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CODING
&
BILLING
4 top reasons ASC claims are
denied + the code that makes up
7% of denials
By Angie Stewart
W
hen evaluating claim denials, ASCs should focus on payers and their individu-
ally negotiated contracts, according to Will Israel, vice president of enterprise
analytics solutions for e SSI Group, a revenue cycle management service
provider.
Mr. Israel told Becker's ASC Review what centers should know about avoiding and resolv-
ing denials.
Note: Responses have been lightly edited for style and clarity.
Question: What are the top reasons ASC claims are denied? Are there
certain codes or procedures that commonly result in denials?
Will Israel: e top four reasons claims are denied in ASCs, by category, generally are:
1. Non-covered charges (Adjustment reason code 96)
2. Duplicate claim/payment (Adjustment reason code 18)
3. Medical necessity (Adjustment reason code 50)
4. Timely filing (Adjustment reason code 29)
at covers that vast majority of denials in ASCs. Certain codes and procedures can cer-
tainly potentially result in denials, but payers are more important, generally, than codes
and procedures.
Q: What steps can ASCs take to ensure their claims aren't denied?
WI: One important step is to have better process design on getting claims out, particu-
larly around claims scrubbing and ensuring that best practice edits are in place to prevent
those denials. Additionally, doing better eligibility checks for plan benefits upfront can
be particularly useful. In a recent analysis, almost 7 percent of all denials had remark
code N130, which is: "Consult plan benefit documents/guidelines for information about
restrictions for this service."
Q: Which coding/reimbursement changes made in the past year are most
important for ASCs to know about?
WI: Coding and reimbursement changes that ASCs need to pay the most attention to are
the ones that apply specifically to each of them individually. at may sound like a cir-
cular answer to the question, but it is not. e individually negotiated contracts are what
actually cause the coding and reimbursement changes, so understanding what, exactly, is
in each of their respective contracts will likely have the greatest impact on understanding
where and what those changes might be.
Q: What step in the revenue cycle do ASCs struggle with the most?
WI: Follow-up seems to be a key area that ASCs have trouble running down. e number
of hats personnel wear in the ASC space means that denial follow up isn't usually top of
mind. Review denials and dollars to try and evaluate whether or not actually bringing in
someone with this specialty is worth considering.
Q: What is your No. 1 piece of advice for ASCs trying to maximize their
payments?
WI: It's two-fold: one, make sure the claims going out the door are clean, and two, follow
up on the denials that are actually worth following up on. Preventing easy mistakes (e.g.
missing information) on the claims going out means they don't have to be worked on the
back end, and those accounts that really need additional looks can be focused on. n
The top 5 procedures
performed at ASCs
By Rachel Popa
D
efinitive Healthcare's database
tracks the top procedures per-
formed at ASCs.
Below are the top five:
1. Cataract surgery with insertion of in-
traocular lens - 1,228,147 procedures
2. Moderate sedation by diagnosing
physician - 761,379
3. Moderate sedation by physician per-
forming endoscopic service - 779,231
4. Esophagogastroduodenoscopy with
biopsy - 541,997
5. Colonoscopy with lesion removal -
378,081 n
5 states with the
highest medical
malpractice payouts
By Angie Stewart
M
edical malpractice payouts in
the U.S. amounted to $4.03
billion in 2018, according to
LeverageRx's 2019 Medical Malprac-
tice Payout Report.
LeverageRx, a lending and insurance
broker for healthcare professionals,
compiled the report with information
from HHS, as well as the National Prac-
titioner Data Bank, Health Resources
and Services Administration, Bureau
of Health Workforce and Division of
Practitioner Data Bank.
Five states with the highest medical
malpractice payout amounts in 2018:
1. New York: $685.3 million
2. Pennsylvania: $369 million
3. Florida: $346.9 million
4. California: $269.2 million
5. New Jersey: $226.7 million n
