668 OASC 05 13.qxd:06 05 OMD COVER€¦ · incidence of toxic anterior segment syndrome (TASS), endophthalmitis and methicillin-resistant Staphylococcus aureus (MRSA) (these two infections

Finding an EHR software package for your ASC

Managing same-day cancellations

Taking a snapshot of your ASC’s financial health

P.10P.16P.20

Also Inside:

Taking the Pulseof Your Ophthalmic ASC

Clinical and business benchmarks from the Outpatient Ophthalmic Surgery Society’s annual survey. P.4

The Ophthalmic ASCMay 2013

668 OASC 05_13.qxd:06_05 OMD COVER 4/19/13 9:58 PM Page 1

Proven therapeutic utility in a variety of superfi cial ocular infections—including blepharitis, conjunctivitis, and others Profound activity against common gram-positive pathogens—Streptococci, Staphylococci,1 and MRSA2,3

A sensitivity and resistance profi le that’s remained virtually unchanged over time4

Unsurpassed safety profi le—allergenicity and side reactions are practically non-existent1

Convenient dosing—1-3 times daily1

Tier 1 co pay vs. leading brands5

Important Safety InformationBacitracin ophthalmic ointment should not be used in deep-seated ocular infections or in those that are likely to become systemic.This product should not be used in patients with a history of hypersensitivity to Bacitracin.

Proof positive for more eyes

www.ferapharma.com

BACITRACIN OPHTHALMIC OINTMENT USP

References: 1. Bacitracin Ophthalmic Ointment [Package Insert]. Locust Valley, NY; Fera Pharmaceuticals, LLC;2009. 2. Kowalski RP, Karenchak LM, Romanowski EG. Infectious disease: changing antibiotic susceptibility. Ophthalmol Clin N Am 2003;16:1-9. 3. Freidlin J, Acharya N, Lietman TM, Cevallos V, Whitcher JP, Margolis TP. Spectrum of eye disease caused by methicillin-resistant Staphylococcus aureus. Am J Ophthalmol 2007;144:313-315. 4. Recchia FM, Busbee BG, Pearlman RB, Carvalho-Recchia CA, Ho AC. Changing trends in the microbiologic aspects of postcataract endophthalmitis. Arch Ophthalmol 2005;123:341-346. 5. http://fingertipformulary.com/drugs/Bacitracinopthalmicointment/

©2012 Fera Pharmaceuticals, LLC Printed in USA FAB-001 02/12

Please see adjacent page for full prescribing information

Proud sponsor of

668 OASC 05_13.qxd:06_05 OMD COVER 4/20/13 1:09 AM Page 2

EDITORIAL STAFFEDITOR-IN-CHIEF, Ophthalmology Management:

Larry E. Patterson, MD

EDITORIAL DIRECTOR, SPECIAL PROJECTS: Angela Jackson

EDITOR, SPECIAL PROJECTS: Leslie Goldberg

DESIGN AND PRODUCTIONPRODUCTION DIRECTOR: Sandra Kaden

PRODUCTION MANAGER: Bill Hallman

EDITORIAL AND PRODUCTION OFFICES323 Norristown Road, Suite 200, Ambler, PA 19002

Phone: (215) 646-8700

BUSINESS STAFFPRESIDENT: Thomas J. Wilson

EXECUTIVE VICE PRESIDENT AND PUBLISHER: Douglas A. Parry

ASSOCIATE PUBLISHER: Dan Marsh

PROMOTIONAL EVENTS MANAGER: Michelle Kieffer

Copyright 2013, PentaVision, LLC. All Rights Reserved.

The Ophthalmic ASC

Table of ContentsFEATURES

COLUMN

4 Taking the Pulse of Your OphthalmicASCBy Virginia Pickles, Contributing Editor

10 As EHR Use Expands, Attention Turns to ASCsBy Desiree Ifft, Contributing Editor

16 Managing Same-day CancellationsBy Virginia Pickles, Contributing Editor

20 Numbers for Managers: The Balance SheetBy Maureen Waddle, MBA

24 ASC Medicare Compliance and ChartDocumentation in Cataract SurgeryBy Riva Lee Asbell

BACITRACINOPHTHALMIC

OINTMENT USPSTERILE

DESCRIPTION: Each gram of ointment contains 500 units of Bacitracin in a low melting special basecontaining White Petrolatum and Mineral Oil.

ACTION: The antibiotic, Bacitracin, exerts a pro-found action against many gram-positive patho-gens, including the common Streptococci andStaphylococci. It is also destructive for certain gram- negative organisms. It is ineffective against fungi.

INDICATIONS: For the treatment of superficialocular infections involving the conjunctiva and/orcornea caused by Bacitracin susceptible organisms.

CONTRAINDICATIONS: This product should not be used in patients with a history of hypersensitivityto Bacitracin.

PRECAUTIONS: Bacitracin ophthalmic ointmentshould not be used in deep-seated ocular infec-tions or in those that are likely to become systemic. The prolonged use of antibiotic containing prepa-rations may result in overgrowth of nonsuscep-tible organisms particularly fungi. If new infectionsdevelop during treatment appropriate antibiotic or chemotherapy should be instituted.

ADVERSE REACTIONS: Bacitracin has such a low incidence of allergenicity that for all practical pur-poses side reactions are practically non-existent.However, if such reaction should occur, therapy should be discontinued.

DOSAGE AND ADMINISTRATION: The ointment should be applied directly into the conjunctival sac 1 to 3 times daily. In blepharitis all scales and crusts should be carefully removed and the ointment then spread uniformly over the lid margins. Patients should be instructed to take appropriate measures to avoid gross contamination of the ointment when applying the ointment directly to the infected eye.

HOW SUPPLIED: 3.5 g (1/8 Oz) sterile tamperproof tubes, NDC 48102-007-35.

Manufactured for:Fera Pharmaceuticals, LLC

Locust Valley, NY 11560FPBC00N Rev. 08/09


Taking the Pulse of Your Ophthalmic ASC

4

he news is good for ambulatory surgery centers specializing in ophthalmic procedures, says Kent Jackson, PhD, vice president of member research and development for the OutpatientOphthalmic Surgery Society (OOSS). Dr. Jackson has been hunkered down, crunching the numbers

from the fifth annual benchmarking survey, which reflects activity in the calendar year 2011. Although therewere no dramatic changes compared with 2010, Dr. Jackson notes revenue and profitability increased, suggest-ing tighter management and improved productivity, while quality and safety were maintained at a high level.Here are some highlights from the latest report.

Efficiency and ProductivityIn the 2012 survey, facilities reported average case times for cataract, retina, glaucoma and oculoplastic surgeries, breaking down total case times into pre-, intra- and postoperative times for each procedure (Table 1).Trend data are available for cataract cases only, as2012 was the first year the survey included casetimes for the other procedures.

