A.
The form can be somewhat perplexing. Here are some guidelines on how to fill out some of the most confusing portions.
Item #20 -Outside Diagnostic Services: If you sent the patient to another provider for diagnostic tests, put an X in the "yes" box, and also complete item #32. Give the name, address and national provider identification number of the clinical laboratory or other supplier that performed the service. If the patient underwent multiple tests, you must submit each one on a separate claim form. Enter the purchase price of the tests in the charges column. Show dollars and cents, omitting the dollar sign (e.g., 25.00 or 67.25). The charges will be subject to purchase-price limitations.
If the tests were performed in the physician's office or supervised by the physician, put an X in the "no" box.
Item #21 -Diagnosis or nature of illness or injury. Freestanding ASCs must include an ICD-9-CM diagnosis code(s) on each request for payment, just as physicians do. The code identifies the diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter. Enter up to four codes in priority order (e.g., primary, secondary condition).
Item #22 -Medicaid Resubmission: You won't need this box for a Medicare claim. It's strictly for use when resubmitting a Medicaid claim; you put the code and original reference number of the Medicaid claim here.
Item #23 -Prior Authorization Number: It's necessary to fill out this field when the procedure requires prior approval by the Peer Review Organization (PRO). Enter the authorization number for those procedures. It's also necessary to fill out this field if you are using an investigational device in a Food and Drug Administration-approved clinical trial. In the box, enter the Investigational Device Exemption (IDE) number.
Item #24 This is probably the most confusing set of boxes on the form. Here's help on completing them.
Item 24A: Date(s) of service. Enter the month, day and year for each procedure, service or supply. If you've provided several identical services over a period of time, note both the "from" and "to" dates and enter the number of days in column 24G.
Item 24B: Place of service. The reverse side of the HCFA-1500 lists the Place of Service codes for Medicare claims. The ones that relate to ambulatory surgery include:
22-Hospital
23-Hospital Emergency Room
24-Ambulatory Surgery Center
62-Comprehensive Outpatient Rehabilitation Facility (CORF)
Item 24C: Type of service. You don't have to put anything here, but ambulatory surgery centers may do well to routinely enter "F" in this box, for Ambulatory Surgery Center facility service. This helps reduce confusion on the part of the payer, and it is a must when billing a HCPCS Level II "Q" code for an approved New Technology Intraocular Lens. (See the May 2000 issue of Outpatient Surgery Magazine for more information about coding and billing for NTIOLs.)
Item 24D: Procedures, services, or supplies. Enter the procedures, services or supplies you've rendered using the codes from the Current Procedural Terminology (CPT) coding system or the HCFA Common Procedure Coding System (HCPCS) Level II systems.
ASCs can often prevent problems by appending the modifier -SG to each of these codes. Without the modifier, some carriers will inappropriately process and pay an ASC claim as a professional fee for the surgeon's performance of the procedure(s), using the Medicare Fee Schedule. The -SG modifier alerts carriers that the claim is for the facility services associated with the procedure.
Item 24E: Diagnosis code. The diagnosis reference number in "Item 21" (i.e., 1, 2, 3, 4) or the ICD-9-CM diagnosis code shown in "Item 21" relates the date of service and the procedures performed to the specific diagnosis. Show a maximum of four diagnosis codes. When you have provided multiple services, enter the diagnosis code warranting each service.
Billing Implants
Just one final note. Some ASCs don't realize that they can receive payment for several different types of implants/prosthetics. These include metacarpophalangeal, interphalangeal and metatarsal joints, temporomandibular joint, orbit, mandible, maxilla, distal humerus, proximal ulna, scaphoid, lunate, trapezium carpus, extensor tendon (hand/finger), tendon, patella, palate, cochleas, testicle, ossicles, breast, ocular, and vascular grafts1. Intraocular lenses are considered to be covered under the global fee for cataract extraction and IOL implantation; do not bill for these separately.
To bill for these items, list the CPT for the covered ASC procedure. Then, on a separate line, list the HCPCS Level II code for the implant as well as the applicable charge.
Attach a complete legible copy of the actual invoice to the claim form. The invoice must indicate the actual or acquisition cost of the implant, any handling or dispensing fees involved, and any discounts the ASC receives. Some ASCs attach both the invoice/purchase order and product charge sheet to the claim.
Do not file this type of claim electronically. Mail a hard copy of the HCFA-1500 together with the supporting documents to your Medicare carrier.
Keep the original invoice on file, available for your Medicare carrier to review if necessary.
There is no national uniform payment rate for implants inserted in ASCs. The Medicare carriers will determine the payment based on their review of the claim and invoice documents.
1. December 31, 1991, Federal Register, page 67677
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