Q We're developing a freestanding surgery center and would like to know what specialties to include. Can you give us an idea of the most common specialties?

A Performing at least 7 million surgeries a year in more than 3,600 centers nationwide, ASCs are one of the fastest-growing segments of the American healthcare industry. As you can see in the chart depicting the percentage of procedures by specialty, about 50 percent of the procedures performed in ASCs last year were in either ophthalmology or gastroenterology. Orthopedics, gynecology, plastic surgery and pain management are other common services performed at ASCs.

Q Insurance companies frequently refer to "clean claims." What does that mean?

A Aclean claim is one that is submitted on the appropriate claim form with the required information specified by the insurance contract. In addition, if your contract specifies other information be attached (such as the operative note or invoice), this information must accompany the claim form in order to constitute a clean claim submission. If applicable, you must also coordinate benefit information.

Submission of a clean claim benefits your facility by providing accurate, timely reimbursement of services provided. Be sure to review your contracts to ensure you're submitting your initial claims appropriately. By understanding the contract requirements, you can ensure that insurance payers do not delay claim payment by requesting additional "unnecessary" information to determine their payment responsibility. It's also a good idea to be aware of your state's clean-claim and prompt-payment statutes.

Q A surgeon has asked me to code a procedure differently than is dictated in the operative note. What should I do?

A Speak with the physician and present the procedure code(s) the coder has selected based on the dictated documentation. Ask the doctor to explain why he feels a different procedure code(s) should be billed and how his documentation supports that decision. The coder may have misunderstood the surgical technique or language in the operative note. If so, ask for further clarification so the coder will better understand the surgeon's documentation and techniques in the future.

However, if the physician has actually performed techniques not in the operative report, ask him to dictate an addendum to the operative report to fully document the services provided. Explain that the procedures code(s) he has requested cannot be billed because the documentation does not support them. Remind him that, in the event of an OIG audit, medical records are reviewed for accuracy against services that were billed. If the documentation does not support the billing submitted, any payment received will be taken back, along with any fines or penalties that may be assessed. The auditor's guidelines are "if it isn't documented or legible, then it wasn't done." If there's still a problem with physician compliance, ask your compliance officer to investigate and determine appropriate action.

QWhich laparoscopic procedures are approved to be performed in ASCs?

AHere's a list of laparoscopic procedures approved by Medicare for performance in an ASC. Note that any laparoscopic procedures not on the Medicare-approved ASC list may possibly be reimbursed under other managed-care contracts but probably would require negotiation for coverage.

Q One insurance company often takes much longer to pay claims than the rest. What can I do to decrease payment turnaround time?

A Review your contract and your state's prompt-payment statutes. Does your contract specify a timeframe in which they will pay claims? If so, contact your provider representative and advise them that your claims are not being paid within the time guidelines in the contract and/or state prompt-payment law. Depending on your state's prompt-payment legislation, remind the payer it may also be liable for interest on claims not paid within guidelines. If this does not provide the desired response, notify the insurance commissioner in your state and file a formal complaint. Usually, letting the insurance company know you are aware of the contract guidelines and/or the state regulations and plan to enforce them will often be enough to get your claims paid in a timely manner.

If your contract does not specify a timeframe in which claims must be paid, request an amendment and have a clause added for timely payment of submitted claims. This can be specified by your state's prompt-payment statute and/or reasonable guidelines agreed upon by you and the insurance company. A suggestion might be 21 days for electronic-claim submissions and 30 days for paper-claim submissions. Some states require interest be added to claim payments not paid according to state guidelines.