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Q&A with Jessica Nelson, Vice President of Revenue Cycle Services, and Brandy Hente​, Revenue Cycle Manager, for Surgical Information Systems

Jessica Nelson, Vice President of Revenue Cycle Services, and Brandy Hente​, Revenue Cycle Manager, for Surgical Information Systems (SIS), recently hosted a webinar on "ASC Coding Quirks: The Rules You Need to Know." During the program, they explored a range of coding topics, obstacles for accurate ASC coding, key rules for correct coding, and common coding errors. They also provided guidance for identifying and addressing coding errors and shared tips for maintaining high levels of coding accuracy.

The audience was engaged and asked great questions during the Q&A portion of the program. For those questions Nelson and Hente did not have time to answer, they provided responses in writing. Below are the highlights of those questions and responses, edited for readability. To view the on-demand webinar, visit the SIS Resource Library.

Q: Does an ASC have to wait for pathology results to bill a facility claim when biopsies are obtained or is it okay to bill based on indication for the procedure?

A: While having the pathology results would confirm the most accurate representation of the reason for the procedure being performed, it would be appropriate for the ASC to bill the facility claim without the pathology results only when the operative note contains a definitive preoperative diagnosis. The indication alone does not always confirm the medically necessary reason for the current procedure being performed as it may be noted from previously known pathology.

If the pathology results are expected within a few days, it may be reasonable to delay billing the facility claim until the results are available. This can help to avoid potential denials if the pathology results do not support the indication for the procedure.

If billing without the pathology results, you should be prepared from a documentation perspective to submit the results to the payer upon request.

Q: Do you have any suggestions for a good workflow for authorization management concerning physician offices? We are having trouble getting the offices to understand the authorizations that are required. We have provided educational documentation, but some of our offices are not responsive to it.

A: Educating your physician offices is the most important step you can take to improving the authorization process and management. It may even require ongoing education to keep everyone involved on the same page with any changes or challenges your ASC is experiencing.

One thing to consider as part of the education would be to include a dashboard consisting of data points related to authorizations. This can be presented to the physician offices weekly, bi-weekly, or monthly at minimum. Consider including an outcome-based result as the metric or indicator you want to improve (e.g., percentage of overall denials that equal to authorization missing or invalid) along with the target goal or benchmark you are trying to achieve.

Perhaps there are leading indicators that can be provided more frequently to bring awareness as to the specific reason for these denials. For example, if 50 cases were scheduled this week and 10 of them required authorization, you could share that indicator with a brief breakdown of the 10 that were not received (e.g., required but not obtained, auth # didn't include ASC TIN, auth # incorrect). This would provide both entities visibility into the reason(s) and hopefully enable you to work more closely together to develop a plan going forward that shares the responsibility on behalf of the physician.

Q: My ASC is struggling with knowing whether we have the right person in the right role at my ASC. Are there any alternative staffing models we can use or ways we can measure the success of our efforts in providing additional education?

A: You should invest in the people that you have so that they can become more accurate and productive for your ASC. But if you need to bring in additional assistance, and want to do so through alternative staffing models, you can consider looking outside of your local geographical area and using remote coders. Coders love a comfortable work environment so they can focus, and that can be a cozy place in their homes.

Outsourcing your coding to a company that specializes in the types of procedures you perform and ASC coding in general is an option. You can also look to partner with coding schools. There may be an opportunity to bring in talent from these schools, possibly those individuals looking for experience as part of their work toward certification or professional development continuing education.

Speaking to the second part of the question, you can measure success in a few different ways through audits, such as by coding accuracy and compliance with payer-specific guidelines. If you set internal benchmarks based on an initial audit result, you're ultimately looking for improvement.

Q: What tools or resources are available to help with denial analysis/data, and how can I get buy-in from my team to implement changes required to improve coding?

A: There are various technologies that can assist you from a denial analysis data perspective. Start with your clearinghouse, given that you're submitting all your claims data to them and hopefully receiving back electronic remittance data. Clearinghouses will often automatically present denials based on the 835 data. The key there is setting up as many electronic remittance enrollments as possible based on the claims you're submitting.

Your practice management system is another technology option. Using this system would require defining transaction codes that can be posted and reported on with any of your financial reporting at month end or throughout the month.

To get buy-in from your team to implement changes, it's critical to have a feedback loop. If you don't have the same person doing your coding and your follow-up where they see the denials, make sure you have mechanisms in place to keep everyone current on what the data is telling you. Solicit advice or suggestions from your team on how they can improve the numbers you're putting in front of them.

Buy-in is often absorbed better when workers participate in the decision-making process. Solicit their input and then collaborate with them to make a plan to roll out changes.

Q: You covered multiple coding roadblocks today. What are the top three you are encountering in your ASCs?

A: First would be incomplete and improper documentation, especially concerning implants. We need to ensure we have invoice logs and invoice totals. We need to make sure coders can pull those quantities and details out of the documentation. Communicate with your providers so they know what information you need from them to get implants properly coded and out the door.

Number two is a lack of training. When coding changes occur, turn to training tools, such as webinars and blog posts. Find whatever resources are needed to get your coders comfortable with following the new rules. As soon as you know about upcoming changes, make sure your coders know about them and ask what your coders need to prepare.

Number three would be modifiers. There are so many of them, and there are so many different rules that vary from payer to payer. We recently needed to make adjustments for some of our payers, changing from the -50 modifier to the -LT/-RT modifiers. Stay current on your payer manuals. Communicating with your payers is also key. Use your provider representatives as a resource. If you have any doubts about whether you are following the correct coding rules, ask your reps.

Q: When a procedure is discontinued, and based on when you select a -73 or -74 modifier to append with your procedure code, will the facility be reimbursed for all or partial of the expected amount from the carrier?

A: There should be reimbursement allowed from the carrier, but check each of your payer websites as they should outline their guidelines.

Procedures which are discontinued or terminated before planned anesthesia has been provided should be reported with modifier -73. These would be eligible for up to 50% of your allowable, if the payer permits it.

Procedures which are discontinued or terminated after anesthesia is induced or the procedure is initiated should be reported with modifier -74. These would be eligible for up to 25% of your allowable, if the payer permits it.

Q: How can we better keep our physicians accountable and compliant with documentation?

A: Communication is very important. Stress the importance of complete and accurate dictation to your providers. You don't necessarily want to be pointing fingers at your physicians and making them feel like you're telling them they're not doing a good job. But you are there to help them to help you. Compliant documentation not only keeps the days to bill down and the revenue coming in efficiently, but it will make everything run smoother for your providers.

Documentation compliance may be a learning experience for some providers. They may not know they were missing something in their dictation that you require for accurate coding.