee schedule, then the ASCs should report the HCPCS service for the device or implant that is as it's covered by the payer. The rules can vary across the individual payers. So we're gonna focus mainly of course on Medicare because that is our big payer, but just know that some of the guidelines can differ with how they want items reported. So, but when you're reading through an operative report and you're looking for any type of DME service, you're really verifying through that procedure log from the facility, but you're also wanting to compare it to what the physician says they did. If, for example, if you're doing like a device implant, we're used to seeing the type of device that's being implanted, and almost always the provider will detail in that note the model of the device. They'll give the serial number, the model number, the vendor, all that detail is usually always in the report. I can tell you that I always compare it to what the physician states in their report, but I will then verify that through the facility log itself too, so that I know that they match. A lot of the vendors actually have excellent resources on their own websites where you can actually crosswalk the product that was implanted into the patient, and it will crosswalk it to an appropriate HCPCS code for you to report accurately. And what that looks like is an example here on this slide. So this is a vendor, Medtronic, and this patient had a new defibrillator implanted, so we're only gonna look at the generator portion for this example. So when I went to Medtronic's website, I took what the model number was in my operative note and my facility log, and they did match. So I put that model number on their website. They have a little special area where you can look up a product, and then it will crosswalk it over to the appropriate C code, so you know which is the accurate C code to report for that HCPCS reporting. So the CPT reporting would be the 33249, and then you would also report that C code for the DME product or that device product. All right, so looking at our payment indicators, there's many payment indicators, so I didn't put them all here. These are just the most common ones that I see. The first five listed here, these are all of our payment indicators that have dollars attached to them. So if you see this indicator on a CPT code on the fee schedule, it will have dollars attached to it, meaning there will be reimbursement. The N1 is the area I get the most questions on. So this one means it's a packaged service or item. There is no separate payment made. So when you think about that, you think, well, why do I bother reporting it? Because they're not gonna get a separate payment for it, right, it's packaged. Well, if you look in the Medicare regulations in their manual, actually chapter four, it states specifically in the manual, and I'm gonna quote it. It states, if a claim contains a service that results in an APC payment, but also contains packaged services, so that's talking about this. It states separate payment for the packaged services is not made since that payment would be included. However, charges related to the packaged services are used for an outlier in transitional payments, as well as for future rate setting. So they go on to state, therefore it is extremely important that all HCPCS codes consistent with their descriptors, along with CPT and applying your correct coding principles, meaning you're looking at any policies like your NCCI edits, all that stuff, and all that's applying it. So whether or not it's falling under that N1 status, they still want it reported because they look at it for future rate setting for that primary service being provided. So even if you see an N1 status, again, Medicare wants them reported because they look at that information for the future transitional payments for later down the road. So again, you might report a bunch of stuff. You may have three CPT codes that have that N1 status, and your primary service that was performed has a payment status. So you will get paid for it, but they're still keeping track of all those additional services being provided. So some common HCPCS codes for ASD services. We're not going to obviously go through the entire list because it is large, but some areas that I want to point out, this one is a big one. So when you're looking at your PCI services for your coronaries, for your stents, you have two options to choose from. Obviously, we're familiar with the 92928 and the 29 because those are just our regular stent with angioplasty, if needed, being performed. But on the facility side, if there's a drug-eluting stent, Medicare created these C codes, the C9600, and then the C9601 for additional branches. These are both on the fee schedule. So the C9600 is active with payment, the 92928 is active with payment. And they actually bundle with NCCI edits. So if you're thinking about a scenario, so say we have a drug-eluting stent that is placed in the LD vessel, and then the provider does a bare metal stent in their right coronary. So now that's why these can be reported separately. So you would report your C9600 with your LD modifier, and then you would report your 92928 with your RC modifier for that right coronary. So the same rules apply. So say we only had drug-eluting stents, but you had multiple vessels that were intervened upon. So it's the same concept as with the 92928, it's per primary vessel being performed. So say we had a stent placed again in our LD and also the RC for a drug-eluting stent, then you would report that C9600 twice with the appropriate vessel modifiers. The C9600 is the same as the 92929 as far as the fee schedule structure goes from a Medicare perspective. They don't reimburse those additional branches per form, but you still want to report them because Medicare does track these. The hope is for one day that they will start reimbursing these services for that additional work. Some common services for our device implants. So remember if you're doing like a initial device implant, you're going to report your CPT code, but you're also going to report those applicable HCPCS codes too. So if you're doing a single chamber generator system, whether it be a pacemaker or