Eliminate Common ASC Coding and Billing Compliance Issues
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BY KEN BULOW
Noncompliant coding and billing can lead to increased denials, missed reimbursement opportunities and unnecessary refunds. Additionally, poor compliance outcomes harm surgeon and patient satisfaction and could lead to more serious consequences, including loss of payer contracts and legal ramifications.
Unfortunately, maintaining compliance can prove challenging. Coding rules change regularly. Denials from incorrect coding can force an ASC to allocate resources to file appeals and resolve inaccurate information. Undercoded claims can leave potential revenue on the table and cause the ASC to receive lower reimbursement than it deserves. Undetected upcoding can lead to higher "unearned" reimbursement. When this happens, ASCs will be expected to refund the overpayment. More extreme upcoding can lead to regulatory scrutiny.
Billing rules also change frequently. While rules sometimes overlap between payers, to submit clean claims an ASC must understand typically substantial differences in payers. The documentation payers require to approve a claim also can vary.
Since coders and billers review details about patient cases, this means they are handling protected health information (PHI) and must follow the Health Insurance Portability and Accountability Act (HIPAA) of 1996 regulations. If a coder or biller fails to appropriately safeguard PHI and runs afoul of HIPAA, they and their ASC could face penalties. A more serious HIPAA violation, perhaps one resulting from a data breach caused by coder or biller negligence—even if accidental—could lead to more severe penalties and ramifications. Shortcomings with technology compliance also can leave an ASC more vulnerable to data breaches.
The Road to Improved Compliance
Consider the following to remain on the right side of requirements.
Employ certified ASC coders. Whether your ASC performs coding in-house or outsources it, make sure to hire certified ASC coders to maintain consistency between those performing the coding. Surgery center procedures bring their own unique coding rules. A certified, experienced ASC coder will be better suited to achieve compliant coding.