HCFA lists proposal for surgical APCs

By Rita A. Scichilone, MHSA, RRA, CCS, CCS-P
Professional Management Midwest
Omaha, NE

According to the proposed hospital outpatient prospective payment system published in the Sept. 8 Federal Register, it is Medicare’s intent to use the same surgical groups in the payment systems for hospitals performing outpatient surgery and freestanding ambulatory surgical centers (ASCs). It does not intend to reclassify procedures from one group to another routinely but will restrict changes to additions, deletions, and revisions in the coding systems.

Any changes to ambulatory patient classifications (APCs) will maintain budget neutrality. Under the proposed rules for ASC prospective payment, published in the June 12, 1998, Federal Register, cataract surgery code 66984 is grouped to APC 668 with a proposed rate of $863 (down from the current rate of $928). For the hospital, code 66984 is grouped to APC 668 also, with a projected payment rate of $976.91. In both settings, intraocular lens reimbursement is included in the payment for the surgery.

A cystoscopy with biopsy code 52007 groups to APC 522 in both settings. Performed in an ASC, the allowance is $393 (down from $422), while the hospital performing this procedure would receive $530. Payment amounts are based on proposed rates only.

Multiple surgery reduction

When more than one procedure is performed during a single session, Medicare would pay the full amount for the first procedure, then reduce the second and subsequent procedures by 50%.

As expected, the hospital modifiers are used to communicate discontinued or terminated procedures that are not carried out as planned. Modi fier -53, which is assigned when the patient has undergone anesthesia and the procedure is under way when it is terminated, allows 100% of the payment for the APC. Modifier -52 is used for those patients who are prepared for surgery and have been sedated, but not to the point of anesthesia induction. For these patients, 50% of the APC payment will be made.