1. Not coding fully. “Less experienced coders often code only from what the scheduler keys into the system or from the title, rather than looking through the body of the operative note,” Ms. English says. “Sometimes the doctor performs more procedures than what is listed in the title, which is why you need to read the entire report. ASC billers must understand when to code additional procedure codes to optimize reimbursement yet remain fully compliant with state and federal healthcare laws.”
2. Using untrained coders. Ms. Serbin advises employing certified experienced coders as a routine best practice.
“Those who lack a coding background could inadvertently unbundle codes, which is a compliance issue,” she says.
3. Failure to update coding reference guides. Finding outdated CPT and ICD-9 reference books is not uncommon in ASCs, says Ms. Serbin.
“They don’t always recognize this as an important investment,” she says. “But keeping up with frequently changing regulations and requirements is priority. The Office of the Inspector General has made it abundantly clear that they will monitor and enforce changes. Purchasing annual CPT and other coding materials is a small price to pay for compliance.”
4. Failing to use coding modifiers. Modifiers, Ms. English says, are usually two-digit numbers or letters added to CPT codes (procedures) to identify variations or specificities affecting the procedure. They might indicate a number of things such as complications, interrupted surgery, which toe or finger, etc.
“Many coders do not realize the importance of using modifiers,” she says. “This can negatively affect your reimbursement and possibly cause an unnecessary denial.”
5. Failing to verify a patient’s insurance. The importance of eligibility determination cannot be overstated, says Ms. Serbin.
“Determining whether a patient’s insurance will reimburse your center is paramount,” she says. “Some insurance payors require an authorization number for payment. Workers’ compensation claims require dates of injury, authorization codes, etc. Non-contracted carriers (out-of-network) often do not have out-of-network benefits — question them carefully.”
6. Not providing financial counseling. In today’s managed care markets, most patients owe a copayment and/or deductible, plus a co-insurance out-of-pocket amount. This co-insurance can also be paid through a secondary insurance payor, Ms. English says.
“After the patient’s insurance has been verified and the amount they owe has been determined, it’s best to contact the patient in advance of the surgery date and let them know what their financial responsibility will be,” she advises. “There are more and more high deductible plans and some patients will have difficulty meeting these amounts. Offer alternatives such as credit cards, medical credit companies or promissory notes. I don’t think payment plans/promissory notes are the best choice, but short-term plans can be offered as a last resort.”
7. Not filing claims on time. Failing to meet timely filing requirements can cost ASCs money, Ms. Serbin says.
“Depending on your contracts, the payor could demand that you bill within 15 or 30 days,” she says. “When negotiating, we aim for a one-year timely filing deadline like Medicare, but if you accept a boilerplate contract from a payor and don’t read the fine print — timely filing language could come back to haunt you.”.
She says sometimes receiving the operative notes could take several days to weeks, and by then you may have already missed your deadline.
“Then you might not get paid at all, something that happens more often than you’d think when the facility doesn’t have sufficient staff members dedicated to coding, billing and collections,” she says.
8. Neglecting to appeal denied or wrong claims. Ms. English recalls one ASC that specialized in ear, nose and throat procedures, but failed to challenge rejected claims.
“The ENT doctor had performed hundreds of procedures in which he put ear tubes in both ears, but instead of billing for tubes in both ears, the ASC only billed for putting a tube in one ear,” she says. “Their coder didn’t realize you must indicate that it is a bilateral procedure on the claim form and the payment poster accepted what the insurance paid as correct. Luckily, they’d only been in business for 18 months and were able to rebill those that were still within the timely filing constraints and were able to regain some of the additional reimbursement.
“Failing to understand how your contract pays can cost you,” Ms. English says. “If a claim is denied or paid incorrectly, you should be aware of what is due and file an appeal immediately. We recommend loading your contracts into your software or, at a minimum, having an insurance matrix with allowances available when posting payments.”
9. Not billing patients on a timely basis. Sometimes weeks or months pass before patients receive a bill, Ms. Serbin says. That’s money just sitting on the books. She recommends collecting deductibles and co-payments prior to surgery and then billing patients for their co-insurance immediately upon receiving payment from their insurance company.
“It’s easy for patients to assume they don’t owe you money if several months go by without receiving a statement,” she says. “It’s very rare that a patient will call and ask you if they owe anything. Don’t forget to monitor payment plans.”
10. Failing to negotiate good insurance contracts. “It’s more important now than ever before to have someone knowledgeable negotiating your managed care contracts,” Ms. Serbin says. “Managed care has been tightening their contract requirements and reimbursement amounts for years, but it seems to have gotten much worse in the last couple of years. Negotiating a good managed care contract can take months, so it’s important to know what you need and what you can sacrifice to get what you need.
“[Payors] are becoming more and more imaginative in finding ways to lessen the amount of your ASC’s reimbursement,” she says. “For instance, check for implant allowances. If the payor absolutely refuses to reimburse implants, try to carve out implant-containing procedures at a higher reimbursement to cover the cost of the implant. You’re not in the business to lose money.”
Ms. Serbin (cas@surgecon.com) is president and founder of Serbin Surgery Center Billing, an ASC coding and billing company, and Surgery Consultants of America, an ASC management and development firm. Judith English (jle@surgecon.com) is vice president of business operations for both SCA and SCB. Learn more about Serbin Surgery Center Billing and Surgery Consultants of America.
