What You Need to Know in Ambulatory Surgical Center Billing

The basics in ambulatory surgical center (ASC) coding and billing are simple to learn. However, they differ from physician and facility requirements. For example, Medicare has different rules than some insurers. Some insurers also have various regulations on medical necessity, permitted procedures, and other filing requirements.

Even experienced billers find that keeping up with the newest updates is challenging without the help of third-party claims management services. It is due to the ever-changing nature of payers like Medicare. If you’re new to Ambulatory Surgical Center coding and billing, here are the five key points that can help you get off to a better start and boost your chances of receiving a faster, more comprehensive reimbursement. 

Defining Ambulatory Surgical Centers 

The Medicare Carriers Manual defines an ASC as a separate and distinct organization to provide outpatient surgical treatment and services. A hospital-run facility for Medicare purposes can be either a provider-based department of a hospital or an ASC. To be eligible for Medicare payments, ASCs must sign a participating provider agreement with the Centers for Medicare & Medicaid Services (CMS). The CMS is pushing for cost reduction by introducing a “bed-less hospital” with most outpatient services. It will also include same-day surgery with patients who will recuperate at home but still touch with providers via digital means. These facilities will re-define ambulatory care as it would serve as a one-stop-shop for quick medical services. 

Basic Coding and Billing for ASC Charges 

Some insurance carriers allow an ASC to bill using ICD-10 procedure codes. An ASC uses a combination of physician and hospital or clinical billing, employing CPT and HCPCS level codes. Here are some basics that you need to keep an eye on in coding and billing for ASCs:

• Medical or surgical supplies that aren’t on a “pass-through” status, surgical cloths, splints, casts, associated materials, anesthesiologist supervision by the operating surgeon are examples of “packaged” services.

• The ASC covers device-intensive operations like pacemaker insertion but not as a separate line item. The cost will be included in the procedure code and submitted as a single line item. Most ASCs cannot charge their services based on the Medicare Physician Fee Schedule’s allowable code.

• Most other insurers use the UB92 form, whereas Medicare requires to file all ASC charges electronically using the CMS-1500 form.

• When reporting the charges to Medicare, coders and billers must use the modifier SG to indicate ASC-provided services. Other payers may wish to see the SG modifier differentiate between a facility’s charge and a physician’s bill. Always check with specific insurance to see what ASC billing restrictions they have.

CMS’s Regulations for Covered Procedures 

Centers should always keep in mind that not all operations in a hospital are permissible in an ASC setting.

For a procedure to be “authorized” by Medicare, CMS must establish that it does not pose a considerable risk of harm or the need for an overnight stay following the treatment. When in doubt, call Medicare.

The following criteria are the basis for the approved procedures list:

• If it is urgent
• They can be elective
• If medical providers cannot safely perform the procedures in a physician’s office
• The procedure cannot be life-threatening or of an emergency nature, such as reattaching a severed limb or a heart transplant.

Common Billing and Coding Errors in Ambulatory Surgical Center

Here are common billing and coding errors in ambulatory surgical centers and how you can solve them:

Operational Billing Errors

Most of the billing errors stem from operational mistakes that can be easy to repair: 

• Lack of staffing

When you’re trying to manage all of your billing, coding, and collections with a small team to cut costs, there will be mistakes. If you don’t have the budget to recruit extra administrative staff, consider outsourcing some of your billing and coding to a reputable ASC billing agency. It will help you save time and money and eliminate errors and increase your cash flow.

• Unclear definition when reporting

If you don’t explicitly define all of the procedures or elements included in a single surgery, your coding staff may miss the opportunity to bill some of them. In addition, don’t assume that your employees will be aware of additional implemented procedures. To ensure accuracy in the coding process, pay close attention to detail when finishing your documentation.

• No denial tracking process

Even if your staff is on top of processing denials, resolving issues, and getting them paid, if you don’t track denial patterns, you could be stifling your cash flow. You should have a system in place that tracks all denials, including who denied the bill, why they rejected the bill, who did the initial coding, and what the outcome was. You can next look at the aggregate data to see if there are any patterns. Then, whether you’re experiencing denials from a lot of payors owing to procedure coding mistakes or just one payor that denies the majority of your bills the first time, you’ll be able to identify the issue and fix it.

Coding Errors

The reporting process might sometimes be the source of your coding problems. Here are a few things to keep in mind when writing your report to avoid coding errors:

• Outdated forms

You’re probably missing out on some key revenue opportunities if you haven’t updated your patient encounter forms in a while. The coding system is constantly changing, and using obsolete forms means you may not have access to some of the more recent codes. Even forms that are only a year old can be outdated, making this a priority for more revenue.

• Incomplete procedure reporting

When the procedure report title refers to an open operation yet the report specifics refer to an arthroscopic technique, your coding staff may become perplexed, resulting in billing errors. Because open operations are more expensive to the bill, it’s critical to know what kind of treatment was performed. Suppose an arthroscopic procedure begins off as arthroscopic but ends up requiring open surgery, ensure sure. In that case, state it clearly in the report so that your coders know to bill for open surgery rather than arthroscopic.

• Inaccurate modifier usage

A mistake in the use of modifiers is one of the most prevalent grounds for a billing denial. These errors can cost you a lot of money, whether they’re caused by confusing reports from your patient encounters or by coder oversight. Ensure your documentation is clear for your coders, so they understand when a modifier is required in the coding.

• Not using different codes for different techniques.

It is crucial to make it evident that there was a difference in your reporting so that your coders are aware. For example, code two methods separately if you remove numerous cysts, and two of them were preserved by one technique. A different technique removed the rest since preservation was not necessary.

Providing you with the Best

Choose only the best for your Ambulatory Surgical Center coding and billing process.

At 1st Providers Choice, we understand the need and expectations of our clients for a higher level of performance for billing software and EHR. That’s why we only offer the best and tailored medical billing system and EHR with features that will allow your practice to operate at its optimum potential and triple your revenue.

You can call us at (480) 782-1116 for immediate assistance, or you can schedule a free demo with our experts TODAY.