Ambulatory Surgical Billing: Guidelines, Rules, and Requirements

Navigating the rules and requirements of ASC billing is complex, but surgery centers can implement strategic solutions to enhance their revenue cycle compliance and performance. 

It's a fact: Ambulatory surgery center (ASC) billing is difficult. Navigating the always-evolving regulatory environment can be tedious. Payer complexities and complicated coding rules and requirements can compound the challenge of keeping up with compliance and getting paid what you deserve. However, there are ways to overcome these obstacles. 

This article on ambulatory surgical billing sheds light on the role of billing compliance and how ASCs can better ensure revenue cycle compliance. It also provides some ASC billing guidelines to help you meet requirements. 

The Importance of ASC Revenue Cycle Compliance 

Billing compliance is a critical area of focus for ASCs. An ASC revenue cycle workflow with strict documentation rules, guidelines, and procedures can help reduce risks and ensure timely, accurate payments. 

Failure for ASCs to comply with billing regulations can result in civil and even criminal penalties. For example, violating the No Surprises Act, which establishes rules and requirements to protect patients from “surprise” or unfair medical billing, may result in civil monetary penalties of up to $10,000, according to the American Medical Association (AMA). 

Medical coding mistakes due to lack of adherence with Medicare National Correct Coding Initiative (NCCI) Edits, which help ensure correct payments and protect against inappropriate, fraudulent, or abusive medical billing practices, can result in similarly steep fines or even exclusion from Medicare programs. 

HIPAA violations, such as improper disclosures of protected health information (PHI) or improper disposal of PHI, can incur civil penalties ranging from $100 to $50,000 per violation and criminal penalties ranging from one year to 10 years of imprisonment, according to the AMA. 

Penalties aren’t the only concern for surgery centers. Inefficient, disorganized, and improper documentation can lead to audits, delayed payments, denied claims, takebacks, and other negative consequences.  

However, when ambulatory surgical billing compliance is prioritized, streamlined, and strengthened, it can transform revenue cycle management into a well-oiled machine that ensures everyone involved, from patients to staff to payers, is satisfied with the billing experience. 

Primary Challenges of Ambulatory Surgical Billing Compliance 

To improve ASC revenue cycle compliance, it’s important to first understand the billing challenges facing ASCs. These include the following: 

• Coding difficulties. Medical coding rules can vary by payer. Common mix-ups, like unbundling codes (using multiple codes for individual parts of a procedure when a single code is available to capture all parts), wrong modifier usage, and upcoding (inaccurately reporting the level of a service, such as reporting a higher-level service than the patient’s condition reflects) can result in denials and penalties. 

• Evolving legal requirements. The regulatory landscape is constantly changing, and new coding and/or billing rules and requirements are being introduced regularly, which may impact ASCs. Staying abreast of these changes and when they go into effect at both the federal and state levels can be challenging to navigate and may require complex process adjustments to ensure compliance. 

• Payer complexities and denials. Payer policies tend to vary, and something that doesn’t trigger a denial from one payer may trigger a denial from another. Common denial triggers include the coding examples noted earlier as well as lack of specificity, incorrect patient identifier information, timely filing, and bundling or duplicating services. 

• Patient-facing problems. During registration, patients must provide specific documentation, such as financial consent, advance beneficiary notice, notice of privacy practices in compliance with HIPAA, and more. Missing information can delay collection or cause confusion and even pushback from patients.  

• Internal challenges. Ensuring in-house ambulatory surgical billing compliance requires employing staff with the knowledge and expertise to complete all steps of the revenue cycle management process. However, internal challenges, like staff shortages, turnover, and burnout, can make it difficult to find and retain the right staff to ensure ongoing compliance. 

• ASC revenue cycle inefficiency. Many ambulatory surgery centers may have revenue cycle solutions in place but may not realize better, more efficient solutions exist today. Relying on paper or legacy technology systems can bog down the entire ASC revenue cycle process. While embracing change and moving away from a system that works may be difficult, new systems can introduce agility and keep pace with the modern compliance landscape. 

• Poor return on investment. Tightening reimbursement, combined with rising costs, can make it difficult to achieve or grow case profitability. An ASC revenue cycle plagued by inefficient processes that stall workflows and lead to compliance issues make it difficult to collect proper payment promptly, especially when services are not coded and billed accurately and correctly. Getting the best return on investment relies on streamlining every aspect of ambulatory surgical billing. 

