ASCs are the fastest growing healthcare service in the US. Yet the revenue earnings fail to match up with the pace of the service growth. Reason being the field of ASC is beset with many unique challenges that come in the way of improving revenue performance. For instance to bill services, the ASC must meet the pre-requisites laid down by the Centers for Medicare and Medicaid Services (CMS). Any violation in meeting rules can lead to a denial. Secondly, the service rendered should be triggered by a medically necessity as required and defined by the provider. In many cases, providers fall short of establishing this necessity.
Why do ASC Billing Mistakes Happen in the First Place?
There are numerous reasons for ASC medical billing going wrong. It can happen when coders do not read an operative note completely to find out if a procedure was arthroscopic or open. As a result they end up reporting both techniques as one instead of two different procedure. Sometimes it so happens that physicians list a particular procedure in the heading of an operative note but end up documenting different procedure in the body of the note.
Also Read:- Why Medical Billing Outsourcing Will Become the Cornerstone of US Healthcare Industry by 2025
In some cases, it happens because of specific reasons such as reporting fewer levels of coding radiofrequency ablation of lesions or coding the wrong count of lesions. We have even handled denial cases that happened because of mixed up coding of anatomy or confusion in referring the correct polyp removal technique. Given below are some common reasons.
Errors Due to Unbundling
Some healthcare services are complex and comprise a series of procedures. Such services can be billed by bundling the services codes. For instance, if a patient undergoes a bone x-ray, followed by treatment for a broken bone, the services can be billed together or bundled under one code. To maximize payments, providers sometimes unbundle the related service contrary to CPT instructions. While this may happen either because of error in judgment or lack of knowledge it gets interpreted as a deliberate attempt to mislead the payer.
Therefore, it is important for ASC billers to understand when separate reporting of services is correct and when it can become a risk. Much of these can be avoided by up to date training procedures not eligible for separate reimbursements such as incidental procedures, mutually exclusive procedures, integral procedures etc.
Documentation plays an important role in realizing claims. Claims get rejected because of poor operative report documentation; overlooking operative report while documenting, hasty reading of report, or coding only from the report procedure summary. There is a well-established way to handle all sorts of documentation errors. These include carrying out regular reviews of operative reports for improvement; educating physicians on documentation requirements and ensuring only operative document is considered for review. The last point can be a trap because sometimes procedures may be documented in the summary section but not in the body of the report.
As per Medicare rules only procedures jotted down in the body of the op report has to be billed. It therefore falls on the coder to go through the entire operative report to ensure the codes are correct and all that has to be coded is appropriate and properly documented.
Upcoding and Undercoding
These are the most common billing issues with ASC medical billing and can even get you embroiled in serious trouble. The risk with upcoding or over coding is a lot higher, because you may get reimbursed more than you are entitled to. And if it gets flagged, your practice will have to undergo a strict payer audit. And if the payer interprets it as a deliberate act, you me be accused of fraud that may invite severe penalties. Undercoding or inadequate coding is like self-inflicted financial loss. Payers will deny claims because your code doesn’t match with the surgeons coding.
However, there’s a catch here. In your bid to match the physician’s codes, you cannot afford to code wrong just because the surgeon has coded wrongly. If this leads to a denial, which in most cases it may, you can file an appeal successfully.
A majority of ASC medical billing claims denials happen because the codes say there was no “medical necessity” for the procedure to be carried out. Again, this can be attributed to undercoding. The coding accompanying the need for medical necessity falls short leading to denials. In other words, these denials are because the diagnosis coding did not make it clear to the payor about the necessity of the procedure.
In one such ASC coding audit for a practice we found that the Medicares Local Coverage Determination (LCD) policy was violated leading to denials. The practice was found to bill for hemorrhoids as the only diagnosis on a colonoscopy claim to Medicare even though hemorrhoids are a common finding during colonoscopy. If your ASC practice carries out a procedure with a related Medicare LCD, it is important to check and cross check the diagnosis coding list in the LCD for the right options.
Do not cook up a diagnosis just because you have to bill the payer. If the operative report is inconclusive (prior or post procedure), have a closer look at the pathology report for a postoperative or a preoperative symptom that might be on the LCD list.
