Here are 10 best practices pertaining to coding, billing, and collections in ambulatory surgery centers from 10 revenue cycle experts.
Once staff members have started the appeals process, they must follow through to the end of the process, says Caryl A. Serbin, RN, BSN, LHRM, executive vice president and chief strategy officer of SourceMedical. “Staff members in charge of appeals may start the appeals process and give up because it’s too lengthy,” she says. “When you appeal, there can be anywhere from four to five levels.”
She says surgery centers must follow payor rules when it comes to filing appeals. This means using the correct forms, following the payor’s appeal process and understanding which information payors require to support the claim. “Surgery centers want to take a shortcut and get innovative, but you have to think of it as the government when you’re paying your taxes,” she says. “You don’t get to fill out any form you want to — you have to fill out their form.”
“If [a] payor intends to include payment for implants in the APC rate as a global allowed amount, then ensure you have completed a reimbursement analysis to determine if the APC rate is high enough to cover your cost of surgery plus the implant,” writes I. Naya Kehayes, MPH, managing principal & CEO of EVEIA HEALTH. “In addition, ensure there is no value loss when compared to the total reimbursement allowed under the Medicare-grouper based methodology with the additional payment on the implant.”
Physicians may list certain procedures in the procedure heading of the op note but will actually document different (fewer or more) procedures in the body of the operative report, says Jessica Edmiston, coding manager with National Medical Billing Services. You can tell the coders who don’t read the entire op note because the coding will match the procedure heading. She says coding from the procedure heading alone is incorrect. Coders must always read the entire operative report and question and discrepancies.
If your data indicates a high or increasing number of denials, Bill Gilbert, vice president of marketing at AdvantEdge Healthcare Solutions, says the problem probably lies with your front-end staff. “That means a need for training, maybe some job aides and adjustments to how front end staff are using the system.” He says problems with denials can be caused by a variety of errors, and not understand the billing system can cause problems easily. When your center implements new software, take a few days to coach your staff on the ins and outs of submitting claims. This will save you a lot of time re-submitting denials that arise from a lack of comfort with the system.
Older coders may be considering retirement as the ICD-10 implementation deadline looms, says Rosalind Richmond, CCS, interim coding compliance officer for Genascis. “Older coders don’t want to learn a new classification system, especially one that is alpha-numeric,” she says. These coders may have experienced the switch from ICD-8 to ICD-9 in the early 1970s and know the transition will be a significant undertaking, she says. She expects the move to ICD-10 to be even more complicated because of the numerous software applications affected by the change in each facility.
She says facility leaders should speak with coders to determine whether they plan to slog through training and implementation of ICD-10 — or whether they are planning to move to different positions or retire prior to Oct. 1, 2013. Getting a sense of coders’ plans will help facilities prepare for coder shortages.
Coding rules can vary by Medicare carrier. In the listservs, which anyone can sign up for at no cost, the local MAC or fiscal intermediary regularly updates changes, says Paul Cadorette, director of education for mdStrategies in Houston. For example, TrailBlazer, the carrier for Colorado, New Mexico, Oklahoma and Texas, e-mails necessary updates as often as several times a week. “If they are going change or modify any of their guidelines they will send you an e-mail,” Mr. Cadorette says.
Lolita Jones, RHIA, CSS, independent coding and billing consultant, says ASCs should develop a plan for the payment issues that will inevitably arise in the three months after ICD-10 implementation. She says the ASC will likely have to spend more time on billing tasks, meaning the center may need to hire a temporary biller to stay into the evenings. The ASC should also have a contingency plan in case a staff member leaves the center. “There are things you can’t plan for, and you need to know that if a person left tomorrow, you would be able to bring someone else in to pick up where they left off,” she says.
Reevaluate surgical implant discounts on a regular basis, says Larry Taylor, president and CEO of Practice Partners in Healthcare. Ask for price breaks, reminding the implant company that lower prices can translate into higher case volume and thus increase its business. “One key strategy in reducing implant costs is to develop a capitated plate and screw plan with a key vendor,” Mr. Taylor says. Work with the vendor to establish one price for plates, screws and drill bits, allowing for a greater number of profitable cases going through the ASC.
“One of the easiest ways to decrease your days outstanding is to manage your lags and turnaround time,” writes Michael Orseno, revenue cycle director for Regent Surgical Health. “The charge entry lag is measured from the date of service to the date charges are entered. This number should be less than five days, with the gold standard less than two and a half days. Claims should always be sent the same day charges are entered, so the claim lag should be the same as the charge lag. If centers are experiencing a significant difference between the two, this is an indication that your billing department may be holding claims or that they’re entering charges prior to receiving the operative report.”
“Some centers have sound billing practices, but their charge lag suffers from slow turnaround times,” Mr. Orseno writes. “For outsourced transcription and coding services there’s an easy fix — demand 24-hour turnaround times. If either of them can’t do this, then it may be time to look to other companies. Physicians not dictating in a timely manner is a much tougher problem to solve. Often it is only one or two physicians, and sometimes they’re owners and/or board members. Strong policies and procedures may not be enough in these circumstances — it may be necessary to bring the statistics up in board meetings to exert peer pressure on the offending physicians. Or in extreme cases, a center may opt to impose fines and/or hold distributions.”
Rob Morris, vice president of marketing and new business development for GE Capital’s CareCredit, says ASCs often fail to collect because a front desk staff member calls the patient at home, leaves a message and never hears back before the day of surgery. Mr. Morris says it is essential that staff members talk to patients about their financial responsibilities prior to surgery, meaning several phone calls may be necessary.
“It can be hard to reach the patient, so the patient shows up and says I don’t have the money,” he says. “Usually the ASC will still accept the patient because the doctor is coming in half an hour, so they’re stuck with that case and they don’t collect.” During the pre-op phone call, staff members should be clear that the ASC expects to receive payment on the day of surgery — or, failing that, needs the patient to commit to a payment plan while at the surgery center.
Ref. Becker’s Healthcare
This post was first published September 22, 2011 and was updated July 29, 2020.