a defibrillator, it crosswalks you to these C codes. For a dual system, it would fall under these codes depending on whether or not it's that pacemaker or defibrillator. And then again, if you have a multi-chamber implant happening, these were the C codes. The event monitors, the implantable ones are that loop implants as we like to call them. Again, that would be your 33285 along with your C1764. And then there's also HCPCS codes for your leads that are implanted. So if you have a pacemaker lead being implanted, it would be your C1898. So say with your defibrillators, you have a dual chamber system being placed, your atrial leads always going to be the C1898. Now your ventricle lead on a defibrillator can vary depending on the type of lead they implant. So that's where going to the vendor site and crosswalking that model number is extremely helpful because there are times where, you know, if you're looking at a report, the provider is not going to be as clear and say, you know, it's a single coil lead versus a dual coil. They don't always document that level of detail. So having that model number and the vendor name, of course, is extremely important. That way you can type that information in and have them crosswalk it to the appropriate code. So a lot of times when I'm coding a defibrillator implant, I always have to verify the actual ICD lead for the ventricle lead. Now, if you're doing a left ventricular lead, whether it's a pacemaker or a defibrillator, that will crosswalk you to the C1900. So we have many new HCPCS combination codes for the ASC services starting January 1st of 23. So we're going to cover these now in detail. All of what we will be covering are related to our cardiovascular space and they are all going to be active on the ASC fee schedule at the beginning of 2023. So first we have our dialysis circuit. So this C7513, and if you're billing in this area, if you want to write this down, I think it'll be helpful so you know what it's combining. So the C7513 is actually combining CPT code 36901 and 36907. And then the C7514 is going to combine our CPT code the 36901 and our 36908. And then finally with the C7515, that's going to combine our CPT codes 36901 and the 36909. These are all given a payment indicator assignment of R2. And what that means, it's an office-based surgical procedure that was added to the ASC list for non-facility reimbursement. It is, the payment for it is based on the ops fee schedule or the relative payment weight. So these all have dollar values assigned to them. Intervention-wise, the C7530, this is actually going to combine our CPT codes 36902 and 36908. And again, this one was assigned a payment status indicator of G2, which again has dollar amount reimbursement. And this is based off of the non-office-based surgical procedure. And again, that payment would be based on the ops relative payment weight. Now to get in the common ones that we will see in the ASC setting is all of our coronary casts. So we're going to start with just our coronary angiography. The C7516 is our coronary angiography only. And that is performed in conjunction with an IVAS or the OCT evaluation being performed at the same time. So this one's going to combine your 93454 and your 92978 service. On your C7517, this is a coronary angiography. And this has your non-selective imaging done to the iliac or femoral artery. So that's a non-selective shot. So that would be combining CPT 93454 and that G0278. So the coronary angiography services plus a bypass graft. So the C7518, this again is just your coronary angiography but it's also including bypass grafts. And this would be combined with your IVAS or your OCT imaging. So that's your 93455 and your 92978. On the C7519, this is combining the FFR with your coronary angiography plus graft. So the CPT combinations would be the 93455 and that 93571. And then finally on the C7520, that's going to combine your 93455 and that G0278. So again, that's another coronary angiography with grafts and then that non-selective iliofemoral shot there. One area that I can't answer, so if you have this question, my best advice will be to contact your carrier and see what they want to happen is if you have an IFR performed, because as we know right now with an IFR, we're not fully meeting the CPT definition because we're not administering any pharmacological agent during the FFR service. So we have to append that with the reduced service modifier currently. I will also be calling at the start of the year to find out what Medicare wants with this because I don't know with us having to go to reporting these C codes, are we gonna be required to reduce that service? To me, it's going to ping the service as the entire service was reduced when that's really not the accurate statement because a full cap would have been performed. So we definitely will find out more information as we get into the new year and can get Medicare more involved with that and answering those detailed questions. Definitely something to think about if you are already working in this space and you are doing a lot of the IFR services, definitely wanna contact your carrier, see how they're gonna want those services reported. All right, further going into our coronary angiography plus a right heart cath. So we haven't added any left heart cath portions yet. So now we're just looking at coronary imaging and then our right heart cath. So the 7521 would combine your 93455 and your 92978. So that's your coronary imaging, your right heart cath, and then an IVAS or OCT. The C7522, that's gonna combine your 93456 and then your 93571. So again, that's gonna be your angiography with right heart cath and then any FFR services performed. Now we're getting into some left heart caths. So the coronary angiography plus left heart cath. The C7523 combines your left heart cath with your IVAS or OCT. So that would be your 93458 and your 92978. And then your C7524 is going to combine your left heart cath along with your FFR. So your 93458 and that 93571. Now we're gonna add some graphs to that. So the C7525 is your 93459 with your 92928, or 92978, sorry. You can see a common theme here. So all these combination codes either have to do with your IVAS and OCT or your