A Planning Playbook for Opening a New Orthopedic ASC
The ASC market continues its rapid growth. In 2023, roughly 116 new ASCs opened in the U.S., many of which were orthopedic-specific in nature....
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By: Lolita Jones
Published: 10/10/2007
To go from the nine ASC payment groups you've grown to know and love - or loathe - to Medicare's Ambulatory Payment Classification (APC) system, you'll need to transform your business office, a process that could take weeks and easily cost $50,000 for the software, reference materials and training you'll need to make it happen. Here's a look at the tools you should have in place before the new payment system goes into effect, presumably, on Jan. 1.
APC grouper software. As you know, APCs are groups of codes that are both clinically related and use similar resources. Each group carries an assigned weight, which is then multiplied by a facility outpatient conversion factor to arrive at a payment level. Every procedure in each group is paid at the same rate. First thing you'll need is a software program called a grouper, which generally costs from $5,000 to $10,000. This software assigns the APC payment group(s) for the CPT and HCPCS Level II codes after you enter the information for a surgical case (see "Sample APC Grouper Data Sheet" on page 20).
With its built-in Medicare reimbursement logic, the grouper calculates the APC payment group reimbursement amount specifically for your geographic location by evaluating the procedure codes and modifiers, and grouping in accordance with OPPS regulations. The software will flag any procedure code that isn't reimbursable under Medicare's new payment system, and calculate the discounting for you according to CMS rules.
APC groupers also let you:
You can also use the APC grouper to analyze the data entered for numerous surgical cases. Most APC groupers can be interfaced with your billing system or other information system.
Coding books and guidelines. To facilitate optimal coding under APCs, your coder should have certain coding resources on her bookshelf. Budget $2,500 per year to renew subscriptions to the following:
Staff training and education. Training your coders in all aspects of coding and reimbursement - including ICD-9-CM diagnosis coding, CPT coding, HCPCS Level II coding and modifiers, National Correct Coding Initiative edits, CMS-1500 claim forms, and the APC System - will enhance their ability to code under APCs. On-site training could cost from $10,000 to $20,000 depending on the number of specialties and physicians (the more of these, the more training sessions necessary). Don't wait too long before you begin training. It's already July; APCs will be here in five short months. Get going.
Coding and billing consulting. If you've read my columns or heard my lectures, you know that I'm a big proponent of coding and billing audits. It's never a bad time to do either.
Blessing in disguise?
You may discover that converting to APCs is an opportunity to improve your financial management practices, to become leaner and meaner, and to eliminate such poor practices as coding off the surgery schedule without bothering to approach surgeons about missing documentation.
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