Did you know that ambulatory surgical billing services are entirely different from other medical billing specialties? It’s very crucial to learn about ambulatory surgical services before taking up its billing and coding tasks. Basically, ambulatory surgical billing specializes in claiming surgical services especially for outpatient treatment. Some may include billing procedures related to pain management or diagnostic procedures like colonoscopies.

Procedures performed at Ambulatory Surgical Centers are more extensive compared to the services performed at healthcare professionals’ office. Moreover, they don’t require a hospital stay either. For ambulatory surgical billing, it needs to qualify certain requirements and also additionally enter into written document with Centers for Medicare and Medicaid Services.

Unlike physician or hospital billing, ambulatory surgical billing services must be well known for the billing department to handle those claims accurately for the services rendered. Medicare has separate set of guidelines for ambulatory surgical billing services and other insurance companies will have their own set of guidelines differing from one payer to another depending on medical necessity, approved procedures as well as other filing requirements.

What is Ambulatory Surgical Billing?

  • Ambulatory surgical billing is a whole new scenario where ambulatory surgical centers use a mixture of hospital and physician billing and the process is often confusing depending on insurance companies and their acceptance of different CPT and HCPCS level II codes.
  • Medicare has a whole different set of guidelines for ambulatory surgical billing services and it’s not covered under part B. Though the list is published yearly by Medicare, it’s essential for ambulatory surgical centers to bill and code according to Medicare requirements.
  • These procedures come as a package when it represents ambulatory surgical billing reimbursement or revenue payments. Certainly, related line items are paid with one set reimbursement.
  • Few insurance companies fail to follow CMS guidelines for ambulatory surgical centers and it becomes very complicated for ambulatory surgical billing and coding professionals to file claims.
  • Missed procedures, inaccurate coding, late reimbursement, changing contracts along with an expanding procedure pool can cause much hassle for ambulatory surgical centers and billing staff.

What are Ambulatory Surgical Centers?

  • Ambulatory surgical centers are defined as separate and different with the purpose of providing patient’s surgical treatment and procedures.
  • Under certain regulations, hospitals or healthcare organizations run a facility where Medicare purposes are either healthcare provider based or of an ambulatory surgical center.
  • Medicare seeks ambulatory surgical centers to involve and enter into provider participating agreement with CMS in order to be eligible for reimbursement.
  • New trends introduced by CMS for cost reduction are moving to a zone of occupying beds in the hospitals with more services including surgeries.
  • Medicare needs ambulatory surgical billing services to be more precise in following the guidelines. Ambulatory surgical centers define the meaning of ambulatory care as offering surgery.

How are basic Ambulatory surgical centers charges billed and coded?

  • As discussed, ambulatory surgical billing center uses a combination of healthcare professionals and hospitals or clinical billing by employing CPT and HCPCS level II codes.
  • Few insurance companies allow ambulatory surgical billing services to use ICD-10 procedure codes just like in hospitals.
  • Some so called “packaged” services including medical and surgical supplies do not pass through on a status along with surgical dressings, splints, casts and related services, under the supervision of an anesthesiologist and the operating surgeon.
  • Medicare requires the use of modifiers while submitting the charges to indicate those services performed by an ambulatory surgical center.
  • Other insurance companies also might prefer modifiers that help in distinguishing the facility’s bill and healthcare professionals’ bills. An advance check with insurance companies regarding ambulatory surgical billing requirements is recommended before getting into conclusions.

What are CMS regulations to determine which services are covered by payers?

  • While dealing with the Centers for Medicare and Medicaid Services, ambulatory surgical centers must be aware that not all services or procedures allowed in hospitals are permitted in an ambulatory surgical center setting.
  • It has to be approved by Medicare and CMS has determined that a procedure can’t significantly take risk nor of incurring an overnight admission by following the procedure.
  • The criteria of the approved procedure list is given below:
  1. They can’t be life threatening or of an emergency in nature that includes reattaching a limb or a heart transplant.
  2. Procedures that cannot be safely performed in healthcare professionals’ office
  3. Procedures those can be urgent and elective.

What are the Common Ambulatory surgical billing and coding errors?

  • One of the most common coding errors is coding that’s based on procedure’s heading instead of a surgical report.
  • Most of these ambulatory surgical billing procedures and the other outpatient facilities wait for the complete report from healthcare professional rather billing immediately for the scheduled services because few services are noted annually in the report.
  • The other common errors include misreporting of open and arthroscopic techniques as combined procedures. It usually happens when procedures are started arthroscopically and later on converted into an open procedure.
  • Most of these ambulatory surgical billing and coding teams mistakenly bill for both when only open procedure has to be coded.
  • Remember that the above does not apply in cases where the healthcare provider does one procedure arthroscopically with another one using the open technique.

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