ASC terminated surgery claim payment

Payment for Terminated Procedures

The following criteria determine the appropriate ASC facility payment for a scheduled surgical procedure that is terminated due to medical complications that increase the surgical risk to the patient. Contractors may pay a different rate percentage in certain situations where documentation supports such action.

• Medicare will deny payment when an ASC submits a claim for a procedure that is terminated before the patient is taken into the treatment or operating room either for non-medical or medical reasons before the ASC has expended substantial resources.

Example: Payment is denied if scheduled surgery is canceled or postponed because the patient on intake complains of a cold or flu.

• Medicare will pay 50 percent of the rate if a surgical procedure is terminated due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating room but before anesthesia has been induced. (Use modifier 73.)

Example: Fifty percent is paid if the patient develops an allergic reaction to a drug administered by the ASC prior to surgery or if, upon injection of a retrobulbar block, the patient experiences a retrobulbar hemorrhage that prevents continuation of the procedure. Although some supplies and resources are expended, they are not consumed to the same extent had anesthesia been fully induced and the surgery completed. Medicare may pay a different percentage of the rate if, in an individual case, documentation supports such action. Facilities should use the 73 modifier to indicate the procedure terminated prior to induction of anesthesia or the initiation of the procedure.

• Medicare will make full payment of the surgical procedure if a medical complication arises that causes the procedure to be terminated after anesthesia has been induced or the procedure initiated. (Use modifier 74.)

Example: Medicare will make full payment if, after anesthesia has been accomplished and the surgeon has made a preliminary incision, the patient’s blood pressure increases suddenly and the surgery is terminated to avoid increasing surgical risk to the patient. In this case, the resources of the facility are consumed in essentially the same manner and to the same extent as they would have been had the surgery been completed. Facilities should use a 74 modifier to indicate the procedure was terminated after administration of anesthesia or initiation of the procedure.

• An ASC claim for payment for terminated surgery must include an operative report kept on file by the ASC and made available if requested by Medicare. The operative report should specify the following:
o Reason for termination of surgery.
o Services actually performed.
o Supplies actually provided.
o Services not performed that would have been performed if surgery had not been terminated.
o Supplies not provided that would have been provided if the surgery had not been terminated.
o Time actually spent in each stage, e.g., preoperative, operative and postoperative.
o Time that would have been spent in each of these stages if the surgery had not been terminated.
o HCPCS code for procedure had the surgery been performed.

• Beginning January 1, 2008, payment for the IOL is included in payment for the surgical procedure to implant the lens.

• Beginning January 1, 2008, Medicare will apply a 50 percent payment reduction for discontinued radiology procedures and other procedures that do not require anesthesia. Facilities should use the 52 modifier to indicate the discontinuance of these applicable procedures.

• Beginning January 1, 2008, ASC surgical services billed with the 52 or 73 modifier are not subject to the multiple procedure discount.