ASC GI Billing Services

Gastroenterology is the largest ASC specialty with nearly 20% of surgery center procedures classified as Gastroenterology (GI) [per the ASC Association]. Twenty-five to thirty percent of all single-specialty centers are GI-specific (SDI’s 2008 Outpatient Surgery Center Market Report), making GI surgery centers the largest single-specialty ASC. Trends in Medicare reimbursement have not been favorable for GI ASCs. Despite this trend, or perhaps because of it, growth in ASC GI procedures continues. Improvements in anesthesia are an important factor. Patients are also attracted to the “friendly” outpatient environment of an ASC versus the hospital alternative. Finally, payers are recognizing the cost savings associated with ASC procedures compared to an HOPD option.

Skills required for ASC Gastroenterology Billing

Billing for ASC GI procedures can be complex. Gastroenterology represents a wide variety of procedures (some examples are listed below) and underlying causes (diagnoses). Payer rules are not consistent and can be confusing. As a result, it is recommended that centers employ only experienced GI coding and billing staff. Billing staff must be knowledgeable in coding, charge posting, claims filing, payment posting, customer service, A/R follow-up including denial management, and reporting.

Many centers find attracting and retaining these skills in a relatively small staff to be a challenge. For this reason, hiring a firm who specializes in ASC GI billing may be the best option. The right firm offers an ASC the ability to hire a team of experts, specialized and skilled in each of the billing disciplines, while only paying for a fraction of the costs. Since a professional ASC billing company performs coding and billing for many ASC’s, economies of scale are realized and passed along to clients. The volume of work justifies having specialists and experts and avoids the risk that an ASC faces with internal staffing: “jack of all trades, but master of none.”

ASC Gastroenterology Billing Considerations

Insurance underpayments are an issue for all specialties, but they can be particularly troublesome for GI ASCs given the thin margins and, frequently, declining reimbursement rates. Underpayments can represent 10% or more of a GI surgery center’s revenue.

Patient billing can also be an issue for GI ASCs. Patients can be surprised by the size of their bills (many do not realize that they will receive separate facility and physician bills along with an anesthesia bill and the average GI charge is over $2500 per case according to VMG Health, LLC), and confused by payor reimbursement explanations. Billing staff and procedures designed to minimize these roadblocks can be much more successful in collecting patient balances in a timely manner. For example, patient education in advance about insurance reimbursement procedures and amounts has proven to be highly effective for some centers.

“Days in A/R” is always an important metric. Studies have suggested a national average for GI surgery centers of over 50 days. In contrast, high performing centers (including AHS clients), typically see average days in A/R in the mid-thirties. This represents a significant one-time cashflow improvement and ongoing acceleration of income.

As everyone knows, GI coding rules are constantly changing. Careful coding of “common” GI procedures is very important. At its most basic level, this means coders must carefully review the operative note and assure they’ve accurately and completely captured exactly what was done. For example, the coding associated with lesions and polyps varies based on the number, location, and type. And removal of polyps can change the way in which the entire colonoscopy is coded. Another example arises with screening colonscopies where Medicare coverage varies depending on whether the patient is deemed “high risk.” In this case, proper pre-certification procedures are essential.

Reducing GI Claim Denials in Surgery Centers

In an interview with Becker’s ASC Review, Bill Gilbert, vice president of marketing, and Brice Voithofer, vice president of ASC and anesthesia services for AdvantEdge Healthcare Solutions, discuss tips for reducing denied GI claims and what surgery centers can do to receive proper reimbursement if a claim is denied.