Becker's ASC Review

How ASCs Prevent CPT Mismatches with Health System Partners By Elaine Dunn, chief administrative officer and Bill Slife, chief operating officer, nimble A s 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: 1. Code Alteration: Your ASC's procedure codes may be altered to align with professional charges, potentially leading to down-coding and reduced revenue. 2. 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.

• Cover