Why Surgeon Coding and Facility Claims Must Match — The ASC Synchronization Problem Payers Are Now Auditing

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Ambulatory surgery centers (ASCs) are facing increasing pressure to keep professional and facility claims consistent. A surgeon may submit a professional claim for a procedure while the ASC submits a separate facility claim for the same encounter. Although these claims serve different billing purposes, the clinical details behind them should tell the same story. When surgeon coding and facility claims do not match, payers may see inconsistencies that can trigger claim reviews, payment delays, downcoding, or denials. The problem is not always an incorrect CPT code. Sometimes the issue is that two correctly prepared claims do not appear synchronized. The ASC Synchronization Problem ASC billing involves multiple parties. The surgeon or physician group submits the professional claim, while the facility submits the institutional claim for the services and resources provided by the ASC. Both claims can contain different codes because they represent different components of the same encounter....
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Durable Medical Equipment (DME) Modifiers

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Equipment that gives therapeutic advantages to a patient and is basically for the long haul and home use is named Durable Medical Equipment (DME). Because of a wide assortment of models for DME, Places for Medicare and Medicaid Administrations (CMS) established the Healthcare Common Procedure Coding System (HCPCS) and modifiers which relate to the boundaries policy and LCD and make the HCPCS code legitimate before claim processing.

Modifiers are divided into several categories:

Routinely purchased Pricing Modifiers:

NUPurchase of New DME
RRRented DME
UEPurchase of Used DME
NRNew when rented
Capped Rental Items and modifiers: One can utilize RR in this classification with the exception of wheelchairs where the patient is permitted the choice to get one. Others are:

BRThe receiver has elected to rent
BPThe receiver has elected to purchase
BURent or purchase not selected past 30 days despite a notification
KHPurchase or First rental month
KISecond and third rental months
KJFourth to thirteenth rental months
KRRental but partial month billing
LLLease/Rental (Medicaid)

Other Categories:

MSMaintenance DME
MMMaintenance and Servicing
RPReplacement and repair
A1 to A9Surgical Dressings
CGSpinal Orthosis

Modifiers for Oxygen and the Corresponding equipment:

RRRental
QEPrescribed oxygen is less than 1 LPM
QFPrescribed oxygen exceeds 4 LPM and portable oxygen is prescribed
QGPrescribed oxygen is greater than 4 LPM
QHWhen an oxygen conserving device is used with an oxygen delivery system

Functional Modifiers for Prosthetics and Orthotics:


K0 to K4Used for various categories in Lower Limb Prostheses
RAReplacement of DME, orthotic or prosthetic
QFReplacement of a part of the above

Osteogenesis Stimulators:

KFmodifier (FDA Class III device) to be used with E0747, E0748, and E0760.

Tape (A4450, A4452):

AXItems in concurrence with dialysis services
AUItems in urological, ostomy, or tracheostomy supply
AVItems with a prosthetic or orthotic device
AWItems in surgical dressing with billing codes for tape A4450 and A4452

Drug Formulations (pedorthics.org):

KOSingle drug unit dose formulation
KPThe first drug of a multiple drug unit dose formulation
KQSecond or subsequent drug of a multiple drug unit dose formulation

Anatomic Modifiers:

RT (Right) and LT (Left)modifiers are used in cases such as refractive lenses, eye prosthesis, facial prosthesis, orthopedic footwear, etc.
KMReplacement of facial prosthesis including new impression
KNReplacement of facial prosthesis using previous master model
KXUsed in cases such as external infusion pumps, home dialysis supplies, nebulizers, hospital beds, walkers, cervical traction devices, etc.
KSThe patient is glucose monitor supplied, not insulin

Up-gradation/Prescription requirement:

EYUsed when a supplier does not have a doctor’s order.
GAWhen a supplier has an ABN on file.
GZItem denied as not reasonable.
GYWhen an item is not covered and does not have a Medicare benefit.
GK and GLmodifiers are upgrades wherein GK is a necessary upgrade of the equipment whereas GL is not.

Added modifiers:

KB or 99used in cases of 4 or more modifiers.
KL (delivered by mail), KV, KT, J4, KE, KG, KK, KU, KW, KYRefers to DMEPOS items and their bidding.
As referenced above, DME modifiers are two-character alpha or numeric codes that are added to the furthest limit of HCPCS codes to elucidate the advantages when billed. Adding these augments the reimbursement process.
Location: 539 W Commerce St #1482, Dallas, TX 75208, USA

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