Chances are you're missing out on at least a few opportunities to increase cash flow — all because you're not looking in these 3 unlikely places.

1Ancillary procedures. These are the additional sources of revenue for services provided outside of standard OR charges or procedure revenue: imaging, lab and neuro-monitoring. Good documentation is the first step to capturing this revenue. This depends on a clear communication loop among the OR, materials management and the business office (see "Growing Revenue Is a Team Sport").

For some revenue sources, specifically those for contracted services such as neuro-monitoring, study your agreement with the service provider to determine whether your facility or the service provider will bill for the service. In addition, know whether you're billing for the technical component (TC modifier) or the professional and technical component (no modifier). Clearly outline documentation of the services in the patient chart, and establish a system for communicating this to billing.

Physician documentation of a C-arm, ultrasound or other imaging used during a case is critical. These services are typically billed for technical component only (TC modifier). Understanding payer guidelines and payer contract coverage is critical in knowing when you'll be reimbursed for these services.

2Implants and supplies. Implants, high-cost supplies and medications used during a case are valuable sources of revenue for your facility. They can be a determining factor in the overall profitability of your cases and, really, the financial success of your center. For implants and high-cost supplies, have a policy that establishes thresholds for what's considered billable. An example: All implants, regardless of cost, are captured on each case and communicated to billing, while high-cost disposable supplies (drill bits, ablators, suture passers and blades, for example) must meet an individual cost of $200 each unit to be captured for billing; anything less than $200 per unit would be absorbed in the case cost and standard fees for the case.

Determining what makes sense for your facility will depend on your payer mix, payer contracts and specific payer guidelines. As an example, Tricare will reimburse a surgery center for dispensed medications with a cost above $40. Tracking these medications and ensuring that they're billed would be key to a Tricare-heavy center.

3Canceled cases. Whether they're canceled before or after you administer anesthesia, canceled cases are often billable and, in the majority of cases, reimbursed by government payers and covered under payer contract terms. If a case is canceled before you administer anesthesia, the primary scheduled procedure is billed with modifier 73; it's billed with modifier 74 when canceled after the administration of anesthesia — say, in the case of a difficult airway or some other unexpected situation that makes the surgery too risky for an outpatient setting.

Payers typically cover these at 50% of the allowable when billed with a 73 modifier and 100% of the allowable when billed with modifier 74. Medicare, for example, covers 50% of the allowable for the primary scheduled procedure when a case is canceled before the administration of anesthesia, but after the wheels are rolled into the OR. Facility resources are being used and OR time is being blocked regardless of whether the surgery is performed, so you want to be vigilant about billing and receiving reimbursement when applicable.

There are a few questions to keep in mind when reviewing your processes for canceled cases:

• Is clinical staff trained to know when a canceled case is billable? For cases canceled before the administration of anesthesia, Medicare requires that wheels be rolled into the OR before the case is considered billable. Many commercial payers follow Medicare's guidance and others have varying guidelines. If necessary, reach out to your provider representative for clarification.
• Is appropriate documentation being captured to ensure billing can occur? As a standard, documentation by the nursing team that states the reason for the cancellation is sufficient. It is recommended, however, that the physician document in the OR record the circumstances of the canceled case if you're billing a case canceled after the administration of anesthesia.
• Are you communicating these cases to the biller or billing team to ensure the case is billed? Every member of your team — from clinical to the business office — should know how these cases are identified in the patient accounting system. There are typically statuses that you should assign to the case in the same way that you assign a "performed" or "canceled" status. If you're unsure of the correct way to assign the case status, ask your software vendor for help. OSM

HIDE AND SEEK
Growing Revenue Is a Team Sport

REVENUE CAPTURE Open communication between the business and clinical teams can help your surgical center identify opportunities to capture more revenue.

Years ago, when I was business director for a surgical center in South Florida, we started doing some new procedures and found there were several unbilled items. I had a good relationship with the nurse manager, so I asked her to walk me through the case so I could see how every item was being used. It ended up being about $700 per case in "found" revenue. Unfortunately, this doesn't always happen in surgical facilities because the folks from the business office and the clinical team don't often interact. You, your materials manager and business director should meet regularly to discuss your procedure mix and develop a revenue-capture plan. Key points to follow:

1. Identify target areas. Capturing more revenue begins with establishing the specific procedures and services you want to target.

2. Follow the case from start to finish. Work with a charge nurse or another clinical leader to look at the items and services being used in the targeted case, and then review any applicable payer contracts to determine whether you can capture additional revenue associated with each item or service. The more complex the case, the more opportunities you're likely to find.

3. Evaluate your findings. Assemble a procedure summary that identifies the items and services being used for that procedure — all the supplies and implants needed for an orthopedic case, for example — and review every item with the billing team to make sure you're capturing every dollar per your agreement with the payer.

— Rebecca Geise