Understanding these pain points will enable you to devise a strategy to address them.

ASC Billing Guidelines to Help Stay on Top of Requirements 

To better ensure ambulatory surgical billing compliance, start by following some basic ASC billing guidelines and best practices. 

For example, it’s critical to determine who at or outside your ASC is responsible for compliance and what aspects of compliance are included in their job responsibilities. Those with in-house coding and billing must define these team members' role in compliance, develop internal processes, and deliver training to these staff members on rules and requirements. This will help ensure compliance throughout the ASC revenue cycle. 

Identifying all the rules related to your ASC's revenue cycle is also important. This includes understanding government regulations, commercial payer guidelines and expectations, and coding rules. Staff must be trained on these standards, and time should be set aside to review best practices and compliance processes on a regular basis. 

Compliance requirements are ever-changing, so one or more individuals within your surgery center must be responsible for staying current with these changes. For example, the Centers for Medicare & Medicaid Services (CMS) publishes regular updates on areas including payment rates, device and other types of codes, and covered procedures. Monitoring relevant websites, publications, and news announcements can help your ASC stay current with evolving rules. 

Detailed documentation is also necessary. Set up processes to capture relevant patient information, procedure details, and anything else that will be needed to comply with coding, billing, and collections rules. Review these documentation requirements and workflow processes regularly to ensure that staff knows what they need to collect and document, that coders and billers have everything they require to submit clean claims, and that all changes which occur — whether related to payer guidelines, federal guidelines, codes, or procedures and specialties — are updated and captured accurately. 

Finally, recognize that remaining compliant can be an arduous task. Consistently getting it right takes time, practice, effort, and routine reviews. This being the case, foster a no-blame culture. If someone on your staff sees or does something wrong, don’t necessarily punish the offending individual. Instead, see if you can fix the error and train staff to ensure the mistake is not repeated. Staff members are already under pressure to remember complex guidelines while managing their regular responsibilities, so encouraging them with positive reinforcement will help them embrace accountability and course-correct without fear of retribution. 

How to Improve ASC Revenue Cycle Compliance 

Keeping current with requirements is only half the battle. Here are some strategies for maintaining and improving ambulatory surgical billing compliance. 

• Collaborate with and challenge staff. As mentioned, establishing a no-blame culture can help create a more collaborative atmosphere around compliance. In addition to training and educating staff, ask them for recommendations for improvement that can ease the burden of achieving compliance. Also, challenge staff to improve by implementing new goals and rewarding success. 

• Outsource revenue cycle management. Think about what makes the most financial and operational sense for your ASC. Handling billing in-house is always an option, but allocating resources appropriately may be difficult, and finding staff with the expertise and experience needed to support your ASC's surgeons, specialties, and procedures — all of which are likely to change over time — may be difficult. Outsourcing may be the better choice for improving performance. Third-party revenue cycle services can handle all responsibilities for your ASC, or you can outsource specific portions of revenue cycle management, such as coding. 

• Leverage monitoring and auditing tools. Ongoing compliance monitoring is key to ensuring accurate performance and identifying revenue cycle gaps leading to billing and collections problems. Conducting both internal and external audits is also essential to improve coding and billing accuracy and performance. Monitoring and auditing tools can deliver actionable insights that help flag and detect issues, discover root causes of problems, measure staff performance, and identify areas of opportunities to enhance compliance. 

• Invest in modern solutions. The right ASC software can simplify billing and revenue cycle management, including everything from streamlining registration and capturing patient information to analyzing billing performance and beyond. Legacy technology, piecemeal solutions, and paper-based processes can slow operations and introduce easily avoidable issues. A modern solution can deliver a great user experience and optimize revenue cycle compliance at the same time. Thoroughly consider which solution will best serve your ASC’s short- and long-term needs. 

Enhancing Your ASC Revenue Cycle Performance 

While ambulatory surgical billing can be complex and complicated, modern revenue cycle services and software solutions can ease the burden. Optimizing your ASC revenue cycle processes can help keep the money flowing into your center, simplify compliance, and empower your team to focus on what they do best: provide safe and effective outpatient surgical care. 

Looking to learn more about ASC revenue cycle management? Download this detailed guide written for surgery centers.