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Plutus Health Specialties

ASC Billing & Coding Services

Plutus Health revenue cycle management solutions for Free Standing ASCs provide excellent coding and billing services from our experience of many years in ASC billing which are compliant services with all the federal and state regulations.

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Plutus Health revenue cycle management solutions for Free Standing ASCs provide excellent coding and billing services from our experience of many years in ASC billing which are compliant services with all the federal and state regulations. We understand all the nuances of ASC billing and maximize the reimbursement of the physicians using efficient billing methodologies.

Reimbursement for surgical services has become  difficult as the ASC space evolves. ASCs are now dealing with very complex insurance carrier policies, multiple guidelines that govern contracted and out of network payer types. This requires deep expertise of payer policies and trends.

There are many important aspects of filing a claim for services rendered through an ASC. Medicare often has different guidelines than some commercial payers, and the payers themselves often differ regarding medical necessity, approved procedures, or other filing requirements.

ASC Coding:  

One of the most common coding mistakes is coding based on a procedure’s headings instead of the actual surgical report. This is bound to result in a denial once it reaches the payer. Other common errors include misreporting open and arthroscopic techniques as one procedure.

Since an ASC uses a combination of physician and hospital or clinical billing, employing the CPT and HCPCS level codes, some insurance carriers permit an ASC to bill using ICD-10 procedure codes. Some “packaged” services such as medical or surgical supplies not on a “pass-through” status, surgical dressings, splints, casts and related items, supervision of an anesthesiologist by the operating surgeon, and so on.

Managed care contract review:

How long you have to submit a claim, how long you have to review an adjudicated claim, what the payment methodology is, why a carrier would reduce multiple procedures and how to appeal a claim that hasn’t been paid correctly. Your ASC should use your managed care contract to bill out, post payments and follow up, and you need it at every point of the revenue cycle.

Appeals :

Plutus Health will deliver sophisticated ASC  appeals for surgery denials that include but not limited to payer exclusions, prior authorization, timely filing, usual and customary allowable etc. Plutus Health’s expertise in changing payer guidelines, denial and payment trends, as well as client-specific issues to ensure surgery reimbursement for your Ambulatory Surgery Center is best in class. Plutus Health will aggressively pursue appeal options as well as negotiated settlements for in and out-of-network claims. Plutus Health’s team of reimbursement strategists brings broad experience from both payer and provider sides.  

Coding for ASCs is a specialty unto itself. It is a facility service, but Medicare requires ASC’s to send their bills to the professional fee (Part B) payers but using the facility fee (Part A) claim form. There are a different set of regulations and bundling edits to use for ASCs. A simple modifier used incorrectly can be denied for an otherwise clean claim for thousands of dollars. You may lose your money if your codes are not in right order.  Insurance Carriers who do not follow standardized coding practices because of HIPAA exemption. Worker’s compensation carriers, small carriers and other carriers that are HIPAA-exempt can come up with home-grown codes, and you are not going to get paid if you use standardized codes. To avoid having your claims rejected, make sure you know whether your carrier is exempt.

Health has built deep expertise of revenue cycle processes to ensure optimal reimbursement for all ASC services. From accurate demographic capture, coding, and pre-billing audits and scrubbing, to deep EOB analysis, we will navigate on your behalf ASC coding & billing as well as denial  complexities.

Since ASC Facility & Professional Services insurance billing & Out of Network collections are specialized activities most billing services have little or no knowledge of the challenges in this area.  One of the issues is  ASC billing uses a combination of hospital and physician billing. However, ASCs use CPT and HCPCS Level II codes to bill most of their services, some payers will allow an ASC to bill ICD-9-CM procedure codes like hospital. Some payers even base implant reimbursement on revenue code classification. ASC billing challenges are many and complicated.

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