As of 2023, nearly half of U.S. hospital and health systems have at least one partnership, affiliation, or ownership interest in ASCs. Reports from industry publications indicate ASCs are becoming central to the overall financial strategy of extensive healthcare service networks and this trend is expected to accelerate due to three main factors: pressure to reduce costs, provide care for aging population, and adapt to changes in government regulation as more complex procedures are approved for outpatient environments.
While ASCs actively pursue these opportunities as a key strategy to expand their footprint, client base, and case volume, participating in a health system partnership can bring unforeseen revenue cycle management challenges, including claims matching.
If you're unfamiliar with the concept of carrier claims matching, your ASC might be facing potential revenue losses. This article serves to build upon our claims matching recommendations from a previous Becker’s ASC Review article while providing specific guidance for navigating this complex process with your health system partners.
What is Claims Matching?
Major payers match ASC CPT codes with professional and anesthesia crosswalk codes, either proactively or retroactively. If the codes on these three claims do not match, an insurance carrier can issue denials. Since carriers don’t automatically match claims to the correct codes, familiarizing yourself with your carriers' claims matching policies is crucial for timely reimbursement.
For example, if a payer matches codes proactively when claims are received, the claim that reaches the payer first and is approved for reimbursement serves as the primary source for that procedure, meaning the coding on the other claims must match. However, there are several codes and several variations of codes for complex procedures. The more complex the procedure, the more likely a claim denial could be issued due to CPT codes not matching.
Claims matching policies can pose two primary challenges for your coders:
- Code Alteration: Your ASC’s procedure codes may be altered to align with professional charges, potentially leading to down-coding and reduced revenue.
- Claim Processing Delays: Claims may not be processed until your accounts receivable department intervenes and pushes them back into adjudication.
The claims matching process can become cumbersome between ASCs and health systems as separate coding and billing teams may have different coding and billing processes and practices. For instance, an in-house team that generally codes for in-patient cases may not have the same nuanced understanding of outpatient CPT codes.
Revenue cycle teams should work together to review codes for each procedure before the claim is submitted. Otherwise, if a claim is denied due to coding misalignment, teams will need to work together, backtracking to determine what was coded on the first claim, if it was correct or if the claim needs to be remitted and approved before the second claim can be resubmitted.
Since hospital systems are referring more complex cases to the outpatient setting and these cases represent high dollar amounts for ASCs, unnecessary delays in reimbursement can directly impact your bottom line.
In our experience, if the same team codes and processes the ASC, professional, and anesthesia claim for each procedure the chances of rejection are substantially minimized; this is a practice that nimble offers for our clients.
Orthopedic Claims Matching Example: CPT 29916 and 29915
Consider a scenario where the ASC’s hip procedure claim was submitted to a large national payer. The claim was denied because the codes didn’t match the professional claim, which had already been submitted, approved, and paid.
In this instance, the ASC coded and billed:
- 29914 - Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion)
- 29916 - Arthroscopy, hip, surgical; with labral repair
The professional side coded and billed:
- 29914 - Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion)
- 29915 - Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion)
In this example, there are two different interpretations of how to code a particular hip procedure. Although the coding on both claims is technically correct, the codes themselves are not identical. This discrepancy between CPT 29916 and CPT 29915 led to the ASC’s claim denial because it was the second claim to reach the payer.
For the ASC to be paid, the codes can be changed to match the professional claim. However, this can impact the facility’s reimbursement amount and lead to down-coding if the allowed amount for CPT 29915 is less than CPT 29916. Ideally, both coding teams should’ve coordinated prior to claim submission to confirm which code (CPT 29916 or CPT 29915) is to be used.
For the anesthesia claim to match, coding is based on the primary procedure performed. Each code has its own “base” units built in. Anesthesia coders add the start and stop time for the total anesthesia units and any physical status units that are applicable. If the anesthesia claim reaches the payer first and was approved, then the payer anticipates the ASC and physician claims will reference the same primary procedure for the patient.
