Maximizing Reimbursement: Navigating Insurance Billing For Surgery At Ascs

Billing insurance for surgery at an ASC (Ambulatory Surgical Center) involves a few key steps and considerations. Firstly, it's important to understand the patient's insurance plan, which may include co-pays, deductibles, and co-insurance. The insurance company will be billed directly for services provided by the ASC, including physician fees, assistant surgeon fees, anesthesia fees, and lab fees. CPT (Current Procedural Terminology) codes are used to accurately document and bill for procedures, ensuring proper reimbursement and compliance with regulations. Medicare has specific guidelines and requirements for ASC billing, including approved procedures that do not pose significant safety risks and do not require an overnight stay. It's crucial to verify insurance coverage, understand the patient's financial responsibility, and provide accurate estimates to avoid surprises.

ASC billing uses CPT codes to document and bill for procedures

ASC (Ambulatory Surgical Center) billing and coding use CPT (Current Procedural Terminology) codes to accurately document and bill for procedures performed at the facility. CPT codes are standardised codes used to describe medical procedures and services. CPT codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care reviews.

CPT codes are assigned to each procedure or service performed in the ASC to help identify the services provided for billing purposes. The CPT codes ensure ASCs receive appropriate reimbursement for their services and help maintain compliance with regulations and guidelines set by insurance companies and government agencies.

CPT codes cover a wide range of procedures and services, including:

• Surgical procedures: excision of lesions or tumours, arthroscopy procedures, endoscopic procedures, and laparoscopic procedures.
• Diagnostic procedures: diagnostic endoscopies, diagnostic colonoscopies, diagnostic arthroscopies, and diagnostic laparoscopies.
• Anesthesia services: covering anesthesia provided during surgical procedures.
• Ancillary services: pathology and laboratory services, rehabilitation services, and other services.
• Supplies and materials: reporting supplies and materials used during procedures.

Modifiers can be used with CPT codes to provide additional information about the procedure or service rendered. For example, modifiers can indicate that a procedure was performed on multiple sites or under unusual circumstances. Accurate use of CPT codes and modifiers is essential for proper reimbursement and compliance with coding regulations.

CPT codes cover a range of surgical, diagnostic, and anesthesia services

Current Procedural Terminology (CPT) codes are used to accurately document and bill for procedures performed in Ambulatory Surgical Centers (ASCs). CPT codes cover a wide range of surgical, diagnostic, and anesthesia services, each helping to identify the services provided for billing purposes.

CPT codes for surgical procedures fall within the 10000 – 69999 range and include a variety of procedures performed in ASCs, such as excision of lesions or tumors, arthroscopy procedures, endoscopic procedures, and laparoscopic procedures.

Diagnostic procedures are coded within the 70000 – 79999 range and include diagnostic endoscopies, diagnostic colonoscopies, diagnostic arthroscopies, and diagnostic laparoscopies.

Anesthesia services are coded within the 00100 – 01999 range, covering services provided during surgical procedures in the ASC.

CPT codes also cover ancillary services (80000 – 89999 range), which include pathology and laboratory services, rehabilitation services, and supplies and materials (99000 – 99091 range) used during procedures.

Modifiers are additional codes that provide further context about a procedure or service. For example, Modifier 73 indicates that a procedure was discontinued before the administration of anesthesia, while Modifier 74 indicates that a procedure was terminated after anesthesia administration. Accurate use of CPT codes and modifiers ensures compliance with regulations and helps ASCs receive appropriate reimbursement for their services.

Insurance plans vary, so it's important to understand your plan

• Deductible: This is the amount you must pay out-of-pocket before your insurance company starts covering costs. For example, if your deductible is $1,000, you will have to pay the first $1,000 of covered medical expenses yourself.
• Copayment (Copay): This is a set fee you pay each time you receive a specific medical service, such as a doctor's visit. Copays are usually lower for family doctors than specialists.
• Coinsurance: This is the percentage of the cost you pay after meeting your deductible. For example, if your coinsurance is 20%, you pay $20 for a $100 service. Coinsurance may apply to both the physician's fees and the surgery center's fees.
• Premium: The amount you pay for your insurance plan, typically on a monthly basis.
• Network: The doctors, hospitals, and suppliers your insurer has contracted with to provide healthcare services. Using in-network providers is usually cheaper since they have negotiated lower rates with your insurer.

