6 Things Your ASC May Not Know About Billing and Coding

As president of National Medical Billing Services in St. Louis, Mo., one of the largest ASC billing companies in the country, Lisa Rock is well-versed in the mistakes ASCs make concerning billing and coding. Here she discusses six things your ASC may not know about billing and coding that can prevent rejected claims and save you money.


1. HIPAA-exempt carriers don't have to use standard codes. Ms. Rock says your ASC should be aware of carriers who don't have to follow standardized coding practices because of HIPAA exemption. "Worker's comp carriers, small carriers and other carriers that are HIPAA-exempt can come up with homegrown codes, and you're not going to get paid if you use standardized codes," she says. To avoid having your claims rejected, make sure you know whether your carrier is exempt. "You may have to do some digging," Ms. Rock says.

2. 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.

3. Medicare will not reimburse for patients treated in a skilled nursing facility. Ms. Rock says many ASCs don't realize that Medicare will not reimburse for a patient who is treated in an ASC that resides in a skilled nursing facility. "It doesn't matter what you do," she says. "Medicare will absolutely not reimburse any procedure for these patients in an ASC."

ASCs that have previously treated patients from skilled nursing facilities will most likely be subject to reimbursement takebacks for procedures that occurred since Jan. 1, 2008. While there's nothing ASCs can do to combat this decision, you should still prepare yourself for takebacks by identifying your skilled nursing facility patients.

4. 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.


1. ASCs can bill for different colonoscopy techniques in the same session. For example, if your ASC removes one polyp with a snare technique and a separate polyp for a hot biopsy, you can report two different codes for the session, Ms. Rock says. "We've talked to many physicians who aren't aware, so they may not even be reporting that they're doing these things," she says. However, if you remove multiple polyps with the same technique, you can still only report it once.

2. Controlling pain post-surgery is considered part of the global surgical package. Medicare will not allow you to bill for a post-operative pain block provided by the surgeon, Ms. Rock says. The NCCI Policy Manual states, "Medicare global surgery rules prevent separate payment for post-op pain management when provided by the physician performing an operative procedure." National Medical Billing Services believes that the pain block, if performed by the anesthesiologist, should be billed by the professional side only and not the ASC.

Read more about National Medical Billing Services.

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