ASC RCM Quick Tips: Optimize Your Reimbursement - Understanding ASC Clinical Policy Requirements

By Angela Mattioda, Vice President of Revenue Cycle Management

One of the most common types of ASC denials occurs when a procedure is not considered medically necessary by a payer. This ties back to a payer's clinical policies. The purpose of clinical policies is to provide a guide to providers about medical necessity, which is used to make coverage decisions. The fact that a procedure is payable in your contract does not mean it will be covered if clinical policy requirements are not met.

That's why it's critical for your revenue cycle team to understand the payer policy guidelines and requirements to help ensure you capture all the reimbursement owed to your ASC. Here are some best practices to follow.

Your coding team should be flagging any case that is not meeting local coverage determination (LCD) requirements. CMS requirements may differ from other payer requirements, so it is important to understand and check clinical policies across all your payers.

Ensure your scheduler, coding team, and billing team are all familiar with payers’ clinical policies and share those requirements with the physicians to use as a reference while completing their dictations. By taking the time to learn and understand these requirements, you can provide feedback and education to your staff and physicians.

Address clinical policy issues on the front end to help avoid delays in reimbursement by waiting for a denial and then submitting an appeal. Some areas to focus on to better ensure successful claim submissions are physician detail in the operative note and detail in the history and physical to support medical necessity requirements. Identify in advance if the physician may need to provide an amended operative report with the necessary detail to support medical necessity.

Common types of denials attributable to physician documentation shortcomings include the physician not identifying the level of a condition. If this detail is not properly dictated, it will likely result in an unspecified diagnosis that will result in a denial. The physician must ensure all diagnoses are documented to the highest level of specificity. For example, complex regional pain syndrome must be documented as "type 1" or "type 2" and include the specific location.

Another common denial concerns procedures that a payer considers experimental and investigational. Did you know that Aetna considers arthroscopic partial meniscectomy medically necessary for only traumatic meniscal tears? If a surgeon performs arthroscopy due to degenerative meniscal tears, Aetna will consider it experimental and investigational and deny the claim, even though CPT 29881 is listed as payable on your fee schedule.

Patient clearance issues can also lead to denials. For example, performing a spinal code stimulation procedure and not getting paid because requirements are unmet can be a devastating loss to any ASC. Besides documentation that other conservative methods of pain management have been tried and failed, did you know that Aetna’s clinical policy requirements state that the patient must have obtained clearance from a mental health professional (psychiatrist or psychologist)?

Tracking denial reasons will help in identifying patterns. Keep an eye on your ASC's top 30 procedures by volume to quickly trend denial causes so proper practices can be communicated to staff and physicians. Knowledge is key. Providing feedback to your physicians is necessary so they understand up front how to meet clinical policy requirements.