5 Surgery Center Coding and Billing Tips

Here are five ambulatory surgery center coding and billing tips from the team at National Medical Billing Services.


1. Use modifiers that meet payor guidelines. Ryan Flesner, direct of A/R for NMBS, says certain carriers have different preferences when it comes to modifiers, and coders must know which carriers prefer which modifiers before they submit a claim. Modifier preferences can differ by carrier and by state, so coders need to do their research to avoid denied claims.

If coders are unaware of a carrier's preferred modifier, he says they can contact the carrier and discuss how the claim should be submitted. He adds that once the center sees a denial, the A/R rep should be able to identify what caused the denial and let the coder know the carrier's preferred modifier.


2. Know the electronic pathway of claim submissions to every payor. Lisa Rock, president and CEO of NMBS, recommends that billing managers chart the path of electronic claim submissions for each payor. Electronic claims are sent from providers to the provider's EDI company and, in some cases, on to several trading partners before the claim reaches the payor. The longer the path the claim takes, the more opportunity for errors. For example, an ASC may use an EDI company that does not have a direct contract with a certain payor. If that is the case, the EDI company would send the claim to a trading partner, which may or may not have a direct contract with the payor. If the trading partner does not have a direct contract, the claim would go to yet another trading partner before reaching the payor. Knowing the pathway of claims can also give billers a better idea of how long claims will take to reach payors, says Ms. Rock.

Billing managers can begin to chart the path by following a claim from the healthcare provider to the provider's EDI company and then determine if the claim goes directly to the payor or to an additional clearing house or trading partner. "For each payor, call your EDI provider and ask if they have a direct contract with that payor. If they do not, ask where they send the claims next," says Ms. Rock. "After you determine where it goes next, call there and ask if they have a direct contract with the payor, and so on."


3. Remember to verify and authorize insurance. It is absolutely essential to make sure the patient actually has coverage before undergoing a procedure, Mr. Flesner says. If the patient does not have the required benefits, you will get a denial. While you check on benefits, you should always check the deductible to see if the patient has a "trash plan," meaning a very low premium and a very high deductible. Mr. Flesner recommends you also remember to verify benefits in an outpatient surgery center rather than just outpatient — there is a difference.

Verifying insurance means contacting the carrier directly for information about the patient's plan, the upcoming procedure and the necessary authorization. During this conversation, the carrier can tell you the best way to submit the claim and where to send it to ensure it is paid. Mr. Flesner says some insurance companies track high-volume surgeries to ensure surgery is necessary for the condition. "Carriers are going to look for a history of a more conservative approach before they offer surgery," Ms. Rock says. "That's why authorization is so important for some procedures, because maybe carpal tunnel doesn't require authorization today but tomorrow it will."


4. You will lose money if your codes aren't in the correct order. Once you've referenced the operative report and you know which codes to bill, it's essential to put your codes in the right order, Ms. Rock says. Make sure you record your codes from highest reimbursement to lowest reimbursement so that you don't lose money unnecessarily. For example, Medicare will reduce the procedure you list second by 50 percent, so if you have one procedure listed at $1,000 and another listed at $750, you want to take the cut on the $750 procedure so that you lose less money.

It may be possible to correct your reimbursement if you make this mistake, but Ms. Rock recommends doing it right the first time to save yourself a lot of hassle. "It's always possible [to fix it], but if you sequence properly the first time, you won't have that problem on the back end," she says.


5. Understanding your managed care contract is essential. Ms. Rock says your biller should have a copy of every managed care contract and understand the details of each one. "You need to understand how long you have to submit a claim, how long you have to review an adjudicated claim, what the payment methodology is, why a carrier would reduce multiple procedures and how to appeal a claim that hasn't been paid correctly," she says. Your ASC should use your managed care contract to bill out, post payments and follow up, and you need it in every point of the revenue cycle. For example, by reading your managed care contract carefully, you will avoid taking an orthopedic case with a $2500 implant attached when you have a carrier that doesn't reimburse implants.

This problem can be solved through simple research. Make sure you have your contracts on hand and refer to them frequently. Understanding the ins and outs of your contract can help you save money and make you more aware of which procedures are most profitable to your center.


Learn more about National Medical Billing Services.

More Articles Featuring NMBS:

ASC Industry Leader to Know: Nader Samii, CEO of National Medical Billing Services

8 ASC Coding Tips for Orthopedic Procedures

13 Things to Know About ASC Operations

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