It's also important to understand the different types of health insurance plans available. Here are some common types:

• Health Maintenance Organization (HMO): With an HMO, you select a primary care physician (PCP) who coordinates your care and provides referrals to specialists within the HMO network. Out-of-network services are typically not covered.
• Exclusive Provider Organization (EPO): Similar to an HMO, but you don't need to appoint a PCP. You are bound to a network of physicians and specialists, and going outside the network results in higher out-of-pocket costs.
• Preferred Provider Organization (PPO): Similar to an EPO, but it covers out-of-network visits at a higher rate than in-network visits.
• Point of Service Plans (POS): You need to appoint a PCP, and you can only visit other physicians with a referral. Out-of-pocket expenses are usually higher, but you still receive some coverage for out-of-network physicians.

When choosing a health insurance plan, consider your individual or family needs. Think about how often you typically need medical care and whether you have any pre-existing conditions that require regular treatment. If you're generally healthy, a high-deductible plan with a low premium might be a good option. On the other hand, if you have a pre-existing condition that requires frequent treatment, you may want a low-deductible plan to save on out-of-pocket expenses.

ASC billing and coding differ from physician and facility billing

Another key difference is that ASC billing is not centred on a specific medical specialty, unlike physician billing, which requires adherence to specialised guidelines for reimbursement. Since ASCs cover various medical specialties, their coding system is more diverse. Additionally, ASCs can only provide services to patients with a diagnosis from a primary care physician and who require medically necessary procedures.

In terms of forms, ASCs typically use the CMS-1500 claim form, while physicians use the CMS-1500 form, and hospitals use the UB-04 form. It's important to use the proper form when submitting claims to ensure accurate reimbursement.

Regarding pricing, ASCs cannot base their prices on the allowable code from the Medicare Physician Fee Schedule (MPFS). They must include the cost of devices or procedures in the procedure code and submit it as one line item. This is a key distinction from physician and facility billing, where separate charges may apply.

Finally, ASC billing requires specialised coders and billers to maximise reimbursement and improve profits. The rules and guidelines for ASC billing are distinct from those for physicians and facilities, and incorrect modifiers or codes can result in significant financial losses.

ASCs must be certified and enter a written agreement with CMS

To be eligible for payment for its services, an Ambulatory Surgical Center (ASC) must be certified and enter into a written agreement with the Centers for Medicare & Medicaid Services (CMS).

An ASC is defined as an entity that operates exclusively to provide outpatient surgical services to patients. To be certified, an ASC must meet the requirements set by the CMS. This includes being a distinct entity that operates exclusively for the purpose of providing surgical services to patients who do not require hospitalization. The expected duration of services should not exceed 24 hours following admission, although rare exceptions may be made in cases of unanticipated medical circumstances.

The regulatory definition of an ASC prohibits the sharing of functions and operations with another entity, such as an adjacent physician's office, during concurrent or overlapping hours of operation. However, the CMS does allow two different Medicare-participating ASCs to use the same physical space as long as they are temporally separated, meaning they have entirely separate operations, records, etc. and do not operate at the same time.

ASCs are also not permitted to share space with a hospital or Critical Access Hospital outpatient surgery department, or with a Medicare-participating Independent Diagnostic Testing Facility (IDTF). However, certain radiology services that are reasonable, necessary, and integral to covered surgical procedures may be provided by an ASC without the need for separate Medicare participation as an IDTF.

To be certified, ASCs must also report quality of care data for standardized measures to avoid penalties. The full conditions for Medicare or Medicaid coverage can be found in 42 CFR Part 416 of the Social Security Act.

In addition to certification, ASCs must enter into a written agreement with the CMS. This agreement outlines the terms and conditions for payment for services provided by the ASC. The ASC must accept Medicare's payment as payment in full for services defined as ASC services. Physicians and anesthesiologists may bill separately for the professional component of the service.

Overall, the certification and written agreement with the CMS are crucial steps for an ASC to receive coverage and payment for its services.

Frequently asked questions