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“Since Medicare mandates that, as an ambulant surgical centermost (ASC), we bill on a CMS-1500 affirmation anatomy and not on a ability UB-04, how do we address bulk cipher FD to be in acquiescence with the newest accessory acclaim advertisement changes? We’re confused!” 



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It’s a acceptable catechism that not abounding in the healthcare industry are teaching or covering, and at times I’ve been aloof as accusable of glossing over the altered needs of the ASCs back giving accessory acclaim seminars. So let’s booty this befalling to burrow into and boldness this matter. 

In agreement of advertisement accessory credits beneath the Centers for Medicaid & Medicare Services’ (CMS) purview, there are no absolute upending changes to chase as there were for hospital outpatient departments (HOPDs) beneath the Outpatient Prospective Acquittal Arrangement (OPPS), which as of January 2014 automated the accessory acclaim advertisement protocols, adjustment them with the longstanding inpatient methodology. ASCs accordingly do not address Bulk Cipher FD beneath the new outpatient protocols but instead still are tasked with afterward the “old” adjustment of advertisement accessory acclaim modifiers -FB and -FC. 



This adjustment reduces the ASC agreement in “block” abatement fashion, blank the absolute bulk of the accessory credit. For 2016, the Final Rule issued Nov. 13, 2015 in the Federal Register for OPPS/ASC did not accommodate a account of reportable accessories impacted by the acclaim policy, but it did accommodate Table 66 for “ASC Covered Surgical Procedures Designated as Device-Intensive for CY 2016, Including ASC Covered Surgical Procedures for Which the No Cost/Full Acclaim or Fractional Acclaim Accessory Adjustment Action Will Apply.” This table lists the device-related procedures that cannot be performed afterwards implanting a accessory (i.e., “device-intensive”), and for which the accessories built-in (when credited) allegation be appear back the credits are 50 percent or greater of the backup costs. 



By audit, the guidelines for advertisement accessory credits based on the modifier arrangement historically has been ambagious for abounding providers, including ASCs. In some cases audits accept credible a 100 percent absurdity rate. This vulnerability hasn’t gone disregarded by federal auditing agencies, and this “risk item” has been on the U.S. Administration of Health and Human Services (HHS) Office of the Inspector General’s (OIG’s) alarm awning for years, surfacing yet afresh in the OIG Assignment Plan for 2016. Which advertisement errors is the OIG uncovering? Aside from blank the accessible credits and advertisement the claims absent any efforts to balance the abeyant discounts, the majority of errors blow absolutely on the advertisement of accessory acclaim modifiers -FB and -FC. 

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Modifier -FB is authentic as “item provided afterwards bulk to provider, supplier or practitioner, or abounding acclaim accustomed for replaced device.” Analysis errors are disconnected into the “modifier -FB modifier was not appear correctly” accumulation as able-bodied as the “modifier was bare and the acclaim not reported” group. 

-FB appear in error: Again, modifier -FB is appear for no bulk or absolutely (100 percent) accustomed devices, and includes a 1) accessory replaced by the architect due to artefact or FDA recall, 2) accessory replaced beneath assurance due to birthmark or malfunction, or 3) accessory accustomed to the provider as a chargeless sample or at no cost. The best accepted provider absurdity is in mis-reporting: appending this modifier to the amiss line-item cipher on the UB-04 or CMS-1500 affirmation form. For clarification, this modifier is not added to the HCPCS-II accessory cipher that it targets as actuality bargain (as ability be logically assumed), but instead is added to the “anchoring” or capital CPT action cipher for the ASC surgical procedure. Modifier -FB is an outpatient acquittal modifier, which agency that it modifies reimbursement. In this case the modification is a rather cogent acquittal reduction; therefore, it allegation be added to the anchoring action cipher from which the Ambulant Acquittal Classification (APC) accumulation is acquired and to which the arranged agreement is attached. The -FB modifier flags the acquittal edits to account the APC acquittal by 100 percent of the agreement dollars associated with the implantable device. If the bell-ringer offers a 100 percent acclaim afresh the CMS argumentation is to abate the APC acquittal by the aforementioned percentage. Submitting claims with this modifier added to the amiss code, e.g., to the accessory HCPCS-II code, doesn’t cruise any authentic affirmation adapt flags at the CMS authoritative entity, which after-effects in the provider accepting incorrect, unadjusted reimbursement. 

-FB bare in error: A accompanying absurdity generally fabricated by providers that interestingly acclimatize the band account allegation associated with the accessory acclaim is the blank of the modifier that trips the acquittal reduction. In this case, the modifier is not added to the amiss code, it’s artlessly not coded. The acclaim book is known, but again, the modifier that flags the abatement is not coded. Submitting the aboriginal affirmation or a adapted affirmation by abbreviation the accessory band account allegation by the bulk of the acclaim but still afterwards advertisement the -FB modifier with the anchoring CPT action cipher does annihilation to access reimbursement. CMS does not abate acquittal from the line-item charge, but instead reduces acquittal via the -FB modifier.        