FFR service. So with the C7526, that's combining our 93459 and our 93571. So now we have a coronary angiography plus a left heart cath and a right heart cath. So the C7527 would crosswalk to our 93460 and our 92978. So again, that has our IVAS or OCT and that's a full coronary angiography with a left and right heart cath. The C7528 is when it involves the FFR. So that would be your combination of your 93460 and that 93571. And on the C7529, that's gonna combine your 93461 and your FFR with the 93571. All right, so on the C7552, this actually combines your 93457 and your FFR with the 93571. And then on the C7553, this would combine your 93461. So that would be your full left to right heart cath, coronary angiography, bypass imaging, but it also includes your 93463. Now moving into some of the interventions, the C7531, this would apply to your peripheral vascular. So this is a combination with your 37224 and your IVAS with the 37252. So that's just your FEMPOP angioplasty with the IVAS imaging included. The IVAS imaging included. And then on the C7532, this combines your 37246 intervention for your vascular studies and also includes IVAS with the 37252. More interventions. So on our C7533, this actually combines our coronary angioplasty. So the 92920, along with that intravascular brachytherapy. So that would combine 92920 with 92974. On the C7534, this is more of, this is in our peripheral vascular area. This combines CPT37225 with that IVAS, the 37252. So that's gonna be an atherectomy with angioplasty if needed to your FEMPOP along with that IVAS. On the C7535, this is also peripheral and that would combine your CPT37226 and your IVAS 37252. They did add some new HCPCS codes for some of the permanent device implants. These are all related to a pacemaker implant. The C7537 is gonna be a combination of your 33206. So that's gonna be your single chamber pacemaker and it'll also include the 33225 for your left ventricular lead. So that C7537 will capture those two services together. The C7538 is gonna be a combination of our dual, or our LV, not our LV, the RV pacemaker implant with the 33225. So again, just combining those two CPTs together. The C7539 is gonna combine a dual chamber pacemaker. So you're getting a right and left lead and then you're, or the two right leads, right atrium, right ventricle. And then you're also getting that left ventricle lead. So that's gonna be our biventricular pacemaker implant. And then it would be reported with the C7539. And then our C7540, this is when it's a battery change out for a dual lead system. So, and then they also are placing an LV lead at the same time. These are all given payment status indicator eight, which means they fall under that device intensive procedure and they will be paid at the adjusted rate per the fee schedule. All right, now we're gonna cover a couple of case examples so you can kind of see how this looks, especially if you're new to the ASC area. So this procedure is pretty straightforward. The indication is they're defibrillator devices at end of its life. So they're just needing a battery change out. The provider report's pretty straightforward. They talk about, you know, the patient was prepped and draped, all that typical language we see. Local anesthetic was given, incision was then made. The device generator was removed. They then implanted the new and attached it to the single lead system. They then cleaned the pocket and secured it and closed it. They then further give the detail of the implanted device. So we have our ICD generator. We have who the vendor is, the model number. And then that serial number. Now, when I go to the Boston website and I look under to search for this model number, the D142, that's where it will crosswalk it over to the appropriate HCPCS code for me. Now, further, I always verify in the procedure log, and I only put part of it, obviously. The procedure log is usually multiple pages, very detailed listing, but you can see how detailed they date it. And then it has a timestamp on every single thing that is done. So I just pulled the portions of when the patient arrived to the lab to when the patient was closed. I now pulled the important pieces out. So again, you can see it matches up exactly with what the provider did. It even lists in here the manufacturer, model number, all that information. So it all matched. So then when I'm looking at my reporting overall, I'm gonna report my 33262 for that generator changeout for a single lead defibrillator system. And I'm also gonna report my C1722, which is that device from the manufacturer for that single chamber defibrillator. All right, now let's look at a coronary angiography. So here I have indications of aortic stenosis. They tell me in the wishlist, they did a left heart cath with an LV. I'm gonna verify that because we never look at the wishlist as a whole, and we never code from that, but it can be a guide at times where you can kind of see what the provider was wanting to do. So we'll verify and see if an LV lead was done. Conclusions after the case, the patient had non-obstructive coronary arteries with severe aortic stenosis. They are recommending that patient for a TAVR. Again, we can see typical language, patient arrived to the room, consent was obtained and verified. Patient was prepped in drapes and local anesthetic was given. They went through the radial artery for access. Then we can see they got their findings from the imaging they performed. We can see non-obstructive disease with mild CAD. And I didn't copy the log here because of the, again, the amount of information that gets put in the logs, but we can see there was no LV gram done. There was no left ventricular done whatsoever. This was truly just coronaries only. So we code this as 93454, and then we're going to append our TC modifier for the ASC services being provided. Now we have a drug eluding stent with a left heart cath. We can see our indications are chest pain. We also had an abnormal cardiac stress test. Wishlist says left heart cath with an LV. Our conclusions show a 99% stenosis in our LAD. They did have a successful PCI with a drug eluding stent and angioplasty to that mid LAD vessel. And then they do give findings of that