The following is a guest article by Isaac Smith, Billing, Coding, and Reimbursement Specialist at Medcare MSO
ASCs are types of medical facilities that are subject to stringent regulations. Each ASC is responsible for ensuring that they are in compliance with the numerous statutes and regulations that are in place at both the state and federal levels. These laws regulate everything pertaining to ASCs, from their day-to-day operations to the manner in which they are compensated.
ASCs must stay current on healthcare regulations that affect billing. New CMS and AMA guidelines, coding changes, and reimbursement methods have been implemented. To avoid penalties, maximize revenue, and accurately document claims, ASCs must understand these changes.
Understanding ASCs Regulatory Changes and Their Billing Practices
Outpatient surgery centers (ASCs) perform many surgical procedures outside of hospitals. Outpatient surgeries at these facilities are convenient, affordable, and specialized. However, ASC billing practices must be followed to ensure proper reimbursement and regulatory compliance.
Medicare Certification
ASCs must sign a contract with Medicare and meet its Conditions for Coverage (CFC) to be paid. ASCs must also meet Medicare’s Conditions for Coverage. From building layout to medical staff qualifications, these ASC regulations cover it all.
CMS publishes a State Operations Manual with interpretive guidelines for surveyors. Appendix L: ASC Interpretive Guidelines provides ASC-specific guidance. This document clarifies the Conditions for Coverage and advises ASCs on compliance.
Two other appendices apply to ASCs. Appendix I, Survey Procedures and Interpretive Guidelines for Life Safety Code Surveys, as well as Appendix Q, Guidelines for Determining Immediate Jeopardy, must be followed by all ASCs.
Medicare Payment Resources
CMS implemented an Ambulatory Payment Classification-based payment methodology in 2008. Visit the Medicare payment resources page on the ASCA website to learn about the changes that CMS has made to the payment system and ensure that your ASC is paid appropriately. The ASCA Medicare Rate Calculator displays national and local payment rates, as well as a chart comparing the rates charged by ASCs and HOPDs for the same surgical procedures, and additional information.
Medicare Quality Reporting
CMS mandates ASC quality data reporting. Future Medicare reimbursement will be denied to ASCs that fail to report. Quality reporting provides ASCA members with current requirements and resources to comply.
Emergency Preparedness
ASCs must have a CMS-approved emergency plan. As of November 15, 2017, ASCs are being surveyed on the new requirements of a September 2016 final rule. ASCs are required to evaluate risk, develop policies, procedures, and a communication plan, as well as train and test their final plan. Refer to the Interpretive Guidelines in Appendix Z of the State Operations Manual and this website for additional information. ASCA members can view an ASC-specific surveyor tag tool.
Other Federal Regulation Information
Affordable Care Act, Section 1557 Resources
The Federal Regulations section of ASCA’s website provides a starting point for understanding federal rules affecting ASCs, but it is not a substitute for a legal opinion from qualified counsel in this specialized area of law.
Compliance is the foundation of ethical and responsible ASC billing. For patient safety, fair reimbursement, and healthcare system integrity, regulatory bodies set compliance requirements. HIPAA, CMS, and state agencies regulate ASCs. ASC billing requirements include coding, documentation, privacy, and security.
Compliance Requirements for ASC Billing
ASCs should prioritize billing practices for compliance. This includes accurate and specific coding to reflect procedure complexity, detailed documentation to support medical necessity, billing and coding guidelines, and proper claims submission. These areas help ASCs reduce compliance risks and improve revenue cycle management.
Compliance Requirements for ASC Billing
ASCs can face serious penalties for not complying with regulatory changes. Updates and proper billing practices are crucial after recent enforcement actions and penalties. Audits, fines, repayment demands, and government program suspensions are enforcement actions. These consequences hurt ASCs financially and reputationally.
ASC billing compliance has many benefits. It promotes accurate reimbursement, reduces legal risks, improves patient safety, and builds trustworthiness and professionalism. Non-compliance risks ASCs’ financial and legal risks, patient trust, and long-term sustainability. Compliance protects ASCs and strengthens the healthcare system.
Maintaining ASC Compliance
Who performs these checks and tasks in your ambulatory surgery center? Besides the administrator! One person cannot handle this. Expecting one person to do everything increases the likelihood that nothing will get done and will cause problems when that person is unavailable (e.g., sick, vacation, leaving the position). To cover absences, other managers, leads, and staff should perform each check and task. Vendors will do some work. This starting task template spreadsheet can help you organize your checklist.
Overwhelming tasks and checks. Delegate, but monitor. Create tools to simplify and stay on track. If you fall behind even slightly, catch up quickly and figure out why and how to avoid falling behind again. Expect the unexpected, such as a leader’s absence or a natural or manmade disaster. Most importantly, treat your staff well. They’ll help your ASC comply year-round.
CPT and ICD Codes In Ambulatory Surgery Centers
ASCs use CPT and ICD-10-CM for diagnosis, procedures, drugs, and devices. ASCs must implement the latest ICD-11 diagnosis updates when they take effect. ASC Medicare billing does not require C-Codes like outpatient billing. Medicare reimburses drugs and devices differently.
ASCs billing Medicare should not use HCPCS II devices and drug codes. Use separate lines to report and bill each device or drug. Practolytics helps ASCs set up the right practices for documentation, coding, and billing. Coding and capturing all patient services can be overwhelming.
Regulatory Changes & Compliance: How Outsource ASC Billing Services Provider Can Help?
In the constantly evolving landscape of healthcare billing, ASCs (Ambulatory Surgery Centers) face the challenge of staying updated with the current regulatory changes and compliance requirements in their billing practices. To navigate these complexities successfully, ASCs can rely on the expertise and support of ASC billing services provider. Let’s explore the current regulatory landscape and how ASC billing services providers can assist ASCs in meeting their compliance needs.
Expert Knowledge of Regulatory Changes
ASC billing services providers understand current regulatory changes affecting ASC billing practices. They follow Medicare reimbursement policies, coding and documentation guidelines, HIPAA compliance, fraud, and abuse prevention, prior authorization, and state-specific regulations. ASCs can reduce errors and non-compliance by partnering with such providers.
Implementation of Best Practices
ASC billing services providers have extensive experience implementing billing best practices. They can help ASCs implement regulatory-compliant workflows, coding, and documentation. This improves ASC billing accuracy, efficiency, and compliance.
Dedicated Compliance Teams
ASC billing services providers often have dedicated compliance teams that monitor and address regulatory changes. These teams actively track updates and keep ASCs informed of compliance requirements. ASCs can benefit from dedicated resources and proactive compliance management by partnering with such providers.
Advanced Technology and Systems
ASC billing services providers use advanced technology and billing systems to streamline operations and improve compliance. They use robust billing software with regulatory guidelines, automated coding checks, and auditing functions. These technologies help ASCs bill accurately, reduce errors, and comply with regulations.
Ongoing Training and Education
ASC billing services providers educate ASC staff about regulatory changes and compliance. They hold regular sessions to update ASCs and their staff on coding, documentation, and industry best practices. ASC billing teams are informed and compliant.
About Isaac Smith
Isaac is a highly accomplished healthcare professional with over 13 years of experience in healthcare administration, medical billing and coding, and compliance. He holds several AAPC specialty certifications and has a bachelor’s degree in Health Administration. He worked previously at a large multi-physician family care and occupational health practice with two locations in northwestern PA and now works for Medcare MSO in the ICD-10 Editorial department to write articles about medical billing services. He enjoys sharing his knowledge and experience as a certified PMCC instructor. He has authored many articles for healthcare publications and has been a featured speaker at workshops and coding conferences across the country.
About Anna Twomey