COLLECT WITH CARE Unbundling, which is when you report separate codes for related services when one comprehensive code includes all related services, is one of several troublesome billing practices.

Reimbursements are the lifeblood of your surgical facility, which is why you fight so hard for every dollar. At the same time, you need to evaluate your entire revenue cycle so your processes are efficient, accurate and profitable. Avoid these 10 common mistakes that could put your reimbursements — and your facility — at risk.

Submitting fraudulent claims. Under the False Claims Act, it is illegal to submit claims for payment that you know or should know are fraudulent. When you bill a claim, your facility is certifying that it has earned the payment requested and complied with the billing requirements. Always let the physician's written clinical documentation determine your code selection. Your center is subject to a take-back of all overpayments when discovered, and it might also incur additional monetary penalties per violation above and beyond the overpayment. If you bill it, federal investigators will take notice.

Reporting the wrong place-of-service code. Although no one should ever misrepresent place of service, there's an uptick in the reporting of the place of service "11: physician office" by the physician office staff for procedures performed in the ASC simply to get claims out the door. The correct place-of-service code reported by the physician office when a procedure is performed in an ASC should be "24: ambulatory surgery center."

Unbundling. Unbundling occurs when you bill multiple procedure codes for a group of procedures that are covered by a single comprehensive code. This erroneously results in higher reimbursement. Unbundling comes in many shapes and sizes, from fragmenting one service into component parts and coding each component part as if it were a separate service to breaking out bilateral procedures when one code is appropriate. Another example is separating a surgical approach from a major surgical service, as in reporting a laparoscopic hernia repair using 2 codes — one for a diagnostic laparoscopy and another for the laparoscopic hernia repair — when that approach is already included in the laparo-scopic hernia repair code.

Upcoding. Then there's unbundling's cousin, upcoding. This is the illegal practice of using a CPT code for a higher level of service and a more expensive service than was performed or of documenting more specific conditions than the operative notes warrant simply to meet medical necessity.

Misusing modifier -59. One of the most common errors I see during facility audits is the misuse and overuse of modifier -59, distinct procedural service, which inadvertently snowballs into the unbundling and upcoding of surgical procedures. Applying modifier -59 to each CPT code listed in an operative session waves an ominous red flag for Medicare and the Office of Inspector General. Modifiers are an integral part of coding, used to indicate that some specific circumstance altered a service or procedure you performed, but didn't change its definition or code. You use modifiers to indicate that the procedure being billed has been modified or altered from its published description, not to seek additional reimbursement.

Use modifier -59 for accurate and appropriate reimbursement when 2 services that normally would be bundled together are in a particular circumstance distinct and separate. For example, a biopsy and an excision of the same lesion usually bundle so you're not reimbursed separately for them. But if you perform an excision of a separate lesion, you'd attach -59 to the normally inclusive procedure code to indicate that the second excision is distinct and separate.

You'll leave a lot of money on the table if you don't use -59 when appropriate, or if you use it incorrectly. Take a colonoscopy, for example. Let's say the physician removes multiple lesions or biopsies multiple sites within the colon. He removes a polyp via snare in the descending colon (45385 primary procedure) and performs a cold biopsy in the transverse colon (45380-59). If you don't bill them separately or bill them without a modifier -59, you're shortchanging your center.

Failing to make adjustment/write-offs. Establish a cap/dollar amount for when administrative approval is and isn't mandatory before adjustment or write-off. It's common for facilities with higher-than-normal days in accounts receivable to never make adjustments/write-offs because:

• no policy and procedure is in place;
• no cap is given, which allows for automatic adjustments when applicable and without approval, particularly when the account is paid correctly per insurance contract; and
• no management approval is initiated for accounts with higher dollar amounts because no policy and procedure is in place to provide direction for the staff.

Require monthly reporting of adjustments/write-offs that require approval to include reporting for those not requiring approval: specific patient name, dollar amount, payer and supporting documentation. Also, require monthly reporting regarding the status of accounts, pending payments and progress made.

Not returning overpayments. Require monthly reporting of credit balances. Some facilities or billing companies keep overpayments until the carrier requests them, but this practice will draw scrutiny of the Office of Inspector General. Returning overpayments is mandatory. Establish a policy for refunds based on carrier contract requirements for timelines of refunds. Some federal payers expect refunds within 60 days, while others range from 15 to 45 days. Monthly monitoring of credit balances and refunds will show a more accurate picture of your A/R.

Waiving co-pays and deductibles. While there are instances of financial hardship, it's not acceptable for an ASC to routinely waive co-pays and deductibles at the request of the surgeon. This practice may violate the Anti-Kickback Statute, which applies to all sources of referrals, including patients. In short, adhere to the contracts you have entered into with the payer by collecting applicable co-pays and deductibles.

Failing to report claims-based quality measures. Under the Ambulatory Surgical Center Quality Reporting Program, ASCs must report quality of care data on their submitted claims for 5 standardized measures to receive the full annual update to their ASC annual payment rate. The top 5 measures are patient burn; patient fall; wrong site, wrong side, wrong patient, wrong procedure, wrong implant; hospital transfer/admission; and prophylactic IV antibiotic timing. ASCs that don't meet program requirements may receive a 2% reduction in ASC payment updates.

While some facilities have ensured that they report these 5 claims-based measures by setting internal billing systems to auto-populate the 2 default codes to all CMS claims, there is no oversight to ensure accuracy if and when an event does occur. In some cases, CMS claims are routinely billed with the 2 default codes unless and until the billing office is verbally instructed otherwise. On the flip side, some ASCs aren't meeting the program minimal reporting requirements and are now being hit with a 2% reduction in Medicare payments. The verification of these quality measures is a clinical function, not a billing function. The last entry before discharge should be to review and verify these measures. How do you do so? Speak to your software vendor about adding a drop-down menu for all applicable claims-based quality measures that must be reviewed and checked off before clinical charting is deemed complete.

Failing to self-audit. Fraudulent billing practices can go unnoticed if you or a central business office or billing company fail to conduct weekly/monthly internal audits of all aspects of the revenue cycle. OSM