ASC Coding and Billing: Know What’s Important


The fastest-growing medical services now include Ambulatory Surgical Centers (ASCs). Before submitting a claim for ASC Billing and Coding Services, you and your billing department must be aware of a few factors that differ from physician-surgeon or hospital billing. For example, Medicare frequently has different policies than some payers, and payers may have various policies about medical necessity, permitting procedures, or other filing requirements.

According to Section 10.1 of the Medicare Carriers Manual, an ASC is a separate legal entity that only provides outpatient surgical services. Office visits, laboratory services, diagnostic tests, etc., are not offered by ASCs.

According to 42 CFR 413.65, an ASC Billing and Coding Services or a provider-based hospital department may be considered hospital-operated facilities by Medicare. To provide and bill for services conducted in an ASC, the ASC Billing and Coding Services must enter into a participating provider agreement with the Centers for Medicare & Medicaid Services (CMS).

What’s Most Important in the ASC Setting?

  • Medicare Claims Submissions: For ASC Billing and Coding Services, there is a different set of billing regulations. While CMS may address some difficulties, getting a local carrier or intermediary advice for most billing regulations is best. A list of links to the CMS website may be all that some carriers or intermediaries offer, while others may publish more complete manuals.
  • Coding for ASC: Ambulatory surgery centre coding is a distinct field of expertise. Although Medicare requires ASCs to send their bills to professional fee (Part B) payers using the facility fee (Part A) claim form, the service is provided in a facility. For ASC Billing and Coding Services, a separate set of rules and bundling edits must be used.
  • Approved Surgical Procedures: You cannot perform any procedures for Medicare patients in the ASC setting. Medicare maintains a list of “authorized” operations for the ASC Billing and Coding Services that CMS has found to not pose a severe risk to patient safety and are not anticipated to necessitate an overnight stay after the surgical procedure.
  • Device Intensive Procedures: For device-intensive operations, a customized payment approach is employed (i.e., procedures explicitly done to insert a device, such as a pacemaker). The ASC will not submit a separate line item for the device but will still be compensated. Instead, the ASC Billing and Coding Services would offer a single line item and include the device’s cost in the process code.
  • Modifiers in the ASC: While some of the modifiers employed in the ASC are common among physicians, others are specific to the ASC facility. ASC Billing and Coding Services have their modifiers for a procedure that has been discontinued. 73 Modifier When prepping for surgery has started, but anaesthetic has not yet been provided, the discontinued outpatient hospital/ambulatory surgery centre (ASC) technique is employed.

ASC Coding Process

ASCs use a combination of physician and hospital billing. While physicians and ASCs use CPT® and HCPCS Level II codes to bill most of their services, some payers let an ASC bill ICD-9-CM procedure codes (like a hospital). Even some payers base implant reimbursement on the classification of revenue codes.

It’s crucial to file claims using the correct format. Medicare uses the CMS-1500 claim form and pays for ASC Billing and Coding Services under Part B. The CMS-1500 form is accepted by some third-party carriers, whereas the UB04 is permitted by others.

Tips and challenges in ASC Billing and Coding Services

Regarding enhancing revenue performance, there are several challenges that ASC Billing and Coding Services continue to face. Let’s go through some of them –

  • Cancellations: Cancellations have been one of the leading causes of concern. Patients are frequently discouraged from rescheduling elective operations because of the high costs. Since you couldn’t fill the available OR with another surgery, same-day cancellations of the scheduled surgeries might frequently have a negative financial impact. However, this does not eliminate your practice’s labour and overhead costs.

ASCs must identify the causes of cancellations and take the required steps to address the issue. Cancellations can frequently be reduced with constant monitoring of the patient’s health and open communication with the patient.

  • Surprise Billing: Even after paying all copays and deductibles, patients frequently receive additional bills from out-of-network physicians. Surprise billing is a prevalent issue nationwide, and many states have laws to address it. ASC Billing and Coding Services must be mindful of these laws as well, or else they run the risk of losing patients. The following actions can be taken to safeguard your patients from surprise billing:
  • Verify the in-network status of the lab personnel, pathologists, and anesthesiologists.
  • Make sure to inform the patients if these specialists are not included in the network. The patients must be notified that this will increase their bills.
  • Managing the Payer Contracts: ASCs frequently experience difficulties handling payer contracts, which keep changing. Payers have their own set of guidelines and requirements regarding care plans, local coverage determinations, bundled payments, and preventive care. Managing such payers includes the following advice:
  • Think about merging the primary and secondary complimentary payer arrangements with the direct commercial payer relationships.
  • You can get around closed networks by telling the payers that a surgical centre is part of their network. Highlight the specific services you provide, as well as the geographic and therapeutic advantages.
  • Pay close attention to the contract’s language.
  • Keeping Track of Coding Changes: Continually monitor ICD-10 and CPT code changes. ASCs are required to be informed of and execute yearly upgrades and modifications. Every October, ICD-10 codes are typically revised. These new codes must be incorporated into ASCs’ software updates. Having a partnership with a knowledgeable ASC Billing and Coding Services might relieve some of your pressure. The medical coding businesses ensure that claims are submitted without error and provide the best reimbursements.

Advantages of Outsourcing ASC Billing and Coding Services

Your Ambulatory Surgical Center (ASC) success depends not just on patient happiness but also on a dependable and accurate medical billing procedure. When your ASC loses money because of poor revenue cycle management, your facility is unnecessarily at risk of losing more money than it earns, resulting in incredibly stressful circumstances.

Medical billing problems are one of the many issues that beset a private Ambulatory Surgery Center. Medical codes are constantly and abruptly changing. Regulatory updates can alter how you manage your ASC billing process because they happen frequently. It costs money to fall behind on these adjustments.

According to a Black Book survey, approximately 80% of hospital directors are contemplating outsourcing their revenue cycle management services. Some ASCs may continue to handle financial services in-house, but there are various benefits to outsourcing your ASC billing and coding systems.

  • Billing businesses are skilled at dealing with payers, and any faults can be efficiently handled with rigorous follow-up.
  • Overhead costs of recruiting a billing team and dealing with the accompanying staff difficulties may drain the practice’s time and money. In this situation, outsourcing can help reduce the costs of hiring your team.
  • When you outsource, someone is constantly working on the claim. Small internal teams may make mistakes when a member is absent and needs to be covered by another.
  • The ASC medical billing team stays up to date with any changes to the law. The coding team at the ASC can be small and unable to keep up with the evolving legal requirements continuously. On the other hand, a medical billing company has professionals who stay current and make fewer mistakes.
  • Outsourcing seems wise with the impending ICD-10 because it will save you money on staff training and system upgrades. The personnel at billing businesses are prepared to implement the new coding system and ensure that there are few billing problems, as well as a denial management strategy to deal with denials.

Billing and coding for ambulatory surgical centers require much medical work for complex procedures, so outsourcing these services could increase their benefits and lower costs.

How would Plutus Health ASC Billing services help?

Plutus Health provides comprehensive transparency, control, and actionable information into the ASC revenue cycle, as well as recommendations and tested strategies. These services will increase the ASC’s productivity, financial success, and physician reimbursements. Contact us to learn more about the medical billing and coding services offered by Ambulatory Surgical Center (ASC).

Author Bio:

Brian Adams holds a Ph.D. in Medical Sciences. As a medical writer, he has been writing for ASC Billing and Coding Services and giving suggestions to pharmaceuticals, healthcare agencies, hospitals, health tech firms, and healthcare communication agencies. He brings seven years of exposure.

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