DOING BUSINESS


Attain Compliant Revenue Cycle Management Focus on providers’ reports, coding, billing and patient confidentiality BY CARYL SERBIN


Obtaining the full reim- bursement you deserve while remaining compliant with federal, state and managed care regulations


is imperative to keeping your doors open and achieving year-over-year growth. Several areas in your revenue cycle that affect compensation also are potential areas for noncompliance.


Compliance in Providers’ Reports The first step in the post-procedure revenue cycle is the providers’ pro- cedure reports. Accuracy, detail and timeliness all are essential if your ASC is going to optimize the coding of the procedures performed. Without these reports and those elements, the only option for obtaining reimbursement is “assumption” coding or the coding of a diagnosis or procedure without sup- porting clinical documentation. This practice, however, does not adhere to federal and state regulations. There- fore, it is important that all necessary documentation (e.g., operative report, pathology report, applicable invoices for implants and/or supplies) be avail- able to the coder in a timely manner.


Compliance in Coding To collect the full amount your ASC has earned requires you to optimize the coding of the procedures delin- eated in the operative report. In this era of payment based on diagnostic and procedural coding, however, the professional ethics of health informa- tion coding professionals continue to be challenged. Following standards of ethical coding, developed by the American Health Information Man- agement Association’s (AHIMA) Cod- ing Policy and Strategy Committee,


Attend ASCA’s Coding Seminar


ASCA will host its 2018 Winter Sem- inars January 11–13 in Las Vegas, Nevada. Learn how to prepare for the coding and billing changes in 2018 at the Coding & Reimbursement Seminar. For more information, go to http://www.ascassociation.org/ 2018coding/home.


and approved by the AHIMA board of directors, should be the primary goal for all medical coders and is a large part of the education required in a cod- er’s certification process. The coding process offers several possible compli- ance pitfalls. Five that ASCs should be aware of are: 1. Coding without proper documenta- tion of services/implants/supplies deemed medically necessary and ordered by the licensed provider.


2. Alteration of documentation or ad- dition of undocumented codes (up- coding) to improve reimbursement.


3. Unbundling of codes. The Nation- al Correct Coding Initiative Policy Manual for Medicare Services defines unbundling as billing mul- tiple procedure codes for a group of procedures that are covered by a single comprehensive code.


4. Failure to properly use modifiers (e.g., falsely appending modifiers to indicate a bilateral or an espe- cially difficult procedure to obtain additional reimbursement).


5. Improper diagnosis codes to sup- port either procedures that were not performed or to indicate com- plexity that is not present.


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A certified, experienced coder rec- ognizes and avoids noncompliance. Whether billing in-house or outsourc- ing, utilizing a fully credentialed, cer- tified coder with ASC experience is your best option for managing your revenue cycle compliantly.


Compliance in Billing and Collecting It is essential that all members of your revenue cycle team are experienced and well-educated in compliant bill- ing and collections. These skills and knowledge are vital to obtaining earned revenue while remaining compliant. Areas that should be monitored for noncompliance include: ■■


duplicate billing intended to produce duplicate payment;


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billing for additional, non-provided pro- cedures to gain extra reimbursement;


inappropriate balance billing to the patient if billing for the full amount that the payer did not pay (not adjusting fees for contracted allow- ances) and/or billing for a balance that is covered by a secondary payer such as Medicaid;


routine waiver of cost-sharing amounts such as copayments and deductibles. Federal and state regu- lations prohibit waiving cost-sharing amounts unless


genuine ■■ hardship has been documented;


improper discounts and professional courtesy. The Stark law and anti-kick- back legislation may view these dis- counts as an improper inducement to providers for referrals to your ASC;


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inadequate resolution of overpay- ments. To maintain compliance with federal and state regulations and avoid any possible penalties, audit your credit balances at least monthly


The advice and opinions expressed in this article are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion. 20 ASC FOCUS OCTOBER 2017 |www.ascfocus.org


financial


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