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3 Tips for Reducing Delayed Claims in Surgery Centers

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Mike McFadin, operations manager of national bill review at Sedgwick Claims Management Services, a third-party claims administrator and productivity management firm, and David Kessler, DC, MHA, medical director of Sedgwick CMS's Ohio managed care operations programs, provide three tips for reducing delayed and denied insurance claims in ASCs.

1. Use revenue code 278 for surgical implants.
One of the most common reasons ASCs are asked to resubmit claims is for the use of inappropriate revenue codes for surgical implants. ASCs bill for surgical implants under a variety of supply codes, including 270 (medical/surgical supplies), 272 (sterile supplies) and 279 (other supplies and devices); however, facilities should use revenue code 278 for implants to ensure expedient claims processing, says Mr. McFadin.

"The most appropriate and direct way to bill for surgical implants is to use revenue code 278, regardless of whether the implant is carved out or paid as bulk," he says.

2. Ensure that surgical procedure codes that can be billed under multiple revenue codes are billed using the most appropriate code. Certain surgical procedures may be billed using multiple revenue codes. When this occurs, it is important that coders take care to bill using the most appropriate revenue code. For example, a spinal injection (CPT 62310) may be billed under pharmaceutical revenue code 250 or surgical revenue codes 360 (operating room services) and 490 (ambulatory surgical care). Code 490 is the most appropriate for that procedure and will help improve the timeliness of claims processing, says Mr. McFadin.

3. Include documentation of medical need for multiple first assistants. Dr. Kessler says that it is becoming more common for physicians, especially in Ohio, to bill for the use of first assistants and even multiple assistants, such as an assisting physician or physician assistant, in the OR. When additional physicians and/or PAs are used for an operation, claims should include upfront documentation explaining the medical need for the assistants, says Dr. Kessler.

"If there is a proactive comment on the claim of why the use of an assistant or assistants was required, such as because of the severity of medical problem, then the claim can more easily move through the system," says Dr. Kessler. "If it is unclear whether or not all individuals were reasonably necessary for the procedure, the claim will undergo peer review. By using documentation of its necessity of a lead in, providers can receive approval more quickly."

Learn more about Sedgwick Claims Management Services.

The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.

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