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Common coding pitfalls in ASCs & best practices to avoid falling in the traps

Stephanie Ellis, RN, of Ellis Medical Consulting in Franklin, Tenn., divulges common coding traps ASCs fall into, as well as key strategies for avoiding these pitfalls.

ASCs specializing in orthopedics, pain management, gastroenterology, podiatry as well as ear, nose and throat, should especially heed these tips, as the coding is quite complex.Stephanie Ellis Photo

Ms. Ellis outlines the top five errors ASCs make during the coding process:

1. Pre-certification errors. A procedure undergoes a pre-certification process with a payer, during which certain codes are authorized. The payer will only pay for the authorized codes, determined prior to surgery. A common error is mismatching the authorized codes to the actual surgery performed. In this case, the ASC only has 24 hours, on average, to connect with the insurance company about changing the authorized codes. Ms. Ellis emphasizes not all procedures will require a pre-certification, but the ASC must demonstrate diligence in ensuring which surgeries must go through the process.

2. Poor operative report documentation. Inadequate OP report documentation, such as failure to document performed procedures, will result in denials or lost money. A "canned OP report," which denotes an identical report for every procedure of the same type, can document aspects that were not performed for a certain patient, may not accurately document the performed procedure or omit any complications encountered.

"Sometimes these 'canned OP reports' do not even document if the surgery was done on the right or left eye, or knee, etcetera," says Ms. Ellis.

3. Undercoding and upcoding. Coders unfamiliar with ASC coding may unintentionally undercode or upcode. Undercoding can result in lost revenue, due to not billing for all procedures or omit billing for implants, and upcoding can lead to compliance problems and payer refunds.

4. Incorrect diagnosis coding. Since transitioning to the ICD-10 coding system, very specific diagnosis codes are necessary to avoid denials.

"You can't code an unspecified cataract of an unspecified eye — you have to code the exact type of cataract and on which eye the surgery was performed," explains Ms. Ellis.

5. Improperly using modifiers. Coders lacking knowledge about ASC coding may inaccurately use modifiers for ASC facility billing, which aligns more closely with a hospital's use of modifiers as opposed to a physician's use of modifiers.

To evade these coding downfalls, Ms. Ellis recommends coders attend ASC coding seminars regularly, to gain expertise in guidelines specific to ASCs.

Additionally, successful ASCs establish procedures for pre-certification so staff is on top of obtaining and verifying accurate authorized codes. Ms. Ellis suggests a specific employee, perhaps a nurse, take the lead on changing the authorized codes within 24 hours of the surgery to ensure proper payment.

Another best practice involves the coder checking the chart for pathology reports as well as clarifying any confusing information on the OP reports. If information proves missing from a report, the coder should write a query to the surgeon. The coder should also consult a patient's history and physical examination information to ensure proper diagnosis coding.

Coders and ASC schedulers should also familiarize themselves with the Medicare ASC List, noting what Medicare covers and what it doesn't. The list is updated every January on the national ASC Association's website.

"It's important that the ASC facility's scheduler has that list, so that when surgeries are scheduled for Medicare patients, they can make sure the procedure is covered by Medicare. If not, they can divert the case to the hospital," says Ms. Ellis.

As the industry heads deeper in value-based care, accurate coding will prove critical to an ASC's success. "Since ASCs are usually not able to break out charges for drugs, supplies, anesthesia time, recovery time, etcetera — like hospitals can — we have to be extremely efficient and accurate in billing for ASC services correctly," Ms. Ellis explains.

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