ASC Billing Guidelines

Ambulatory surgical centers, or ASCs, face billing challenges that are even more intimidating than the normal healthcare provider. The billing rules for these entities include some that are designed for doctors and individual healthcare professionals, and some that are designed for hospitals and clinics. The combination increases the complexities of compliance. However, it also produce numerous opportunities for healthcare providers to streamline their billing procedures and make their business more efficient.

The healthcare billing professionals at Fortis Medical Billing have the experience necessary to comply with the numerous requirements that ASCs face, and to ensure that your healthcare company is not leaving any money on the table with outdated or inefficient billing procedures.

ASC Billing Regulations and Guidelines are Constantly Changing

One of the most important things to know about billing guidelines for ASCs is that they are always changing and updating.

The Centers for Medicare & Medicaid Services, or CMS, updates the surgical and ancillary procedures that are covered by these government healthcare programs and provided by ASCs every quarter. This includes payment rates for the procedures, as well as wage rates, including regional variations. Those updates are all posted on the CMS website.

Staying up to date on all of these changes is critical. Following rules that have since been replaced is still a failure to comply with ASC billing requirements and can lead to significant problems.

Not All Procedures Can Be Billed By ASCs

The definition of an ASC is a healthcare provider of outpatient surgical services. To ensure that this is followed, CMS does not approve of procedures that:

• Can be life-threatening
• Are urgently needed
• Are elective
• Cannot be performed safely in an office setting
• Could lead to major blood loss
• Involve a long surgical intrusion

CMS provides a long list of surgical procedures that are not approved. These procedures are not approved because they pose a risk to patient safety or because they have more than a minimal risk of leading to an overnight stay in the hospital – something that runs directly counter to the definition of an ASC. However, this list of non-approved procedures updates constantly, based on the perceived risks of the procedure and medical advancements. ASCs are expected to stay abreast of these developments or face penalties of noncompliance.

All Codes Must Match Services Actually Provided

One of the most important things about all medical billing is that the billing codes must match the healthcare services that were actually provided. This is the case for ASCs, as well. While ASCs tend to provide surgical procedures that are less complex or invasive than those that are done on an inpatient basis by hospitals, the lack of formality surrounding the procedure can actually lead to noncompliance if you are not careful.

Surgical procedures can evolve once they have begun. Surgeons can find that the problem is better or worse than it was originally anticipated and change the scope of the procedure accordingly.

This can lead to a discrepancy in the final services provided and the ones that had been scheduled. Billing the insurer for the scheduled procedure, therefore, runs the risk of over- or under-billing, exposing the ASC to liability and increased scrutiny, on the one hand, or a reduction in revenue, on the other.

All medical bills submitted should use codes that reflect the final provision of healthcare services. This means waiting for the procedure to be completed before drafting or submitting the bill, and closely scrutinizing the final surgical report to see if there are any discrepancies with the intended procedure.

ASCs Use Both Professional and Facility Codes

ASCs are seen as a hybrid between healthcare facilities, like hospitals and clinics, and individual healthcare providers, like doctors.

Unfortunately, this conception of ASCs as straddling the line between the two also applies to how ASCs bill Medicare.

Medicare requires ASCs to send bills to professional fee payers, or Part B payers. However, ASCs still have to use the facility fee claim form generally reserved for Part A. Medicare requires all of this to be filed electronically on the CMS-1500 Form. Some other insurance carriers, though, let ASCs submit bills using the ICD-10 procedure codes, much like a hospital. These are often filed using a UB92 Form.

Worse, the services that can be bundled together is different for ASCs than it is for healthcare individuals or facilities. Following the rules that apply to individuals, like a doctor or a surgeon, or the rules that apply to hospitals or clinics can amount to noncompliance if you do not recognize the exceptions to both sets of rules that ASCs have to follow. On the other hand, you may be bundling services and supplies that can be billed separately, and at a higher rate.

Whether services or items get bundled or not is even more complicated when the procedure involves an implant or surgical device, like a pacemaker. In many cases like these, the billing code for the implanting procedure includes the payment for the device being implanted. This makes ASC billing different than medical billing in other situations. It also exposes the ASC to serious risks if the regulations are not followed: If you bill for the implanting procedure on one line and then for the device on another line, you will have overbilled the payer and can face disgorgement as well as audits, penalties, and additional scrutiny.

Frequently Asked Questions About ASC Billing

What is an ASC?

An ASC is an ambulatory surgical center. According to section 10.1 of the Medicare Carriers Manual, an ASC exclusively provides outpatient surgical services. ASCs can be either independent or operated by a hospital. Those that are operated by a hospital can choose to be considered as an ASC by Medicare or as a provider-based department of the hospital. Regardless, all ASCs have to enter a written agreement with the Centers for Medicare & Medicaid Services (CMS) to bill government programs like Medicare.

However, this definition is feeling the effects of changes to the healthcare system as providers move away from inpatient care. Lots of surgical procedures that used to require short hospital stays are now being performed at a healthcare facility, only for the patient to be transferred back home to recuperate. Rather than being on premises for monitoring, patients stay at home to recover and notify doctors about their condition.

As a result, some healthcare providers may find themselves falling into the definition of an ASC without changing their practices or even being aware of their legal evolution.

What are the Penalties of Noncompliance?

Not complying with ASC billing guidelines can lead to either billing too much or billing too little for medical care.

If you send a bill for too little to the patient’s insurer, you will not recover the revenue that you deserve. You are essentially leaving money on the table – money that you already earned by providing healthcare services.

But billing too much is far more problematic. Even if the overbilling was accidental or the result of a coding error, your company will still be on the hook for reimbursing all of the overcharge, as well as potentially paying civil fines and penalties. Additionally, subsequent bills can face closer scrutiny, which can reveal other discrepancies, which can compound the problem. If things get out of hand, you may find your company losing its contract with the insurer or getting excluded from Medicare.

Why Should I Outsource My Needs to Fortis Medical Billing?

Because Fortis Medical Billing has a staff that is comprised of experienced medical billers and coders, as well as healthcare fraud investigators who know how to audit your billing procedures and uncover problems. This ensures that your company stays compliant without losing money by leaving it uncollected in an invoice that asked for too little. We have a 99 percent client retention rate, and every single one of our clients reported an improvement in their billing process. They have also all benefited from the fact that they no longer had to worry about their billing procedure – a peace of mind that lets them focus on providing the top-notch healthcare that is their true professional calling.

Outsource Your ASC Billing to the Professionals at Fortis Medical Billing

Medical billing is widely regarded as the most onerous aspect of running a healthcare service company. The trials and tribulations of billing get even worse when your company is an ASC. Understanding the billing guidelines for ASCs is a gargantuan task. Staying on top of them as they evolve and change is even more challenging. Failing in any respect can leave thousands of dollars on the table in uncollected revenue or can expose your company to substantial legal liability, increased scrutiny, program exclusion, and auditing.

The medical billing professionals at Fortis Medical Billing can help. Our staff consists of experienced medical billers, including those who have handled ASCs, before, as well as former healthcare billing investigators for the Federal Bureau of Investigation (FBI) and the Office of Inspector General (OIG). We know how to correctly bill healthcare insurers and government healthcare programs.

Contact us online or call us at (866) 808-4160 to handle your medical billing needs for you.