“We saw a downward trend in total average case time for cataract surgeries in 2011,” Dr. Jackson says. “The overall time of 86 minutesrepresents a decrease of 6 minutes, or 5%, comparedwith 2010. The reduction occurred primarily in preoperative time with a slight decrease in post-operative time. This suggests facilities have improvedpreoperative and pre-arrival patient preparations and

Clinical and business benchmarks from the Outpatient Ophthalmic Surgery Society’s annual survey.

T

By Virginia Pickles, Contributing Editor

Table 1. Average Case Times in MinutesCataract Retinal Glaucoma Oculoplastic

Preop 49 46 48 41Intraop 19 46 45 48Postop 18 25 22 27

Total Time 86 117 115 116


recovery care, and it may be related to an increase inoverall staffing also noted in the survey.”

According to Dr. Jackson, several OOSSBenchmarking Roundtable experts suggest reducedcase times may be associated with implementation ofEMR systems and enhanced patient screening andscheduling. For example, with EMR, pre-op andpost-op orders, consent forms, post-op instructions,discharge summaries and operative reports are com-puter-charted and ready for all users to access at thesame time, improving overall efficiency.

This improved efficiency may seem at odds with a9% decrease in the average number of reported casesper day: 20 cases in 2011 versus 22 in 2010. Dr. Jackson suggests the difference may result froman increase in the number of more complex cases,including retina, glaucoma and oculoplastics, beingperformed in the reporting facilities.

Overall employee hours per case increased slightlyfrom a median of 6.5 hours in 2010 to 7 hours in2011, with clinical employee hours per case averaging5 hours per case and business employee hours averag-ing 2 hours per case (Table 2).

Quality MeasuresOOSS has been tracking incident measures for severalyears, aligning them with the same categories used bythe ASC Quality Collaboration (www.ascquality.org)and, more recently, with mandated quality require-ments for Medicare-certified ASCs.

Dr. Jackson notes a slight uptick in hospital trans-fers and postsurgical readmissions to the ASC in the2012 survey. “Neither would appear significant,” hesays. “Postsurgical readmissions are primarily thephysician’s call and are related to surgical outcomes.Hospital transfers are typically unrelated to surgicalissues and can be addressed by employing and adher-ing to patient selection criteria coupled with soundpreoperative screening.” To put these and related datainto context, 71% of facilities reported no postsurgi-

cal readmissions; 51% reported no transfers to a hospital from the ASC; and 95% of facilities reportedno admissions to an emergency department within 72 hours of surgery (Table 3).

“We will be watching these measures closely withthe 2013 survey of 2012 performance to see if anymeasurable trends are developing,” Dr. Jackson says.“It’s important to note that the rate of hospital trans-fers for all ASCs, as measured by the ASC QualityCollaboration, has been trending up. The rate forophthalmic-driven benchmarking facilities is 0.63 per 1,000, which is about half the rate for allASCs (1.19 per 1,000), as reported by the ASCQuality Collaboration.”

As for incidents of errors, inflammation and infec-tion, the 2012 OOSS survey of 2011 results indicatesno apparent change from data reported for 2010. “It’snotable that ASCs in general are reporting a down-ward trend in the aggregate of these measures, accord-ing to the ASC Quality Collaboration,” Dr. Jacksonsays. “While small, the aggregate across all ASCs is lessthan for ophthalmic ASCs, and this is associated withthe wrong implant measurement for ophthalmic

Table 2. Average Employee Hours per Case

Average (Median) Employee Hours per Case 7 Hrs

Average (Median) Clinical Hours per Case 5 Hrs

Average (Median) Business Hours per Case 2 Hrs

5

About this Study

Of the 241 facilities participating in the OOSS annual survey for calendar year 2011, 88% were single-specialty ophthalmic centers and 12% were multi specialty centers with a strong ophthalmic component. Although not a longitudinal study in thestrictest sense, approximately 80% of reporting facilities were repeat participants.

In the section comparing quality measures, 194 facilitiesreported complete case and incident information, representing 445,421 ophthalmic cases.

The results include all participating facilities to the extentto which they responded to each of the questions.


6

ASCs. All ASCs reported an aggregate measure of0.045 per 1,000 for 2011, compared with an oph-thalmic ASC aggregate measure of 0.12 per 1,000.The wrong implant measure is separated out in theOOSS benchmarking survey and in 2011 accountedfor 0.08 per 1,000, or 67% of the aggregate.”

For the first time, facilities were asked about theincidence of toxic anterior segment syndrome (TASS),endophthalmitis and methicillin-resistantStaphylococcus aureus (MRSA) (these two infectionswere combined in one question) and torn capsulerequiring vitrectomy. The survey found the following:

• 89% of facilities reported no cases of TASS, fora mean incidence rate of 0.16 per 1,000 cases

• 64% reported no cases of endophthalmitis orMRSA, for a mean incidence rate of 0.30 per1,000 cases.

Dr. Jackson notes the aggregate of these twomeasures in 2010 was 0.36 per 1,000 cases, slightlyless than the aggregate of 0.46 in 2011.

The mean incidence rate for torn capsule requir-ing vitrectomy was 3.97 per 1,000 cases; 27% offacilities reported no cases of torn capsule requiringvitrectomy. Dr. Jackson notes this measure was alsonew in the 2012 OOSS benchmarking survey and is

related to a more detailed breakdown of cases intoplanned and unplanned anterior and posterior vitrec-tomies. “The 2012 survey was the first to break outvitrectomies in this manner,” he says. “The combinedpercentage of cataract cases with a vitrectomy is downfrom 3.9% in 2010 to 1.13% in 2011.”

Table 3. Incident Measure per 1000 Ophthalmic Surgical Cases

Post-Surgical Readmissions to ASC 1.08

Patient Transfers to Hospital from ASC 0.63

ER Admissions w/in 72 Hours of Surgery 0.14

Hospital Admissions w/in 30 Days of Surgery 0.04

Patient Burns 0.01

Patient Falls 0.06

Wrong Side/Site/Patient/Procedure 0.04

Wrong Implant 0.08

Wrong Drug/Wrong Dosage 0.16

TASS Inflammations 0.16

Post-Surgical Infections (Endo/MRSA) 0.30

Torn Capsule Requiring Vitrectomy 3.97

Perks of Participation

OOSS members and facilities that participated in theannual survey receive periodic reports throughout thesurvey period and final custom reports after the survey closes each year.

OOSSMark benchmarking results are also presentedat regular OOSS events and in course offeringsaddressing ophthalmic ASC benchmarking at annualmeetings of the American Academy ofOphthalmology and the American Society of Cataractand Refractive Surgery.

Ophthalmic ASCs interested in participating can learnmore at www.ooss.org or by contacting Kent Jacksonat [email protected].

CONTINUED ON PAGE 8


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8

Same-day cancellations were also addressed inthe process measures section of the 2012 survey.“This measure was refined to substantially hone inon more specifics to aid facilities in evaluating andaddressing cancellation concerns,” Dr. Jackson says.(We take a closer look at same-day cancellations onpage 16.)