While it may be challenging for staff-strapped ASCs and professional coding teams to coordinate this process with their health system partners prior to each claim submission, outsourcing to a revenue cycle management (RCM) company with expertise in coding all three claims can ensure consistency upfront.
An RCM team with claims matching expertise is also advantageous when carriers match claims retroactively. Your ASC may discover which payers participate in this practice if you receive a negative balance invoice. In this instance, your claim was approved, you received reimbursement, but after reviewing the coding on the three claims, the payer down-codes your CPT codes to match the first claim, stating you were overpaid. The carrier will likely request a refund and deduct this amount from future payments, a policy that could prove costly for your ASC and challenging to adjudicate.
Preventing CPT Mismatches with Health System Partners
The rationale behind matching claims for ASC, professional, and anesthesia charges has its merits. These claims should tell the same story about what was performed on the patient; therefore, the coding should correspond.
To avoid financial impacts, align coding best practices with health system partners and include the following five strategies:
- Rely on Medical Records: Avoid coding based solely on charge sheets or superbills; use medical record documentation to substantiate your coding decisions.
- Daily Code Matching: Establish a daily spreadsheet to match ASC codes with the surgeon's codes on the front-end.
- Code Discrepancy Discussions: Review coding on all claims and engage in discussions to resolve code discrepancies before submitting claims.
- Avoid Arbitrary Code Changes: Refrain from making arbitrary code changes to align codes artificially as this could lead to compliance concerns.
- Internal Coding Audits: Regularly audit your claims and your coding techniques to ensure accuracy; communicate any coding updates to external teams.
When seeking to prevent claim matching issues, also review instances when coding should not align. For example, sacroiliac joint injections are coded with G0260 for ASCs for some payers, including Medicare, while the professional side reports 27096. Both codes represent the same procedure description, and the G code is specific to the ASC only. In such cases, the facility and professional claims should not match, and this is entirely acceptable to the payer.
Coding updates that exclusively apply to ASCs can also create situations where ASC claims and professional claims do not match. For example, due to a 2024 ASC coding update for bunionectomy, CPT 28296 (correction of hallux valgus, distal metatarsal osteotomy) is reported by the professional side. However, if the physician does not remove the medial eminence of the metatarsal head during the procedure, then the ASC should report 28306 (osteotomy for angular correction).
HCPCS “C” codes present another example. CMS reporting guidelines state that ASCs do not receive reimbursement for CPT add-on codes. However, the Medicare Complexity Adjustment allows ASCs to use a CPT code and qualifying add-on code for certain services. In these instances, ASCs report HCPCS “C” codes. Medicare specific “C” codes allow ASCs to receive greater reimbursements since these codes take into consideration the fees associated with the add-on code. Additionally, many carriers follow "C" coding for specific procedures in the ASC setting, but Medicare might not require a “C” code in these instances.
Here’s a “C” code example where professional and ASC claims should not match:
- Percutaneous lumbosacral vertebroplasty at two levels
Professional: CPT 22511, 22512
ASC: C7505
The “C” code is specific to ASCs and Medicare carriers
Medicare specific “C” codes and coding exceptions like these can change. It’s important for those involved in the coding process to have extensive expertise in ASC coding and stay updated with CMS and payer guidelines to ensure accurate reimbursement.
Takeaways on Claims Matching Protocols
Effective accounts receivable (A/R) follow-up and communication between ASCs and health systems can ensure all parties receive timely reimbursement. If a carrier's claims matching protocols lead to reduced payment for your ASC, you should notify your surgical partners’ billing teams and encourage a corrected claim submission if you’re planning to advocate for your codes or appeal the outcome.
Regular correspondence between revenue cycle management teams can address coding discrepancies to avoid claims matching issues. Partnering with an RCM company that specializes in all three claims can better coordinate this process by consulting with your partners to ensure optimal financial outcomes.
Meet Bill Slife and the nimble team at the Becker's 30th Annual Business & Operations of ASCs Meeting, October 30th – November 2nd in Chicago, or visit nimblercm.com to learn more.