Grouped Surgical Procedures and the ACS List

Saturday, May 10, 2003 | 0

Workers' Compensation Auditor and Bill Review Specialist, Mary Saxon, recently humbled the experts at workcompcentral.com with the following question:

"In regards to outpatient surgery facility fees and CA:

"When using the ACS Grouper List and rates should multiple surgeries from the ASC Grouper List follow the multiple surgical procedure guidelines, e.g., 100%/50%/25%? In my past experience we didn't cut multiple surgeries from the ASC Grouper List, since the rates are already reduced. If I could get some definite documentation I would really appreciate it. And, thank you for your help."

Hey, we know a lot about work comp, but sometimes the heavy duty technical specialists throw us for a loop. Quite honestly, we didn't have a clue:

" Boy Mary - this question is way beyond our expertise. We really don't know. But if you find the answer, please let us know because if you're curious, others are."

Mary found the answer:

"I found where this information is in regards to the ASC Grouper Surgical Procedures and I thought I would share it with you in the event you are ever asked this again.

"According to the Medicare Federal Register Vol. 63, No. 113 dated 6/12/1998:
"'If one procedure on the ASC list is performed in a single session, payment of the ASC facility fee is based on the prospectively determined rate for that one procedure. If more than one surgical procedure is furnished on a single operative session payment is based on:
"'A) The full rate for the procedure with the highest prospectively determined rate and,
"'B) One half of the prospectively determined rate for each of the other procedures."

It should come as no surprise that we have asked Mary for future articles on medical billing topics.

Mary has over 15 years of workers' compensation experience, from claims to marketing to audits and bill review. She is presently employed with USA Managed Care Organization. Mary's e-mail address is mary3438@yahoo.com.