Business Benchmarks“Revenues as measured by net collections increased inall areas this year — per case, per facility, per squarefoot and per full-time equivalent (FTE) employee —all boding well for income trends,” Dr. Jackson says.Specifically, the survey found the mean for all facili-ties as follows:

• $960 per total cases reported• $686 per square foot• $342,232 per total FTE employees

(FTE=2,080 hours/year)“When revenue per square foot increases, it signals

increases in case volume, case mix and reimbursementsand improved management of accounts receivable, allcontributing to enhanced utilization of facility space,”Dr. Jackson explains. “It’s up to each facility to iden-

tify how these factors influence their results.”Accounts receivable for 2011 were about the same

as reported for 2010, with 69% of accounts receivableaging 0 to 60, days down slightly compared with datareported for 2010. Accounts receivable aging 61 to120+ days, representing 31%, were up slightly compared with 2010 data.

Total surgical supply expenses in 2011 were aboutthe same as expenses reported for 2010; however,cataract supply expenses as a percentage of oph-thalmic surgical supply expenses increased by nearly10%. “Interestingly, the relative expenses associatedwith standard and toric IOLs were down slightlyfrom the prior year, while total expenses for premiumIOLs were about the same, but unit costs were upslightly,” Dr. Jackson says. Specifically, average unitcosts were $111 for a standard IOL, $488 for a toricIOL and $897 for a premium IOL.

Most expense measures were down, except for anotable increase in labor costs. Total costs, includingsupplies, labor, general and administrative, and occu-pancy costs per case were $673 in 2011 versus $752in 2010. Total occupancy costs (rent, insurance, utilities, taxes, etc.) were about the same at $50 per


9

square foot, while total labor costs per FTE employeerose from $61,000 in 2010 to $67,606 in 2011. “Incross-checking several data points, it appears facilitiesadded staff and increased overall compensation forstaff in 2011,” Dr. Jackson says. “We will be watch-ing 2012 year-end results to see if this trend contin-

ues and how cost measures relate to revenuemeasures. It may be that facilities were anticipating arise in case volume and invested in their staff accord-ingly. If so, other measures related to bottom-lineperformance suggest that investments in staff are paying off.”

Overall Financial PerformanceOverall, the net income ratio for most facilitiesimproved. Dr. Jackson attributed this improvementprimarily to reduced general and administrative costs(down 3% from the prior year) and reduced occu-pancy costs in relationship to net collections. “Thissuggests a better utilization of overhead costs in lightof some increased revenue,” he says. “We see modestevidence of an increase in overall case volume, with a

modest change in case mix. In general, cases appearto be taking more time and attention and requiringmore staff, while facilities are ably managing the bottom line (Table 4).”

The Benefits of BenchmarkingThe 2012 OOSSMark Benchmarking Survey pro-gram represents the only comprehensive benchmark-ing program that focuses on the ophthalmic-drivenASC. It’s designed to enable the ophthalmic ASCindustry to fairly compare the performance of facili-ties across a number of measures deemed useful forquality and performance improvement, and toaddress the recommendations of accrediting agenciesand clinical and business experts. The programattracts more than 200 U.S. facilities. Participatingfacilities contribute data annually and provide ongoing input to refine and enhance the program.The 2013 survey, capturing year-end results for 2012,will launch in June. �

Table 4. Overall Financial Performance –Median Cost as a % of Net Collections

Surgical Supply Cost 27%

Labor Cost 23%

General & Administrative Cost 10%

Occupancy Cost 7%

Combined Operating Cost (All of Above) 67%

Net Income as a % of Net Collections 33%

“ ”The combined percentage of cataract

cases with a vitrectomy is down from

3.9% in 2010 to 1.13% in 2011.

—Kent Jackson, PhD, vice president of member research

and development at OOSS

Note: The following OOSS Benchmarking Roundtable members collaborated with Dr. Jackson to help provideinsights: Lou Sheffler, MBA, COO, American SurgisiteCenters Inc .; Regina Boore, RN, BSN, MS, president ofProgressive Surgical Solutions; and Albert Castillo, administrator, San Antonio Eye Center. Mr. Sheffler and Mr. Castillo are associate members ofthe OOSS board of directors, and Ms. Boore is resourcemember of OOSS. All are active in the daily operations and management of ophthalmic ASCs.


As EHR Use Expands,Attention Turns to ASCs

10

ue in large part to the CMS MeaningfulUse incentives and penalties, physicianuse of electronic health records (EHR) has

been increasing and has reached an unprecedentedlevel. EHR system utilization among office-basedphysicians increased from 18% in 2001 to 57% in2011 and to 72% in 2012.1 The same cannot be saidfor EHR use in ASCs.

In the absence of an EHR-specific federally pre-scribed program such as Meaningful Use, many ASCowners don’t feel compelled to face the challengesof going paperless. However, few doubt that such aprogram could eventually be applied to their facili-ties. They’re also considering that without EHR,compliance with future requirements or initiatives,such as an expanded ASC Quality ReportingProgram or participation in an accountable careorganization, could be more difficult. In addition,the broader use of EHR by office-based physicianshas illuminated the in-house benefits that can even-tually be realized in areas that have always been keyto the mission of ASCs, such as efficiency and thepatient experience. EHR may even become a sig-nificant recruiting tool for surgery centers, giventhat physicians working toward Meaningful Useincentive payments can apply their EHR use in anASC as long as the facility’s EHR product is certi-fied by the Office of the National Coordinator forHealth Information Technology (ONC) or one of itsauthorized certification bodies.

Whether driven by external or internal factors orboth, more owners of ASCs are beginning to exploretheir EHR options. They’re finding that the availableEHR solutions, the majority of which are designed withthe physician practice in mind, aren’t necessarily well

suited to their needs. They need an EHR package thattakes into account the rules and regulations specific toASCs, primarily state licensure, CMS Conditions forCoverage and the standards established by accreditingorganizations such as The Joint Commission and theAccreditation Association for Ambulatory Health Care(AAAHC). Charting requirements are different in theASC than in the clinic, explains Farrell C. Tyson, MD,FACS, a surgeon with Cape Coral Eye Center inFlorida. “For an ASC, it goes beyond documentation of

the exam and coding,” he says. “An ASC needs to trackand document more of a flow, from the moment thepatient checks in to the moment he checks out. Therecord has to include not only what procedure was per-formed but also what medications, IVs, implants, andso on, the patient received and documentation of everyencounter he has with a member of the ASC team.”

Finding a software package to meet the distinct needs of the ASC can be a challenge.

