Stop Losing Revenue From 5 Common ASC Billing Mistakes

Here are five common mistakes made in ambulatory surgery centers that result in increased denials and decreased revenue.

1. Mismatching fee/service invoices. Since the teams of coders responsible for generating codes for professional and facility fees rarely work together or perform internal reconciliation, it is easy for incomplete documentation to be interpreted and coded incorrectly, says Sean Benson, co-founder and vice president of consulting, ProVation Medical.

"In fact, the OIG estimates that 23 percent of all claims do not match between the facility and the professional components," he says. These mismatched bills are typically returned by the payor and require costly reprocessing before they can be resubmitted. That is the best-case scenario. Worst case is a permanent loss of revenue and even fines by the OIG, which is now checking for billing discrepancies and has already levied record-breaking fines for construed overbilling."

2. How to bill hardware or implant removals. Deep pin removals done in an ASC require the code 20680. The physician will have to make an incision to visualize the implant, but the code is only to be billed once per fracture or previously operative site, regardless of the amount of hardware removed or the number of incisions made, says Stephanie Ellis, RN, CPC, president and owner of Brentwood, Tenn.-based Ellis Medical Consulting. The code can only be billed twice if the surgeon removes an implant or hardware from a completely different surgical or anatomical area.

3. Not knowing coding changes, such as for excision of skin and soft tissue lesions. In the last few years, major coding changes were introduced regarding the excision of skin and soft issue lesions, adding a number of codes for the excision of soft tissue lesions to distinguish from the excision of skin lesions.

"A number of coders are still coding for the skin system when it's actually from the musculoskeletal system," says Lolita M. Jones, RHIA, CSS, an independent coding and billing consultant. "Most payors will pay more for a soft tissue lesion excision than a skin lesion excision." She says centers may lose money if their coders have not properly analyzed yearly coding changes or lack the necessary knowledge on anatomy and physiology.

"In this case, it may be a matter of bulking up on their anatomy a little more and looking at some anatomical diagrams," she says. "They should be saying, 'I'm seeing that the lesion was removed all the way down to the subcutaneous tissue, and that takes me to musculoskeletal for coding.'"

4. Not filing claims on time. Failing to meet timely filing requirements can cost ASCs money, says Caryl Serbin, RN, president of Surgery Consultants of America.

"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.

5. "Defaulting" to 100 percent in-network participation. John Bartos of Collect Rx says he commonly sees providers "defaulting" to a strategy of 100 percent in-network participation, and thus failing to take advantage of the opportunities to obtain higher out-of-network reimbursements. True, out-of-network does not work in every market — but Mr. Bartos says, "the reality is that in most geographies, providers can increase revenue by having a portion of their revenue come from out-of-network patients."

He says this requires an analysis of each of the surgery center's payors. Compare in-network and out-of-network reimbursement levels for your most common procedures on a payor-by-payor basis, and determine which contracts should be cancelled to reap a higher return.

"In addition, providers need to understand both the local payor and employer mix, as well as their relative market share compared to other providers." He says if providers are prudent in picking the payors with which they pursue out-of-network, they should be able to maximize total revenue and profits.

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