AMBULATORY SURGERY CENTER (ASC)

Ambulatory surgery is surgery that does not require an overnight hospital stay. It is also called ‘Day Surgery’, ‘Same Day Surgery’ (SDS), or ‘Short Procedure Unit’ (SPU). ASC may either be affiliated with a hospital or have no affiliation with a hospital. Ambulatory Surgery Centers act as autonomous units and are treated as separate entities.
Ambulatory programs offer patients the convenience of being treated and released the same day without being admitted to the hospital. This means that eligible patients come to the hospital either in the morning or afternoon of the day of surgery, undergo the operation, and are discharged within the same day to recover in the comfort of their home.

Ambulatory surgery centers, or freestanding ambulatory centers, provide outpatient services. This day-care, or ambulatory technique provides an efficient and flexible approach to provision of many surgical and therapeutic procedures. It is a freestanding facility, other than a physician’s office, that operates exclusively to provide surgical services to patients who do not require hospitalization.

OBJECTIVES OF MANAGED CARE

Quality Improvement:

Health care is monitored for quality and necessity. Consequently, services rendered are more effective and efficient. Physicians are encouraged to render appropriate and timely care.
Prevention: Managed care plans encourage preventive care by covering procedures such as annual physical check-ups, cancer screening, prenatal examinations so that doctors can help either prevent illnesses or detect diseases in their early stages. Diseases can be easier and cheaper to treat when detected early.

Accountability:

Managed care plans make the physicians and hospitals more accountable for the services they render. Physicians are prevented from wasting money on costly, inappropriate or unexplained services. They are encouraged to adhere to certain treatment standards and conserve health care resources.
Affordability: By reducing the burden of out-of-pocket expenses on the member, managed care plans aim to make high quality care affordable. They offer insurance at reduced costs, despite the ever-growing cost of health care.

Care Coordination:

Due to the wide range of medical services available, and the growth of medical technology, a patient may need help in deciding what sort of care he/she needs. The patient must be advised of the best methods of treatment or the best facilities available to attend to his/her health needs. Managed care plans provide the concerned medical professionals to ensure that each patient receives the best health care available under the plan.

PREFERRED PROVIDER ORGANIZATION (PPO)

PPO is made up of group of providers who have simply agreed to discount their services for a specific insurance plan; this provider group is generally much larger than the network in an HMO and POS.
With PPO’s, a PCP or even the group of providers does not manage a patient’s care; a patient can see any physician he wants to among the providers offering discounts. Out of all managed care plans, PPO’s give patient the most choice of providers and so they are the most expensive plans. Also, patients are not required to visit a PCP before visiting a specialty care physician.

POINT OF SERVICE (POS)

In POS, patients have the option of using in-network providers or out-of-network providers. A POS plan will reimburse services received from in-network providers at a higher rate than out-of-network providers.
If the patient remains in-network, the patient must still use a PCP to coordinate care; patient who seeks out-of-network care does not need to go through a PCP. Claim received from the out-of-network providers may be rejected or paid at a lower rate. Also the patient responsibility on a bill would be higher if he goes out of network.

HEALTH MAINTENANCE ORGANIZATION (HMO)

HMO consists of a network of physicians, hospitals, and other healthcare providers that have contracted with an insurance company to manage an enrollee’s care. Services rendered by providers outside of network are not eligible for coverage.
With an HMO plan, a patient must first refer a primary care physician (PCP); the PCP then manages the patient’s care and may refer that patient to other provider if necessary. HMO’s are generally the least expensive managed care plans for enrollees because this type of plan has the most restrictions on provider choice.

Modifier 79

Unrelated procedure or service by the same physician during the postoperative
period.

Modifier 79 is used with surgical procedures to identify a procedure or service by
the same physician during the postoperative period of another unrelated procedure.
This modifier should be submitted when an unrelated subsequent service is
performed by the same surgeon within the global period of a major or minor
surgery.

The 79 is used on the 2nd procedure when there is a global period on the 1st code.
It does not matter whether a global period exist on the 2nd code.

Please note: Use modifier 78 if the subsequent surgery is related to the initial
surgery and required a return to the operating room, and both are performed by
the same surgeon.

If the subsequent surgery is related to the initial surgery but does not require a
return to the operating room, and both are performed by the same surgeon, do not
submit separately. Additional related surgical procedures that do not require a
return to the operating room are included in the global fee for the initial surgery.

Modifier 25

Reviewers have noted that often documentation did not reflect a distinct, separate
evaluation and management (E/M) service performed on the same day as a
procedure.

Modifier 25 is defined as a significant, separately identifiable E/M service by the
same physician on the same day of the procedure or other service.

The patient’s medical record documentation is expected to clearly show that the
E/M service was “above and beyond” the usual pre-operative and post-operative
care associated with the procedure performed on the same day.

Inappropriate use of modifier 25 could increase the appearance of high utilization
and could warrant more intense reviews into providers billing patterns and more
Progressive Corrective Action Probes.

Please note: if a significant separately identifiable service occurs during a post-
procedure global coverage period, but not on the same day as the procedure, use
modifier 24.

Modifier 25 is not needed if an E/M patient encounter occurred the day before minor
surgery was performed, since the global period for minor procedures (000 days)
does not include the day prior to surgery.