D

By Desiree Ifft, Contributing Editor

CONTINUED ON PAGE 12


experience

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I often use endoscopy to perform endoscopic cyclophotocoagulation (ECP) in combination with phacoemulsification. The endoscope is ideal for confirming proper lens and haptic placement, treating cases involving dislocated IOLs, and identifying abnormalities of the capsule. Nate Kleinfeldt, MD (cataract surgeon)

The Endo Optiks E2 enables exceptional visualization and precise ECP for successful control of IOP. My glaucoma patients benefit from the surgery and the subsequent reduction in the need for meds. ECP is increasing as a treatment option for mild, moderate and

advanced glaucoma and also when other filtering surgeries have failed. Brian Francis, MD (glaucoma specialist)

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Call 800.756.3636 to learn how to experience the seemingly ENDless ENDoscopy benefits with the Endo Optiks E2 system.

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12

Surveying the LandscapeWhile many EHR companies don’t offer products forASCs, there are some that began targeting surgery centersearly on, such as AmkaiSolutions, Mountain MedicalTechnologies and Source Medical. In between, theoptions vary. For example, companies that offer physician-practice EHR may offer an ASC module oradd-on.

According to Mary Ann Fitzhugh, vice president,marketing & business development at Compulink,“We’re one of the few ophthalmic EHR vendors tooffer ASC EHR integration. Clients who use ourEHR in their surgery center are more efficient andaren’t performing double data entry. Our ASC mod-ule allows them to pass information from their prac-tice management and EHR system in the officedirectly to their ASC. We offer many pre-builtreports within our system and also provide simple,powerful tools for customization.”

IO SurgeryWare from IO Practiceware is anotherEHR package used in ophthalmic ASCs. The com-pany’s Web site says the software is designed solelyfor ophthalmology, and as a result, there have beenno compromises to accommodate other specialties.CEO Gregory Leopold says, “All events occurring inthe ASC can be documented at any level of detaildesired. IO SurgeryWare is an excellent choice forpractices with an ASC that’s used primarily for thedoctors in that practice.”

Management Plus, which provides ophthalmology-specific software solutions, counts ASCs among thefacilities using its EHR. Virginia Williams, graphicdesign and marketing coordinator, says the companyworks with every customer on an individual basisbecause every ASC is unique. “We have the tools tohelp surgery centers comply with various regulations,”she says. “Our software also gives them the ability toquickly and easily show all of the necessary documen-tation during any kind of auditing process.”

Jim Messier, vice president of sales and marketingat Medflow, describes his company’s surgery centerEHR as “a fully developed ophthalmic ASC system.”It can run as a stand-alone program or be interfaceddirectly with a practice management system.

“The goal is to assist ASCs in being fully compliantwith all regulatory and accreditation requirements aswell as create a fully audited and compliant chart,”Messier says. “The software provides specific documen-tation areas for things such as nurse preop, nurse

postop, nurse intraop, CRNA, anesthesia, discharge, doctor op-notes, addendums, orders, post-op CRNA, medications and vitals. Multiple areascan be documenting on the same patient at the sametime. The Advanced Cataract Planning Tool is used inthe operating room to aid the surgeon and staff withlens information and notes on the patient. Signaturepads and bar code scanners are utilized at each stationfor accurate and efficient collection of information.”

Messier cites Eye Care Center of Central PA,whose surgeons perform approximately 4,500 cataractsurgeries in an ASC each year, as a practice that hasbeen using Medflow EHR successfully for 3 years.

“They have created a solid charting process anddeployed a very efficient system that allows a singlesurgeon to perform 50-60 procedures per day in onesurgery rotation.”

Challenges and Rewards to AnticipateDr. Tyson has been making inquiries into EHR forhis ASC. Based on his legwork so far, he says, “Noone company seems to have it all.” One companymay have a solid EHR package for the clinic side andgreat software for the optical but a weaker module forthe ASC. Another may have a different combinationof strengths and weaknesses. “One difficulty for vendors, particularly in regard to ensuring an ASCcan comply with the relevant regulations, is they haveto hit moving targets, and those targets are often contradictory,” Dr. Tyson notes. For example,according to Florida state authorities, every internaldoor in his ASC is supposed to lock. CMS, however,considers this a fire hazard.

In addition, EHR software must meet extensive CONTINUED ON PAGE 14

ASC owners need an EHR package thattakes into account the rules and

regulations specific to ASCs, primarilystate licensure, CMS Conditions for

Coverage and the standards establishedby accrediting organizations such as

The Joint Commission and theAccreditation Association for

Ambulatory Health Care (AAAHC).



14

criteria in order to be certified for use in theMeaningful Use program. Making the grade canrequire companies to modify almost any aspect of theirproduct, which can in turn affect how it functions forthose already using it. The ONC recently released itsStandards & Certification Criteria for 2014, so morechanges could be on the way. “Some companies justdon’t want to get involved with ASC EHR,” Dr. Tysonsays. “They see how so many regulations are open tointerpretation, the way states differ on issues of compli-ance, and how state and federal rules can contradict.”

Another reason Dr. Tyson hasn’t settled on EHR forhis ASC is he has yet to find one he thinks will allowhim to remain efficient, a long-standing concern for anyentity considering adopting EHR. “I can’t have what isnow a simple step becoming a 5-minute step,” he says.“For instance, right now, to document which IOL apatient received, I peel the label off the lens box andstick it to the paper chart. I have seen EHR systems thatrequire me to use separate drop boxes for indicating thetype of lens, the manufacturer, the power and then I stillhave to enter a lengthy alphanumeric serial number.”

Ann Hotaling, ASC director at Ocala Eye inFlorida, would like to bring EHR into the practice’ssurgery center as soon as possible, but is reluctant tomake the leap until she’s certain it won’t cause moreproblems than it fixes. She’s seen the benefits of EHRon the practice side but also the potential hurdles.“For me, the deciding motivating factor is whetherI’ll be able to get through inspections. I think mostASC directors have the exact same thought. Does theEHR have all of the necessary fields and templates tocapture all the data we need to capture?”

Best-case scenario, she states, would be for thenecessary fields to be standard in the EHR’s knowl-

edge base. She points to the ever-expanding list ofwhat ASCs need to document, such as the latestMedicare Conditions for Coverage, which are morecomprehensive than in the past. “For example, weneed a field in the chart for documenting the disposi-tion of the patient’s belongings in a certain way,whether they were given to a family member, placedunder the stretcher, and so on,” she says. “We’ll alsobe facing ASC Quality Reporting requirements in thefuture that demand more sophisticated ways ofreporting than those that are claims-based.”

Hotaling’s ASC recently switched from JointCommission accreditation to the AAAHC and passedits survey with flying colors. “I know that using ourpaper charts we are A-OK for fulfilling our state andfederal responsibilities. Everything we need to docu-ment and report has a field. Not every EHR can reflectthat.” Knowing that some of the ASC’s fields and tem-plates in EHR would have to be specific to her facilityor state, Hotaling would prefer to avoid the need fortoo much customization. “Lots of practices have seenon the clinic side how your EHR customization, whichcan be expensive to create, could be lost if the vendorupdates its software or modifies functionality becauseof Meaningful Use requirements.”

