ASC Claims Matching Strategies for Fair Reimbursement

ASC Claims Matching Strategies for Fair Reimbursement

Jessica Edmiston, BS, CPC, CASCC, senior vice president of coding for nimble solutions

Expertise in coding for ASC, professional, and anesthesia ensures payer claims matching guidelines are followed for fair reimbursement. Major payers often match ASC CPT codes with professional CPT codes and anesthesia crosswalk codes, either proactively or retroactively. This practice, known as carrier claims matching, can have significant implications for your ASC's revenue.

If you're not familiar with carrier claims matching, your ASC might be at risk of losing out on potential revenue.

While I've written about this topic for Becker's ASC Review previously, this blog serves as an update, with additional coding guidance to help you navigate this complex process and ensure your services are reimbursed fairly.

Significant Challenges for ASC Coders

If your facility's payers adhere to a claims matching policy, it can pose two challenges for your coders:

1. Code Alteration: Your procedure codes may be altered to align with the professional charges, potentially leading to down-coding and reduced revenue.

1. Claim Processing Delays: Claims may not be processed until your billing department intervenes and pushes them back into adjudication.

Carriers don't automatically match claims to the correct codes, which is why familiarizing yourself with your carriers' claims matching policies is crucial. You should be prepared to advocate for your codes if they are changed.

How Carriers Match ASC Claims

The rationale behind matching claims for ASC, professional, and anesthesia charges has its merits. These claims should ideally correspond to the same surgical procedure.

However, if the code you're choosing isn't specific enough, the ASC CPT codes, professional codes, and anesthesia codes won't necessarily be the same.

Here's a breakdown of how the process typically unfolds: Let's say you code and bill for an arthroscopic carpal tunnel release at your ASC (CPT code 29848), the anesthesiologist bills for the same procedure (01810), and the surgeon codes it as an open procedure (64721).

The carrier may side with the surgeon's code for various reasons. While the documentation supports the facility claim, if the surgeon's code is at a lower level, your reimbursement might be adjusted to match the surgeon's claim.

Matching can occur either on the front-end or back-end, and you may discover it when receiving a negative balance invoice. Carriers might claim they overpaid you and request a refund, which they will often deduct from future payments.

Regardless of when payers match claims, this policy could prove costly for your facility.

How to Improve Reimbursement on All Three Claims

ASC coders and administrators should consider the following strategies:

1. Rely on Medical Records: Avoid coding based solely on charge sheets or superbills; use medical record documentation to substantiate your coding decisions.

1. Daily Code Matching: Establish a daily spreadsheet to match your codes with the surgeon's codes on the front-end.

1. Code Discrepancy Discussions: Review the coding on all three claims and engage in discussions to resolve code discrepancies before submitting claims.

1. Avoid Arbitrary Code Changes: Refrain from making arbitrary code changes to align codes artificially.

1. Internal Coding Audits: Regularly audit your claims and your coding techniques to ensure accuracy.

If a carrier's claims matching leads to reduced payment, consider these steps for appealing the outcome:

• Communicate with Surgeon's Office: Reach out to the surgeon's office to address coding discrepancies and seek alignment.

• Aim for Alignment: Strive for alignment between the facility and professional claims, as they should ideally match most of the time.

• Leverage Matching: Emphasize the matching of professional and facility claims as a persuasive point in your appeal.

• Corrected Claim Submission: Encourage the surgeon to submit a corrected claim as part of the appeal process.
  

When Claims Shouldn't Match

Now that you have a better understanding of claims matching, it's essential to recognize that there are instances when claims should not align.

For example, consider the following scenario:

Sacroiliac joint injections are coded with G0260 for the ASC for some payers, including Medicare, while the professional side will report 27096.

Both codes represent the same procedure description, but the G code is specific to the ASC only. 

In such cases, the facility and professional claims should not match, and this is entirely acceptable.

CMS reporting guidelines such as the Medicare Complexity Adjustment can also result in scenarios where claims shouldn't match. Typically, ASCs do not receive reimbursement for CPT add-on codes. However, there are some procedures that can qualify for add-on codes, due to the Medicare Complexity Adjustment. In these instances where a CPT code and qualifying add-on code can be used, the ASC reports HCPCS "C" codes which allow the ASC to receive a greater reimbursement, as the add-on code is being taken into consideration.

For example, for a percutaneous lumbosacral vertebroplasty at two levels, the professional side reports CPT 22511, 22512 and the ASC reports C7505 for Medicare carriers.

Medicare specific "C" codes and coding exceptions like these can change, so it's important to stay updated with CMS guidelines to ensure timely and accurate reimbursement.

Final Thoughts on Claims Matching Best Practices

To ensure compliance, optimize revenue, and avoid claim delays related to matching, always base your coding and billing on operative reports and relevant documentation.

Collaborate effectively with the facility administrator, surgeon, and anesthesiologist to streamline this process. By working as a team, you can navigate carrier claims matching successfully and safeguard your facility's financial health.

Partnering with a revenue cycle provider that specializes in all three claimsalso ensures the latest claims matching guidelines are followed.

Are you looking for ways to improve your revenue cycle management? Take the first step towards optimizing your revenue cycle process by requesting a revenue assessment from our team of RCM experts. Request a demo.

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