Becker's ASC Review

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: 1. Rely on Medical Records: Avoid coding based solely on charge sheets or superbills; use medical record documentation to substantiate your coding decisions. 2. Daily Code Matching: Establish a daily spreadsheet to match ASC codes with the surgeon's codes on the front- end. 3. Code Discrepancy Discussions: Review coding on all claims and engage in discussions to resolve code discrepancies before submitting claims. 4. Avoid Arbitrary Code Changes: Refrain from making arbitrary code changes to align codes artificially as this could lead to compliance concerns. 5. 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. n Meet Elaine Dunn, 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.

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