Both Hotaling and Dr. Tyson view EHR as theway of the future and are eager to use the technologyin their ASCs as another source of innovation. Theyhave answered the question of “if,” but they will keepworking on the “when.” �

Reference1. Hsiao CJ, Hing E. Use and characteristics of electronic health

record systems among office-based physician practices: UnitedStates, 2001–2012. NCHS data brief, no 111. Hyattsville, MD:National Center for Health Statistics. 2012.

EHR Feature CheckThe companies that spoke with The Ophthalmic ASC about their EHR products also reported on the items in thechart below.

Company EHR has ability to EHR has ability to Template customization interface with keep track of maintained after

digital ASC equipment scanned inventory software upgrades

Compulink √ √ √

IO Practiceware √ √ √

Management Plus √ √ √

Medflow √ √ √


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Managing Same-dayCancellations

16

n the 2012 Outpatient Ophthalmic SurgerySociety (OOSS) benchmarking survey of 2011data, 159 responding centers reported that

nearly 4% of cases were cancelled by the patient orthe surgery center. This measure reflected a substan-tial uptick when compared with 2010 at 1.3% and2009 at slightly less than 1%. In response to thistrend, OOSS conducted a topical survey of 82 facili-ties in fall 2012. Of those centers, 40% say cancellations are a concern — 6% of facilities consider cancellations a “major problem,” while 34%consider them “somewhat” of a problem.” (For moredetails on the fall survey, see “Breaking It Down.”)

We spoke with representatives from several surgery centers to find out why procedures are cancelled on the day of surgery and how they minimize the impact of these cancellations.

Why Patients CancelAlbert Castillo, administrator at San Antonio EyeCenter in Texas, serves on the OOSS education com-mittee and helped design the same-day cancellationstudy. “I raised the question because we’ve had theproblem of cancellations in our surgery center, and Iwanted to see if others in the industry were experi-encing the same thing,” he says. “After reviewing thedata, I suspect our location and demographics —we’re in a lower-income area with a largely managedcare population — may affect our cancellation rate,especially cancellations by patients.”

Mr. Castillo notes that patients often cancel theirsurgeries at his center because they failed to obtain

clearance from their primary care physicians. “Eitherthey couldn’t schedule a physical examination ortheir physician felt they weren’t healthy enough forsurgery and needed further testing,” he says.

According to Lawrence Lohman, MD, medicaldirector and part owner of St. Clare Eye Surgery &Laser Center in Cuyahoga Falls, Ohio, when apatient cancels his procedure on the day of surgery,it’s usually because of a sudden illness. “A patientmay have the flu or be hospitalized for some reason,”he says. “Depending on how the schedule is running,we may be able to get another patient in if he’snearby and has the flexibility. Most often, however,it’s a lost spot in the surgery schedule that you can’trecoup.”

When patients cancel their surgeries before they

Missed appointments can disrupt patient care and undermine a surgery center’s efficiency. Here’s how some OASCs handle this often unavoidable problem.

I

By Virginia Pickles, Contributing Editor

Breaking It Down

The fall OOSS survey, which focused on same-daycancellations, found the following:

• 60% of cancelled cases were canceled by patientsprior to admission

• 20% were cancelled by the OASC during admission

• 20% were cancelled preoperatively or intraoperatively.

Follow-up questions in the survey addressed threepotential causes for cancellation by the ASC: elevatedblood pressure, unacceptable blood glucose level anda patient’s failure to take preoperative antibiotics.


arrive at the surgery center, there’s little more you can do than reschedule their procedures. When problemsare discovered at the facility on the day of surgery,then the center’s guidelines and the doctor’s discre-tion come into play.

Why the OASC CancelsAnticipating some of the reasons why a surgeonmight cancel a procedure on the day of surgery, the OOSS survey included questions about bloodpressure, blood glucose levels and preoperative antibiotics.

According to Karen Chiles, RN, BSN, adminis-trative director at Commonwealth Eye Surgicenter inLexington, Ky., her center’s guidelines call for dias-tolic blood pressure to be less than 100 mmHg andfor blood glucose to be between 60 mg/dL and200 mg/dL. She emphasizes that these are guidelines,and the final decision on proceeding with surgeryrests with the surgeon and the anesthesiologist. “Wetake into account the patient’s baseline and history,”she says. “Sometimes what’s considered normal is notnormal for a particular patient.”

Ms. Chiles says the center has protocols to man-age elevated blood pressure if the physicians approve.“If a patient’s blood pressure is elevated and we knowit’s usually controlled, we may use palliative measures

to lower it,” she says. “Nine times out of 10, thepatient is experiencing anxiety, or he didn’t take hisblood pressure medications that morning, in whichcase, we administer them. We may observe thatpatient for an hour or two and possibly move his surgery to the end of the day rather than cancel it.”

Dr. Lohman also will try to lower a patient’sblood pressure if his history shows it’s usually withinnormal limits. “We may administer mild sedationand observe the patient,” he said. “We may have torevise our schedule to do that, but if we can lower thepressure, we may be able to get back on track andavoid canceling the surgery. We might give a patientintravenous blood pressure medication, but we don’twant to be overly aggressive because it’s not our jobto manage a patient’s hypertension. If we think it’sjust a temporary situation, we’ll try to treat it andprovide some reassurance.”

Each case is unique, Dr. Lohman notes, but hesays, “In general, if systolic pressure is above 200 anddiastolic is above 100 with sedation on board, wewould consider canceling. In particular, if I’m per-forming a corneal transplant and will have an openglobe for an extended period, I want a patient’s bloodpressure very well controlled.”

Ms. Chiles says Commonwealth Eye Surgicenteralso has protocols for patients who present with high

17


18

blood glucose levels — they may administer fluids,for example — but if the level doesn’t decrease, theprocedure is cancelled, and the patient is referred tohis primary care physician for follow-up.

Dr. Lohman notes, “We have a somewhat hightolerance for blood glucose levels, because we knowpeople with diabetes can have significant fluctuations.As a general guideline, if blood glucose is above 300 mg/dL, we consider cancelling a procedure, butwe don’t have a hard-and-fast rule. We may cancelone person at a lower level and someone else at ahigher level. We have to consider the patient’s normal status and his history, as well as the type ofprocedure we’re scheduled to perform.”

Most OASCs require patients to use preoperativeantibiotics, but few will cancel surgery if a patientdoesn’t use them. Many physicians administer a loading dose prior to surgery. This, too, is on a case-by-case basis and at the discretion of the surgeon. Dr. Lohman is in the majority. “Our preference is that patients start topical antibiotics at home prior to surgery, but if they haven’t done that, we administer the drops at the surgery center,” he says.“Fortunately, that doesn’t happen often, because wespend a great deal of time educating patients prior tosurgery.”

Ms. Chiles also emphasizes the importance of pre-surgical education for patients. “Our schedulers workone-on-one with patients to review all aspects of surgery,” she says. “In addition, we make surepatients have written explanations of everything we’regoing to do and everything they need to do prior tocoming to the surgery center.”