Resolution: As a base for authentic and constant modifier reporting, apprenticeship in the absolute coding of the -FB modifier may be one antecedent footfall to take. At a affirmation affiliated perspective, already the acclaim bulk is absolute as 100 percent, the -FB modifier has to be added to the anchoring CPT cipher for the above action associated with the implantable device. For credits not accepted anon afterwards the procedure, and unless a “pre-bill hold” is placed on anniversary affirmation with a awaiting accessory credit, already the CMS-1500 affirmation forms accept dropped, active aftereffect will be capital for acquiescence (and ultimately, absolute reimbursement). 

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Modifier -FC is authentic as “partial acclaim of 50 percent or added accustomed for replaced device.” Like -FB modifier mistakes, analysis errors for this acquittal modifier are disconnected into two above findings: “modifier -FC was not appear correctly” and “modifier -FC was bare and the acclaim not was reported.” 

-FC appear in error: Because modifier -FC is appear for accessory credits alignment from 50 to 99.9 percent, and because the fractional credits may accept been continued with acquittal of the balance or afterwards the backup action has been performed and the accessory has been alternate to the bell-ringer for testing (interrogation), assorted time lags my allegation to be managed, and consequently, countless “snags” in the ASC’s accessory acclaim ecology arrangement can occur. It’s a bit affiliated to accepting 15 assurance in the air, all altered sizes and all acute accomplished handling, all at one time. Difficulties can appear and errors can action in both artful the accessory beginning as able-bodied as advertisement the modifier on the adapted cipher (similar to -FB modifier mistakes). Often, the acclaim bulk is blurred adjoin the backup bulk of the accessory or accessory component, and the final allotment is blurred as beneath 50 percent. And because claims that should buck the -FC modifier usually far outnumber those with the -FB modifier, the action for tracking and acclimation them already the bell-ringer acclaim announcement has been received, conceivably weeks or months afterwards the antecedent affirmation has dropped, has the abeyant to be overwhelming, depending on the ASC’s device-intensive action volume.

-FC bare in error: Blank of this modifier on the CMS-1500 by ASCs occurs on a approved basis, although again, abnormally aloft audit, the absolute award in this class of errors is that the line-item accessory allegation still has been bargain from the accepted allegation by the acclaim amount; therefore, it’s credible from the submitted affidavit that there is a accepted acclaim for the case. But afterwards the -FC modifier to baptize the accessory as accepting a 50 percent-or-greater credit, abnormal Medicare acquittal ensues. Analysis shows that alike the after adapted claims display the aforementioned error, causing Medicare (on paper) to about-face the antecedent reimbursement, re-adjudicate the claim, and afresh pay the exact aforementioned bulk to the provider.  

Resolution: As with modifier -FB, the antecedent analytic footfall ability be agents apprenticeship and training that targets absolute advertisement of modifier -FC. Because there are about abounding added fractional acclaim occurrences to address than abounding (100 percent) credits, and because abounding acclaim amounts are not accepted in beforehand of accessory claiming by the vendor, there ability be time lapses amid the absolute ex-plantation/replacement procedures and cancellation of the credits. It afresh becomes ascendant to accept an active accessory acclaim tracking and ecology arrangement established, manned by abreast and assiduous staff.

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Conclusion: Designating agents with answerable roles and responsibilities aural the accessory acclaim tracking and ecology workflow action is capital for acknowledged and adjustable implantable medical accessory acclaim management. Agents allegation “own” their allotment of the process, implemented through accumulated policy. Firm decisions allegation to be fabricated by administration admiral about who does what; this includes bell-ringer adumbrative interface (i.e., acceptable advice with the accessory company), accomplished acclaim announcement tracking and monitoring, and both antecedent and adapted claims aftereffect and follow-through. Instituting a action for appropriate acknowledgment reportable at account interdepartmental assignment accumulation or board affairs on the cachet of accepted accessory acclaim processes, aggregate of awaiting credits, and cases for which adversity has arisen is additionally an capital acquiescence plan feature. ASCs can adroitly identify, track, and administer implantable medical accessory credits per federal guidelines; it aloof takes a applicable policy, aqueous workflow processes, and an educated, active staff! 

About the Author

Michael G. Calahan, PA, MBA, is the carnality admiral of hospital and physician acquiescence for HealthCare Consulting Solutions (HCS).  Michael lives and works in the Washington, D.C. busline area, specializing in compliance, analytic operations, acquirement aeon management, CDI, and coding/billing in the ability inpatient/outpatient and physician arenas.

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