Becker's ASC Review

Coding & Billing 36 center market. But ASCs and hospitals are very different in a variety of ways. In this first of a two-part series, ASC leaders will learn about these critical differences, specifically with regards to how ASC and hospital coding and billing differ — and why it's important to the ongoing success of a facility to keep these func- tions separate from the hospital once a JV deal is complete. Coding Hospital coding typically resembles a laundry list, with every pill, bandage and stitch spelled out related to a patient encounter. ASC coding is typically procedure-based, with a list of approved procedures that can be performed in that setting. ASCs use both CMS 1500 forms and UB forms. ASCs also utilize CPT codes, revenue codes and HCPCS codes. Medicare, and a few of the large commercial carriers, utilize NCCI edits and many com- mercial carriers use other edit systems. ere is no standardization of edit systems, which makes ASC coding very complex. Reimbursement ere are two primary differences between hos- pital and ASC reimbursements. e first differ- ence is the rate. ASCs are reimbursed at roughly 60 percent of the rate of hospitals for a similar procedure, which was a primary motivating fac- tor for hospitals in acquiring off-campus ASCs. e second major difference is the reimburse- ment methodology. Procedures performed at hospitals and ASCs are classified under different coding groups. ASCs utilize complex arrangements of "groupers" and percent billed, while hospitals employ a combination of per diem, case rates, revenue codes, as well as some CPT codes — more traditional, straight- forward billing and coding techniques. Unlike hospitals, scant data exists for procedures performed in ASCs, creating difficulties when claims are underpaid. Managed care contracting e Affordable Care Act gave rise to a dramatic expansion of network agreements between providers and payers that create pa- tient volume for hospitals and health systems and stabilize costs for insurance companies. Managed care contracts are negotiated directly with ASCs, a process that requires knowledge of and experience with the ASC revenue cycle, as well as considerable research to ensure procedures are reimbursed at the correct rates; if not, facilities may wind up accepting cases that have no chance of turning a profit. Poorly negotiated managed care contracts for hospitals and ASCs are frequently the source of financially underperforming facilities. Understanding how the contract applies to the entire revenue cycle, and experience negotiat- ing with commercial payers, helps prevent a significant loss of revenue. While ASCs use a complex combination of CPT codes and "percent billed" arrangements, hospital outpa- tient departments frequently use ambulatory payment categories to receive reimbursements from managed care contracts. Staffing specialization Revenue cycle management has become increasingly complex for hospitals, physicians and surgery centers alike. RCM specialization is the key to achieving success for increasingly diversified hospitals and health systems, and few if any providers today are staffed to handle all of the unique billing and coding require- ments associated with their growing rosters of facilities and practices. Outside ASC RCM specialists possess these best practices and key performance indicators, which enable new ASC owners to assess and improve financial performance. is spe- cialization also extends to implementing the best technology for each step of the revenue cycle, as well as business office processes and functions. Taken together, a trusted ASC RCM advisor provides ASC owners with the best opportunity to improve compliance, maximize reimbursement, and create happy patients and physicians. n October 27-29, 2016 l Swissotel, Chicago Register at www.beckersasc.com or email registration@beckerhealthcare.com BECKER'S 23 RD ANNUAL MEETING The Business and Operations of ASCs

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