Dr. Lohman mentions two other red flags thatmay prompt a cancellation at St. Clare Eye Surgery& Laser Center. “We ask patients not to eat solidfood 6 hours prior to surgery, but many people eatanyway,” he says. Depending on the type of surgery

and the anesthesia planned, Dr. Lohman may pro-ceed, or if the patient’s surgery was scheduled forearly in the day, the surgery may be rescheduled forlater that day. The second red flag is bleeding time,which is measured only for patients undergoing morecomplicated surgeries. “If a patient is scheduled foroculoplastic or corneal surgery, for example, and hisinternational normalized ratio is above 2, then wemight cancel the surgery,” Dr. Lohman explains.

Cost of Same-Day CancellationsEstimating the cost of a cancelled procedure in anOASC is difficult because of the variables involved,including the type of surgery, the time of day whenthe cancellation occurs, how surgery time is blockedfor the day, staff allocation and so on. As Dr.Lohman explains, “If we cancel a cataract surgery, arelatively short procedure, and we have a full schedulefor the day, it may not cost the center too much —other than the income from that procedure —because we may be able to move up the other surger-ies in the schedule and send everyone home a littleearlier. On the other hand, if we learn we can’t gettissue from the eye bank for a corneal surgery, theprocedure must be cancelled. That’s a longer proce-dure and cancelling it creates a larger hole in ourschedule, which affects our productivity. We’re pay-ing to staff and keep the center open, so it’s a muchmore costly process.”

Minimize the ImpactSame-day cancellations are inevitable, but their frequency and impact can be minimized by estab-lishing parameters for guidance while giving physi-cians the flexibility to address each patient’s uniquesituation. Thorough patient education is also animportant factor.

According to Ms. Chiles, same-day cancellationsare not a serious problem at Commonwealth EyeSurgicenter. “We perform really good workups in ourclinic prior to surgery,” she says. “Then we follow ourguidelines and the discretion of the surgeon and theanesthesiologist. We do everything we can to avoid cancelling procedures. It’s troublesome for us, and ittakes away a slot from someone who’s on a waitinglist, but it’s also hard on patients. They’re here.They’re ready. They don’t want to cancel, but wehave to look at the whole picture and make sure the surgery will be safe for them.” �

Same-day cancellations are inevitable,but their frequency and impact can beminimized by establishing parametersfor guidance while giving physicians

the flexibility to address each patient’sunique situation.


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Numbers for Managers:The Balance Sheet

20

any ASC nurse directors are thrust intomanagement roles without the benefitof any training in financial reporting.

After viewing financial data, it’s not uncommon forthose new to these positions to voice sentiments ofconcern similar to those expressed by the nursingdirector in the following case study excerpt:

“I’m completely lost,” says the nursing directoron the other end of the telephone. “This ASC hasbeen operating for more than a year and since I took

over a few months ago, our profit and loss statementshows positive income, but there is no money in ourbank account. What am I doing wrong?”

This nursing director is eventually relieved tolearn that she’s not doing anything wrong. She’s justinexperienced at reading and understanding ALL ofthe organization’s financial statements. Her ASC is ina common financial position faced by many youngand growing ASCs. In order to understand her con-cern and see how easily an individual can be misled

by not utilizing all available financial information, it’snecessary to learn the primary functions and limita-tions of all financial statements. It’s rarely possible toget an accurate and complete assessment of an organization’s financial well being from just onesource. Understanding this fact will help directorsgain a more thorough understanding of how to inter-pret important financial data, which in turn will helpthem make better management decisions.

The financial statement that would have helpedthis director better understand her ASC’s predica-ment is the balance sheet. Before we get back to the bewildered nurse director in the case study, let’sexamine some basic information about balance sheets.

What is a Balance Sheet?A balance sheet is a financial report generally pre-pared by an outside accountant. QuickBooks®, themost commonly used accounting software for smallbusinesses, has standard financial reports set up forbalance sheet statements as well as for income state-ments (profit and loss statements or P&Ls).

For a balance sheet to be of optimal use to anASC, it must be set up in the organization’s account-ing software with appropriate categories. This allowsstatements to be accurately generated. Of maximumimportance, though, is understanding how to use abalance sheet as part of a regular financial review sothe report can be optimized as a tool in the ASC’smanagement decision-making process. Additionally,

A Snapshot of Your ASC’s Financial Health

M

By Maureen Waddle, MBA

Note: This is the second artic le in a two-part series designed to help managers better understandthe financial statements of their ASCs. The first artic le, which appeared in February’s issue of TheOphthalmic ASC, focused on income statements.

In order to make decisions based ongood information, the manager must

understand and be able to answerquestions about information found on

the balance sheet.


managers and owners must understand that balancesheets aren’t used solely for their own understandingof the financial health of their ASC, other entitiesmay view these financial statements as well.

The balance sheet is appropriately named becausethe categories must always be in balance. At anygiven point in time, the value of what an ASC (orany business) owns (assets) must be in balance withwhat it owes to creditors (liabilities) or owners(equity). By looking at a company’s assets in compar-ison to its liabilities and owner’s equity, you candetermine the financial position or “health” of thecompany at a given time point.

In a typical balance sheet format, the assets arelisted on the left side of the sheet, and the liabilitiesand equity are listed on the right side. The accompa-nying sidebar (Balance Sheet Terminology) providesdefinitions of key balance sheet terminology, and

Figure 1 shows an example of a balance sheet.

Who Looks at an ASC’s Balance Sheet?Considering that a balance sheet provides a “snap-shot” of the financial health of a company, you canbegin to guess who might want to look at an ASC’sbalance sheet.

Creditors, for one, may need to view a surgerycenter’s balance statement. Creditors may includebanks or equipment-lease companies that might needto make a judgment about whether or not theyshould extend credit to the organization. They wouldmake this determination by evaluating assets in com-parison to liabilities (see ratio explanations in theaccompanying table).

Potential investors or partners may also view theASC’s balance sheet. They would use a balance sheet,in conjunction with other information, to be confi-

Figure 1. Sample Balance Sheet

21


22

dent that they’re buying into a financially viableorganization. If the balance sheet shows the businessis “highly leveraged” (i.e., it has too much debt) thevalue to “buy in” would most likely be reduced.

Manager Uses for a Balance SheetA business manager (regardless of the official job title)has the responsibility to make business decisions thatwill maximize the owner’s return on investment. Inorder to make decisions based on good information,the manager must understand and be able to answerquestions about information found on the balancesheet.

Now that you know the people most likely toreview a balance sheet and have a basic understandingof definitions for terms related to the balance sheet,take a look at the accompanying sample of a balancesheet. Keeping in mind that the balance sheet reportson the financial health of an ASC business, answerthe following question: Is the company representedby the sample balance sheet financially sound?