Likewise, misreporting can lead to errors and denials. For instance, billing open and arthroscopic techniques as a single procedure is one such error. This happens when a procedure is started arthroscopically and later gets converted to an open procedure. When the open procedure has to be only coded, many coders end up coding for both.
Improper Modifier Usage
Another possible reason for claims denial or underpayment is improper modifier usage. Besides denial, it can also lead to compliance risks or claim denials or causing your facility to be underpaid. This mostly happens when modifiers are appended to codes unnecessarily or used inappropriately to seek reimbursements. Likewise, when a modifier is missed, you get underpaid unnecessarily. Let’s take an example. Not unbundling codes when it is permitted to unbundle them can lead to less payments. For instance, if you bundle diagnostic cystoscopy (code 52000) performed with a diagnostic hysteroscopy (code 58555) when CPT says the two can be billed as two different procedures, it will lead to underpayment
Claim form issues
A common reason for ASC denial is incorrectly filled claim forms. A good to way to overcome this problem, is to have multiple checks done before submitting a form. If your practice has too many of them, then you must fall back on trends. Go back to claims that were denied for incomplete-claims reasons or errors in claim-form errors. Cross check each field and try to figure out the problem. In most of the cases you would find it is human error which has led to the problem. To avert a repeat, it is important to train your staff along these lines. A standard yet effective rule followed by most practices is to take a print out of the hard copy of completed claim forms and check if the: the fields are populating correctly; if there are no missing or extra modifiers, if the diagnosis and CPT codes are entered correctly; and other things like place of service and revenue codes are correct etc. This should be done as a random audit to keep staff on their toes.
Billing for cancelled cases and terminated procedures
As a practice, you may lose revenue if you do not bill for procedures that get terminated or is coded incorrectly because of wrong use of modifiers. When this happens, you expose yourself to compliance risks as well. Using modifiers is an accepted way of reporting expenses for a procedure which eventually gets terminated (however in case of cancellation, it cannot be billed).
There are two applicable modifiers in this case.
Modifier -73 is used to indicate the procedure was discontinued prior to anesthesia administration and Modifier -74 which needs to be applied when the procedure was stopped after the administration of anesthesia.
If several procedures were planned, only a few were completed the rules allow you to bill procedures that were completed at full fee without a modifier but to bill any procedure started but not completed at full fee can be claimed with a modifier. In such cases, the rule mandates the need for an operative report with complete detailed information on why the procedure was terminated.
Billing for Implants
To bill for implants, it is extremely important to have complete knowledge of ASC’s managed care contracts and the reimbursement policies for implants and supplies. Not all payers allow billing of all implants and it differs from payer to payer. Here it must be noted that payers do not follow Medicare guidelines when billing for implants—and therefore the slightest of error can lead to loss of revenues for your practice. Here’s an example. Unlike Medicare, not all payers pay for intraocular lens (IOL) to cover cataract procedures (code 66984). Therefore the intraocular lens should be billed as another line item with appropriate HCPCS code.
Another important thing to care for, is to include implant invoices while billing for implants. Also the operative report written by the physician must document in detail the implants used, along with the screw and anchor count. If the operative report is accompanied with supporting information and the information contained is in line with the implant invoice, then it becomes easier to get reimbursement in full.
ASCs can fall into financial mismanagement if due attention is not made to streamline the billing process or if changes are not done on time to sync with changing payer rules. Ensuring these regularly can be too much for ASCs, which is why most ASCs outsource a bulk of their requirements to third-party ASC medical billing specialists. This takes away the big headache of managing revenues to stay afloat. An experienced RCM company can assist you strategize for enhancing the overall cash flow and safeguarding the financial lifeline of your practice.
Who We Are and What Makes us an Authority?
MedBillingExperts has over 10 years of experience in providing ASC medical billing support services to independent and associated ASC practices in the US. Our experts have extensive experience in entering charges, submitting electronic/paper claims to payers, and following up with them on billing questions. Besides, they provide continuous updates and feedback to your revenue management teams about changes and updates or other requirements.