Why Surgeon Coding and Facility Claims Must Match — The ASC Synchronization Problem Payers Are Now Auditing

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Ambulatory surgery centers (ASCs) are facing increasing pressure to keep professional and facility claims consistent. A surgeon may submit a professional claim for a procedure while the ASC submits a separate facility claim for the same encounter. Although these claims serve different billing purposes, the clinical details behind them should tell the same story. When surgeon coding and facility claims do not match, payers may see inconsistencies that can trigger claim reviews, payment delays, downcoding, or denials. The problem is not always an incorrect CPT code. Sometimes the issue is that two correctly prepared claims do not appear synchronized. The ASC Synchronization Problem ASC billing involves multiple parties. The surgeon or physician group submits the professional claim, while the facility submits the institutional claim for the services and resources provided by the ASC. Both claims can contain different codes because they represent different components of the same encounter....
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The Changing Face of Primary Care: An Overview

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The shortage of PCPs in the United States has been a well-publicized and well-documented issue. However, the solutions to the various issues faced by primary care in the country have been obscure even after the implementation of the Affordable Care Act. The complications in finding the solutions to the challenges faced by primary care stem from factors ranging from policy reform to changing demographics. According to a New England Health Institute report, primary care in the country is facing a crisis due to the shortage of PCPs and the increase in demand for such physicians.

Factors Complicating Primary Care Physician’s Tasks

According to a report by the American Medical Association one of the biggest challenges faced by primary care physicians is the increasing number of visits by elderly patients. The report clarifies that the average visit duration has increased due to the fact that an increasing chunk of the total visits by adults to PCPs is to elderly patients. The report also specifies numerous factors that complicate the tasks faced by PCPs in the country, such as the need for PCPs to balance acute care and preventive care, the increasing diversity of the population, and, the recent changes and expanding choices in drug therapy.

The Impact of Reforms

The Patient Protection and Affordable Care Act has numerous provisions that are applicable to it and some of the crucial ones are providing pay-for-performance models, expanding access to primary care services, and models that transition primary care practices away from fee-for-service based reimbursement and toward comprehensive payment or salary-based payment. The Act also lays out financial policies that promote systematic coordination of care by primary care physicians across the full spectrum of specialties and sites of care, such as medical homes, pay-for-performance programs, and capitation arrangements. Section 5405 clarifies the Primary Care Extension Program under the Act and provides support and assistance to primary care providers, in order to enable providers to integrate such matters into their practice and to improve community health by working with community-based health connectors.

To learn more about The Changing Face of Primary Care: An Overview, click here: https://bit.ly/42GrnTL  Contact us at info@medicalbillersandcoders.com/ 888-357-3226.

Location: United States

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