Having a general understanding of assets and lia-bilities, you intuitively know that you want the assetsto be (much) greater than the liabilities. Beyond intu-ition, there are some common ratios and benchmarksto help you define this.

Based on this sample balance sheet, at this pointin time, it’s fair to assess that this business mightneed a prescription (but probably not a major inter-

vention) to nurture it back to health. If we turn backto our case study and information beyond the balancesheet, we may start to feel more positive about thebusiness.

Back to the Case Study Getting back to the nurse director’s concern in theaforementioned case study, we can now address herquestion about having a positive net income yet nomoney in the bank. A start-up ASC typically uses sig-nificant financing through small business loans (inaddition to owners’ paid-in capital) to start the busi-ness. By the time this nursing director had joined theASC, it was operating profitably based on her moni-toring the P&L statement. However, she wasn’t mon-itoring her balance sheet, and therefore only had acursory understanding of the liabilities. Because prin-ciple payments aren’t recorded on a profit and lossstatement, she didn’t have the capability to see thedebt being reduced (as well as the cash beingreduced). These would show up on the balance sheet.The owners, in this particular case, had made a deci-sion to make some extra principle payments toshorten the loan period resulting in a depleted cashflow—despite the positive net income on the P&L.Cash flow statements are a good idea in general, butare especially important for ASCs that are trying tomanage loan payoffs. With all three statements (P&L,balance sheet and cash flow) being closely monitored,

Common Balance Sheet RatiosRatio Formula What You Learn

Current ratio Current assets divided by On it’s most basic level, this ratio can answer the current liabilities question: Can the company meet it’s obligations? A ratio

of 1 (or a 1:1) means there is NO working capital. Youwould like to see this number at least at 2 (meaning thebusiness has twice as many current assets as obligations);but preferably it should be somewhere between 2-6. Ifthe number is much higher than 6, the company shouldprobably look at investments for its excess capital (or payout dividends to the owners).

Assets to liabilities Total assets divided by This gives you a long-term picture of the company. total liabilities Again, you’re looking at the ability to meet obligations.

The higher the number, the better the general health.

Debt (liabilities) to equity Total liabilities divided by This indicates the risk of the company to creditors. The owners (stockholders) equity higher this number (indicating significant debt) the more

the company is considered to be “at risk.”


23

perhaps the managers and owners might have decidedto reduce one of the advanced principle payments orchange the timing of a payment.

Better UnderstandingGoing through this exercise should help ASC man-agers gain a better understanding of balance sheetsand the players who may have a stake in viewingthem. Furthermore, it underscores the importance of

being familiar with ALL financial statements. Withthis knowledge, it‘s possible to view an accurate snap-shot of the financial health of your ASC so you canmake the best data-based management decisions forthe organization. �

Maureen Waddle, MBA, is a senior consultant withBSM Consulting, an internationally recognizedhealth care consulting firm.

Balance Sheet TerminologyThe following list includes basic terminology commonly associated with a balance sheet.

Assets: Resources owned by the ASC

Current Assets — Cash, investments, or other assets that can be expected to convert into cash within the currentperiod (usually defined as “within 12 months from the date of the balance sheet period”). Some examples of non-cash assets might include accounts receivable (money owed to an ASC for services provided prior to the date of thereporting period); notes receivable (money owed to an ASC for loans given, perhaps to an owner or an employee);and inventory of items to be sold in the future (e.g., IOLs).

Non-Current Assets — Also known as long-term assets, this includes items that will not be turned into cash or“consumed” within 1 year of the balance sheet. Examples include intangible assets, equipment, tenant improvementsand investments.

Tangible Assets — Items owned by the company. Tangible assets usually include equipment, furniture, and fixtures, and leasehold improvements. These items are typically valued at the cost of purchase less accumulateddepreciation.

Intangible Assets — ASCs typically don’t have many intangible assets listed on their balance sheet. Examples ofintangible assets include items for which values are difficult to quantify, such as trademarks and patents. Goodwill[not clear on what she means by ‘goodwill’ here] is also an example of an intangible asset that is more commonlyseen on a practice balance sheet but certainly may be found on an ASC balance sheet if the company has pur-chased another ASC or related company. These assets are reported at cost on the balance sheet, though they mayhave far greater value.

Liabilities: Obligations due to creditors

Current Liabilities — Liabilities that will come due in the current period (same period as current assets). Examplesof current liabilities include accounts payable, notes payable, and accrued expenses. Note that liabilities ofteninclude the term “payable” in their titles.

Long-term Liabilities — All other liabilities not captured in current liabilities. This usually includes bank loans andcapitalized equipment leases (less amount paid in current period).

Equity: Company’s obligation to the owners/stockholders

Stockholders’ Equity — If it’s a corporation, the equity is classified as stockholders’ equity.

Owner Equity — All other equity types (e.g., sole proprietor, partnerships, etc.) are classified as owner equity.

Paid-in-Capital — Also called “contributed” capital, this is the money an ASC or other business has received via aninvestment from owners or stockholders.

Retained Earnings — The profits (revenues less expenses) a business keeps (instead of disbursing the funds to itsowners) to cover future business activities. A simpler definition is: The total of all accumulated earnings after taxesand paid-out dividends. This is tracked in the retained earnings accounting item under “equity.”


24

According to statistics compiled in 2010 by the

Association of American Medical Colleges/Physician

Specialty Book, there were approximately 18,000

practicing ophthalmologists, rankings ophthalmolo-

gists twelfth in volume out of all specialists. Statistics

from CMS, also from 2010, show that for allowed

charges of all specialties, CPT code 66984

(phacoemulsification with IOL) ranks #4, CPT code

66982 (complex phacoemulsification with IOL)

ranks #65 and CPT code 66821 (YAG posterior

capsulotomy) ranks #69. No wonder CMS is always

carefully re-evaluating these

procedures.

OOSS has gleaned statistics

showing that there are approxi-

mately 5300 Medicare certified

ASCs of which 900-950 are

ophthalmology specific and a few

hundred others are multispecialty

but perform a high volume of

cataract and related procedures.

With these types of statistics

showing a huge volume of procedures being

performed on a national basis and accounting for a

serious expenditure of Medicare funds, it’s not

surprising that some administrative details become

neglected and that some regulations were never

known. This article reviews some of the important

issues in compliance and chart documentation that

an ASC may encounter.

Chart DocumentationWith so much attention focused on Medicare ASC

audits involving the medical issues and Conditions

for Coverage, it’s important that compliance issues

be a concern as well. The ASC chart should be able

to withstand scrutiny from a compliance/

reimbursement auditor. It’s recommended that the

following items are incorporated into the ASC chart:• The Activities of Daily Living (ADL) form is a

questionnaire the patient completes and signs, and

is dated and witnessed. The form substantiates the

medical necessity for the surgery. It should be an

ASC requirement that the physician supplies a

copy of the ADL when the scheduling information

is sent to the ASC. If a form hasn’t been com-

pleted, then the ASC personnel should have the

patient complete the form prior to

surgery.• It’s recommended that part of the

ASC chart documentation include

the physician visit when the

procedure was scheduled.