left ventricular gram that they performed. Going into the meat of the note with our description of our procedure, again, typical language provided, arrived to the room, consent was obtained, local anesthetic was given. You can see down here, they did our selective left coronary angiography. They then moved to the right. Then they pulled that catheter down into the LV, and then that left ventricular gram was performed. The guide catheter was then inserted. They then switched everything out. You can see they go into the intervention piece here. So they get the balloon catheter inserted first. They inflate it. Then they place that drug eluding stent. It's important when you're coding for the facility, again, to pay attention to the type of stent, because if this was a bare metal stent, our coding would change. So we know here we have a drug eluding stent. It was deployed. They then inflated the balloon again, got excellent results from that. They also did an arterial sheath that they removed, and then they did an angio seal to close the patient. Again, here's just our findings of everything. Looking at the reporting for this, we have our C9600 with that LD vessel for the drug eluding stent. We then had a full left heart cath. You still append your TC modifier. NCCI edits do still come into play with ASC reporting. So we know we're gonna need our 59 because the provider did not know going into this they would be doing an intervention. There are some times where I do see stage procedures in an ASC, so meaning they had a previous cath done or an imaging done, maybe it was a CTA or something, and then they know they're going to do a stent. So you wouldn't report the imaging in those cases like you would normally on the professional side, but here we also have to append that modifier 59. And then that angio seal closure device from the facility perspective, you can report. So it's C1760, it is on one of those pass-through devices. So it's on the allowable list of reporting, but it is given a status indicator of N1. So that means the payment for the service is going to be packaged. We still wanna report it though because Medicare does keep track of these and they'll evaluate this for future rate settings. These are just some helpful resources that I have found from Medicare. Again, your local Medicare contractor is definitely gonna be your best friend if you're trying to learn and grow in this area. National Medicare also has an excellent resource site. They have a lot of detail on their site. I personally find some of the Medicare contractors are easier to maneuver through and find exact information on, but again, National Medicare versus your local Medicare contractor are both great resources. All right, so that takes us to our questions. Let me pull some of these up. So I have somebody asking, we aren't using any C codes currently for devices done in our ASC. Should we be using C codes? You should be if they're on the ASC fee schedule. So if they're listed as an allowable on the fee schedule, even if they have that N1 status indicator, you should be also reporting those services. For IBIS and additional vessels, would we still report the additional IBIS out on code 92979? That's a great question. One that we will have to verify with our local payers to see how they're gonna want those additional services reported. Another area that I can bring up that is gonna need to be asked to our payers is what if a patient has a calf, they have an IBIS and they have an FFR? How do those need to be reported? So again, gonna be very good questions that you're gonna need to ask your carriers directly since these are new C codes starting for next year for the ASC side. So I can't give you a straight answer on those right now. Best bet is just to contact your carriers. Jamie, just as a side note, and I think this is important as we've talked about this with all of us and then of course experts that we work with and reach out to as well. The reporting of those C codes can be variable by certain commercial payers as well, correct? They won't allow them on the claim. So when you look at the Medicare manual that Jamie referenced in chapter four, you can read from a CMS perspective and a guideline perspective, they say they should be reported. However, we can't control what happens of course and know what each and every payer are gonna do with these. So I caution everyone in this ASC space, especially as we continue to expand and develop knowledge through this. I believe you need to contact your payers, you need to make a payer grid and really understand what each of your payers are doing and track those denials, appeals and what your resolution is. I wish there was a blanket answer, but there is not. It is very difficult because like with the C-9600, that code's been around for a while, but some of our commercial payers won't accept it even with a drug eluding stint. So you would still in those cases report your regular 92928 service. I did have a few people ask if I can add the combination CPT codes that correlate with those new C codes. I will actually add that in the Q&A document and get those details listed out. So that way you will have that reference to look at. There is a question about a freestanding OBL being billed under the group tax ID. Obviously disclaimer, not attorneys here. So there are a lot of those arrangements that have to of course be reviewed by your legal counsel. However, most of the OBLs are under the practice tax ID in order to meet the requirement certification and be able to function as an OBL. There are normally under that same group tax ID. All right, well, I think we answered everybody today. So that'll be an easy document to compile our Q&As in. And again, I'll get the detailed CPT list made out for everybody that crosswalks to those new C codes for those CAFs with the IVAS and FFR services. All right, well, thanks everyone. Thanks for a great week and we appreciate everyone's interaction. And as always, we appreciate anything shared with our community on the Listserv for us all to learn. Thank you. Thank you.

coding

reimbursement

office-based labs

ambulatory surgery centers

billing

modifiers

device implants

coronary angiography

Medicare