Payer policies, surgical technology ,CPT code guidelines, and medical necessity requirements can change at a dizzying rate, presenting a significant challenge to ASC administrators hoping to maintain a positive margin.
"Incomplete or inaccurate coding of complex procedures, like spine and pain management, means oftentimes ASCs will leave reimbursement on the table," said Lisa Rock, National Medical Billing Services, during a June 21 webinar sponsored by NMBS and hosted by Becker's ASC Review. Coding errors are a luxury many surgical providers cannot afford as increased patient financial responsibility puts pressure on cash-flow.
Fortunately, ASC administrators, coders and revenue cycle staff can implement certain strategies today to improve charge capture and financial performance.
Here are three ways ASC administrators can enhance revenue cycle performance and four ways coders can improve charge capture, according to Ms. Rock.
1. Identify who pays the claim. "We are in an ever-changing environment with more employer groups going self-funded, so it is important ASCs understand who, in fact, is paying the claim," said Ms. Rock.
In a self-insured group health plan, the employer assumes the financial risk for providing healthcare benefits to its employees. About 26 percent of employers with between 100 and 499 employees self-insure, compared to more than 82 percent of employers with 500 or more employees, according to HHS.
However, a greater number of smaller companies have begun to implement self-insured plans. In some cases, the risk level is simply too great for small businesses, and this can negatively impact an ASC should the employer fail to afford its portion of the reimbursement. Knowing who is responsible for paying medical claims is also important for pre-authorization staff, so they can submit authorization requests to the proper entities in a timely manner.
2. Proactive denials management. Understanding insurance rejections is critical to identifying and addressing issues in ASC revenue cycles. Claims denials can signify an array of simple billing mistakes, such as demographic errors, incomplete claim submission and invalid modifiers or diagnosis codes. By analyzing claims denials on the back end of the revenue cycle, administrators can derive actionable insights, target bottlenecks and implement new documentation strategies on the front end, said Ms. Rock.
3. Understand the out-of-network environment. "Out-of-network providers must be thoughtful and organized to achieve success in today's complex and adversarial out-of-network landscape," said Ms. Rock. Many insurance carriers are using increasingly creative means to combat payment requests from out-of-network providers. This means ASCs must understand the out-of-network policies for each patient's insurance and stay abreast of policy changes throughout treatment.
4 strategies for coders
Many issues that lead to charge capture errors and missed opportunities for payment originate in coding errors. Here are four ways ASC coders can improve spine and pain management documentation.
1. Improve familiarity with CPT codes and anatomy. "For pain and spine, the most important thing for a coder is to be familiar with both anatomy and CPT code sets," said Tamara Wagner, vice president of performance review with National Medical Billing Services. Knowing the full anatomy of the spine enables coders to interpret the correct operative note for surgical approach, level assignment and diagnosis assignment. The coder can then employ the most accurate CPT codes available, ensuring both ASC and physician receive complete and proper reimbursement for services provided.
2. Stay abreast of changing policies among LCD carriers and commercial payers. More insurance carriers are requiring substantive documentation to support medical necessity prior to authorizing procedure approval. This is not problematic in and of itself; however, discrepancies in medical necessity policies among payers can be difficult for coders to navigate. For instance, local coverage determinations of medical necessity for Medicare authorization can differ greatly from requirements set by commercial payers, said Ms. Wagner. In some cases, commercial payers may require more detailed or substantive information. Ms. Wagner recommends implementing a system to track changes to medical necessity policies across the range of accepted insurers.
3. Know your implants, products and instruments. As surgical technology advances, ASCs are continually adding new instruments and medical products to their surgical repertoire. Each new piece of equipment correlates to a new CPT code. Alison Kuley, CPC, a senior spine coder, recommends coding staff thoroughly research appropriate coding practices for each new medical device to ensure claim approval. "It's critical coders vet out information provided by implant and technology vendors to fully understand which codes Medicare allows, and which it does not," said Ms. Kuley.
4. Obtain accurate, detailed physician documentation. It is important physicians provide complete and detailed operative notes to ensure coders indicate the appropriate CPT designations. For instance, in spine surgeries, decompression documentation should specify each nerve targeted at each level for maximum reimbursement. Spine surgery CPT codes also correlate to a particular surgical approach used. "Newer, less invasive surgical technology is transforming how spine and pain management procedures are performed," said Ms. Kuley. To appropriately code for a new surgical approach, coders must understand whether new techniques are considered open or endoscopic procedures.
You can view the webinar recording, here.