The never ending cycle of change is upon us again and its time to learn another set of coding and billing guidelines as they pertain to CMS and Medicare Claims Processing.

As previously discussed it is no longer necessary to append the SG modifier on
CMS-1500 claim forms. The Contractor will assign TOS code "F" (Type of Service) which relates to "Ambulatory Surgical Center (Facility Usage for Surgical Services)" along with Place of Service code 24 (ASC). This identifies the claim for payment of facility fees in an ASC setting.

A change also has been designated for Modifier 50. This modifier will no longer be recognized by CMS for payment of bilateral services. There are two ways in which a bilateral procedure can be reported.

1.) List the service on one line with the number "2" in the units field.
15823 "2"
2.) List the service on two lines without modifiers and as a single unit for each line.
15823 "1"
15823 "1"
* It would be incorrect to list this CPT code with modifier 50 and "1" unit since
modifier 50 is not recognized by CMS and will be reimbursed for the one unit only
leading to an underpayment of services.
15823-50 "1"

Device Intensive Procedures

CPT codes such as 63650, 63655, and 63685 for insertion of neurostimulator electrodes and/or pulse generator are on the list of device intensive procedures and the HCPCS codes for the devices/implants should not be reported for billing. CMS has already package the payment for these devices into the CPT code(s) and will not recognize billing of the HCPCS code which could lead to underpayment of services. Only report CPT code(s) for the surgery and include the cost of devices/implants into the surgical code.

Modifier FB and FC

When you have a Device Intensive Procedure performed the cost of the devices/implants are already included within the payment for the CPT code, so if you had an instance were a neurostimulator generator malfunctioned while under warranty and the manufacturer provided a replacement at no charge or with partial credit then that would be indicated by appending an FB or FC modifier to your CPT code. This alerts CMS that a reduction to the device portion of the payment should be made to compensate for the facility having received a credit.

FB modifier should be appended when the facility receives a full credit or no cost replacement device.

FC modifier should be appended when the facility receives a credit of 50% or more on the device.

This only applies to device(s)/implant(s) that are associated with device intensive procedures.

TABLE 56.-ASC COVERED SURGICAL PROCEDURES DESIGNATED AS DEVICE-INTENSIVE FOR CY 2008

HCPCS Code Short Descriptor CY 2008 OPPS APC CY 2008 Device Dependent APC Offset Percentage
33206 Insertion of heart pacemaker 0089 72.99%
33207 Insertion of heart pacemaker 0089 72.99%
33208 Insertion of heart pacemaker 0655 74.62%
33210 Insertion of heart electrode 0106 56.25%
33211 Insertion of heart electrode 0106 56.25%
33212 Insertion of pulse generator 0090 76.01%
33213 Insertion of pulse generator 0654 77.13%
33214 Upgrade of pacemaker system 0655 74.62%
33216 Insert lead pace-defib, one 0106 56.25%
33217 Insert lead pace-defib, dual 0106 56.25%
33224 Insert pacing lead & connect 0418 82.52%
33225 Lventric pacing lead add-on 0418 82.52%
33240 Insert pulse generator 0107 89.11%
33249 Eltrd/insert pace-defib 0108 89.24%
33282 Implant pat-active ht record 0680 73.15%
36566 Insert tunneled cv cath 0625 58.88%
53440 Male sling procedure 0385 51.56%
53444 Insert tandem cuff 0385 51.56%
53445 Insert uro/ves nck sphincter 0386 63.53%
53447 Remove/replace ur sphincter 0386 63.53%
54400 Insert semi-rigid prosthesis 0385 51.56%
54401 Insert self-contd prosthesis 0386 63.53%
54405 Insert multi-comp penis pros 0386 63.53%
54410 Remove/replace penis prosth 0386 63.53%
54416 Remv/repl penis contain pros 0386 63.53%
55873 Cryoablate prostate 0674 60.27%
61885 Insrt/redo neurostim 1 array 0039 82.73%
61886 Implant neurostim arrays 0315 86.15%
62361 Implant spine infusion pump 0227 80.73%
62362 Implant spine infusion pump 0227 80.73%
63650 Implant neuroelectrodes 0040 56.27%
63655 Implant neuroelectrodes 0061 60.60%
63685 Insrt/redo spine n generator 0222 84.86%
64553 Implant neuroelectrodes 0225 80.57%
64555 Implant neuroelectrodes 0040 56.27%
64560 Implant neuroelectrodes 0040 56.27%
64561 Implant neuroelectrodes 0040 56.27%
64565 Implant neuroelectrodes 0040 56.27%
64573 Implant neuroelectrodes 0225 80.57%
64575 Implant neuroelectrodes 0061 60.60%
64577 Implant neuroelectrodes 0061 60.60%
64580 Implant neuroelectrodes 0061 60.60%
64581 Implant neuroelectrodes 0061 60.60%
64590 Insrt/redo pn/gastr stimul 0222 84.86%
69930 Implant cochlear device 0259 82.94%