• If there were complications

during surgery, operative note

documentation should not come

from only templates.

For complex cataract surgery, the

first paragraph of the operative note should outline

why it was a complex case.

Covered vs. Non-covered ProceduresMedicare has issued a Fact Sheet titled “Medicare

Vision Services,” last revised in December 2012,

which reviews many covered versus non-covered

issues. (See www.cms.gov/Outreach-and-Education/

Medicare-Learning-Network-MLN/MLNProducts/

downloads/VisionServices_FactSheet_ICN907165.

pdf.) Medicare states that in order for a service

or item to be covered it must satisfy three basic

requirements:

ASC Medicare Compliance and ChartDocumentation in Cataract Surgery

By Riva Lee Asbell

ASC Compliance & Coding

CONTINUED ON PAGE 26


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26

• The service must be in a category of services that

by statute is a defined benefit.

• The service must be reasonable and necessary for

the diagnosis or treatment of illness of injury or to

improve the functioning of a malformed body part.

• The item or service must not be excluded from

coverage.

Premium IOLs. Medicare reimbursement policy

underwent a radical change with the advent of pre-

mium IOLs. Medicare refers to them as Presbyopia-

Correcting (P-C) IOLs and Astigmatism-Correcting

(A-C) IOLs. Medicare covers cataract surgery as well

as one pair of glasses or contact lenses postopera-

tively for each cataract surgery performed using a

conventional IOL. On that basis, premium IOLs are

neither glasses nor contact lenses, even though they

may serve the same function. The insertion doesn’t

fall into a benefit category and the portion that deals

with refractive services is not a covered service.

This historic decision allowed physicians and

facilities to charge patients for that portion of the

service that was statutorily excluded from the

Medicare program, namely, the refractive portion of

the IOL. Certain other expenses could be billed to the

patient as well. You would be in violation of compli-

ance if you billed Medicare for these services. These

are considered non-covered services. The Medicare

Vision Services fact sheet states: “…Any additional

provider or physician services required to insert the

P-C IOL or A-C IOL or to monitor a patient receiving

a P-C IOL or A- C IOL are also not covered. For

example, the rotation of an A-C IOL to properly

align the axis is non-covered.”

Femtosecond Laser-assisted Cataract

Surgery. The AAO and ASCRS published

“Guidelines for Billing Medicare Beneficiaries When

Using the Femtosecond Laser” that were revised in

November 2012 as a result of CMS issuing its own

guideline, in which it focused on misleading and

unacceptable promotional advertising. The listservs

are replete with questions and answers, and many

practices still are under the false impression that the

patient may be billed for the use of the laser when

used in cataract surgery. This is completely incorrect;

the only time the patient can be charged is when the

laser is used in conjunction with a non-covered

service, namely, a refractive service.

Coding/Reimbursement IssuesEach ASC deals with the surgical coding in a differ-

ent fashion — some only have the physicians code,

some have coding personnel while others have a

combination of both. Regardless of the system, any-

one who handles coding should be well versed in

Samples of Recent ASC Audit Findings

• Insufficient documentation of problems with Activities of Daily Living.

• CPT code 67005 (manual vitrectomy) being used rather than 67010 for coding mechanical vitrectomy. Thisdoesn’t affect payment since the codes are bundled and shouldn’t be billed together; however, the codingshould be correct.

• Cases coded as complex cataract (CPT 66982) need to have indications for using that code dictated within thebody of the operative note as well as in the physician’s office notes.

• The surgical coding personnel in all offices need access to an Internet-based computerized National CorrectCoding Initiative program, because the CMS program is difficult and time consuming to use.

• The issue of inducements and billing for non-covered services must be addressed. These occur when a physi-cian may take off a minor lesion or similar procedure and not charge for it, nor does the ASC.

• If a cosmetic or non-covered procedure is performed in the same session as a covered one, not only is thefacility charge billed to the patient, but that portion of the anesthesia charge is also billed to the patient.

Note: This was taken from author’s own audit findings.


CPT rules and regulations including mastery of the modi-

fiers. Below are some of the more important uses of

some of the key modifiers.

Modifiers• The SG modifier is not to be appended effective with

the new system.

• Modifier 73 is only to be used after anesthesia is

administered and not when there is an elective cancel-

lation of the procedure. Payment is at 50% of the

allowable amount for the procedure.

• Modifier 74 is only to be used after procedure has

commenced; in other words, the incision has been

made. Payment is 100 % of the allowable amount for

the procedure.

• Do not use modifier 50. Even though modifier 50

appears in the appendix it shouldn’t be used because

the Medicare contractors have issued instructions

regarding this. Instead, use a two-line entry with a sin-

gle unit of service on each line or 2 units of service on a

single line. Use of modifier 50 will result in payment for

only one side when bilateral surgery was performed.

Complex Versus Complications in Coding

Cataract Surgery. CPT code 66982 is used for complex

cataract extraction with insertion of IOL, whereas CPT

code 66984 is used for regular cataract extraction with

insertion of IOL. While the ASC reimbursement may be

the same, CMS has been concerned with the possible

overutilization of the complex code. ASCs may have

their records requested in conjunction with these audits.

Examples of complications include expulsive hemor-

rhage, dropping the nucleus or the IOL into the vitreous,

and loss of vitreous during the procedure but these situ-

ations don’t qualify as complex. I’ve written numerous

articles on this and you should read the CPT definition.

Surgeons often confuse complex with complications. As

the local coverage determination from Palmetto GBA

stated, “The billing of [the complex cataract] has nothing

to do with the surgeon’s perception of the degree of

difficulty. It should be noted that the use of this code is

governed specifically by the fact that the surgery

require(s) devices or techniques not generally used in

routine cataract surgery.” �

© 2013 Novartis 3/13 LSX13058JAD-PI

Caution:United States Federal Law restricts this device to sale and use by or on the order of a physician or licensed

eye care practitioner.

Indication:The LenSx® Laser is indicated for use in patients undergoing cataract surgery for removal of the crystalline

lens. Intended uses in cataract surgery include anterior capsulotomy, phacofragmentation, and the

creation of single plane and multi-plane arc cuts/incisions in the cornea, each of which may be performed

either individually or consecutively during the same procedure.

Restrictions:

Contraindications:

wavelength

the endothelium (applicable to capsulotomy only)

procedure can escape

recurrent corneal erosion, severe basement membrane disease)

Warnings:The LenSx® Laser System should only be operated by a physician trained in its use.

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educational courses. Adult patients should be scheduled to undergo cataract extraction.

Precautions:

AEs/Complications:

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668 OASC 05 13.qxd:06 05 OMD COVER€¦ · incidence of toxic anterior segment syndrome (TASS), endophthalmitis and methicillin-resistant Staphylococcus aureus (MRSA) (these two infections