Ambulatory Surgery Centers (ASCs) are integral to the outpatient market. In the year 2023, more than 6,300 facilities certified by Medicare offered services to 3.4 million beneficiaries enrolled in fee-for-service programs. This number continues to rise annually.
Nevertheless, rapid expansion presents challenges. Numerous ambulatory surgery billings experience delays in revenue collection. On average, an ASC experiences a waiting period of approximately 35 to 50 days before receiving payment for a claim. Any delay exceeding 50 days indicates a significant revenue issue. The most efficient ambulatory billing centers manage to reduce this timeframe to under 35 days.
This guide delineates the six fundamental billing principles that every ASC should adopt to minimize denials, expedite claims processing, and enhance cash flow. Furthermore, it presents five effective strategies to hasten payments.
The Five Essential Principles to Improve ASC Medical Billing and Reduce A/R Days
Every payment processed in an Ambulatory Surgery Center billing must navigate through these five critical checkpoints. When executed correctly, your clean-claim rate can surpass 95%, while denials can remain below 5%.
CPT Code Bundling Awareness
A recent study conducted by the AMA reveals that approximately 12% of medical claims contain coding inaccuracies, including the incorrect unbundling of services. A lack of understanding regarding bundling regulations results in frequent denials, prompts audits, and introduces unnecessary delays in reimbursement, jeopardizing financial stability and increasing administrative burdens.
The approach entails maintaining an accurate internal reference list specifically designed for ASC, which outlines the bundled services and CPT combinations. It is essential to regularly train coding personnel to refer to this list and to integrate bundling logic into billing software or claim scrubbers. Coders must verify composite service coverage against the primary procedure code each time to ensure that bundled items are included correctly rather than billed separately, thereby minimizing denials and improving compliance.
Confirm Procedures with the ASC Covered Procedures List (CPL)
The ASC Covered Procedures List (CPL) is updated every quarter by CMS. This list outlines which procedures (CPT/HCPCS codes) are eligible for payment under ASC regulations. It also provides payment indicators that influence packaging and pass-through status. Often, providers are not informed of the latest CPL updates, resulting in billing for procedures that are not covered by the current CPL.
The solution is to ensure that the procedure is listed on the CPL before billing and is eligible for payment in the ASC environment. Billing for procedures that lack coverage may result in claim denials or the recoupment of payments.
It is essential to consistently verify procedures against the current CPL before billing.
Keep an updated internal list and ensure that schedulers and coders are trained to prevent billing for procedures that are not covered.
Utilize the Appropriate Claim Forms, Location of Service, and Modifiers
Claims for facilities pertaining to Ambulatory Surgical Centers (ASCs) must be submitted following the stipulations of these payers, which encompass the UB-04 claim form (electronic 837I) and the Place of Service code 24, signifying an ASC environment. Nevertheless, if providers fail to comply with the precise requirements established by the payer, it may lead to the rejection of claims or delays in receiving payment.
The approach involves confirming payer-specific requirements for claim forms and modifiers. All facility claims must utilize the UB-04 form with POS 24, while professional claims should employ the CMS-1500 form. Outdated modifiers that are no longer necessary should be eliminated, but those that are still required by commercial payers must be retained. This practice minimizes claim rejections and expedites payment.
Addressing Pre-Service Denial Prevention Before Surgery
Eligibility and prior authorization mistakes account for nearly 50% of all denials. Providers frequently neglect to verify eligibility during scheduling and shortly before surgery, resulting in claim rejections and compliance issues.
The recommended solution is to confirm patient eligibility at the time of scheduling and again 24 hours before surgery, utilizing automated clearinghouses to identify any changes. It is advisable to keep updated lists of CPT codes that necessitate prior authorization and to establish reminders for schedulers. Furthermore, patients who are uninsured or paying out of pocket should be provided with good-faith estimates within one business day, especially if surgery is scheduled to occur within 3 to 9 days. This approach also guarantees compliance with the No Surprises Act.
Efficient Claim Creation, Submission, and Denial Resolution
Providers frequently encounter delays in coding and submitting claims as a result of their busy schedules.
Such delays in coding and claim submissions may lead to late payments.
Inefficient denial management can prolong accounts receivable days and negatively impact cash flow.
It is essential to finalize coding within 48 hours after surgery, submit claims within 24 hours of completing the coding, and resolve clearinghouse rejections on the same day. Corrected claims should be refiled within 24 hours, and it is important to monitor payer-specific filing deadlines, intending to submit claims at least 90 days before the earliest deadline. It is crucial to sustain a clean claim rate exceeding 98% and to target first-pass payments within a timeframe of 15 to 21 days. In the case of denials, appeals should be initiated within two business days, denial trends should be monitored, weekly performance should be shared, older claims should be escalated, and senior staff or external partners should be involved as necessary.
Seven Accelerators to Accelerate Payments in ASC Medical Billing
These strategies are founded on the five fundamental billing principles mentioned earlier. High-performing Ambulatory Surgery Centers that implement a minimum of five of these strategies experience a 3–5% rise in clean claim rates and decrease gross accounts receivable by 10–12 days within a span of two quarters.
Accelerator |
What It Looks Like in Daily Operations
|
Front-End Eligibility and Pre-Authorization Playbook |
|
24-Hour Claim-Out Rule
|
|
Quarterly Coding Audits and Rapid Training
|
|
Modifier-Management Cheat Sheet
|
|
Denial-to-Appeal in ≤ 48 Hours
|
|
Scoreboard Key KPIs
|
|
Use Technology or Outsourcing During Volume Spikes
|
|
When these accelerators are integrated into the daily billing workflows of ambulatory surgery centers (ASCs), they experience quicker payments, reduced denial rates, and improved cash flow. This strategy transitions ASC medical billing from a reactive function to a high-efficiency, revenue-generating system.
2025 Compliance and Risk Monitoring List for ASC Medical Billing
The Centers for Medicare & Medicaid Services (CMS), Congress and state Medicaid programs are progressively implementing more stringent regulations for Ambulatory Surgery Centers. Failing to meet even a single requirement can convert a clean claim into a zero-pay denial or initiate a post-payment audit. This checklist is designed to assist your ASC in staying ahead of these regulatory changes.
- NCCI Edits v31.2 (effective July 1, 2025): The introduction of 1,470 new code pairs, the removal of 130 pairs, and 42 pairs that will no longer have the modifier 59 override, making certain appeals impractical.
- 72-Hour Bundling Rule: ASCs owned by hospitals are required to bill related pre-operative services alongside the hospital’s Part A claim to prevent recoupments.
- No Surprises Act (2025 Update): Good-faith estimates must be provided within one business day for surgeries scheduled more than three days in advance; Independent Dispute Resolution timelines are being tightened.
- CMS 2026 Proposed Rule: Introduction of site-neutral drug payment, reduction in device offsets, expansion of the covered procedure list, and adjustments to the wage index.
- California Medi-Cal Manual Pricing: Numerous ASC codes are priced manually and may utilize outdated rates; it is essential to verify rates in writing before undertaking high-cost surgeries.
The Importance of Outsourcing for ASC Medical Billing
Even the most proficient in-house teams encounter limitations, particularly during periods of rapid expansion, employee turnover, or unexpected increases in surgical volume. By outsourcing some or all of your ambulatory surgery billing, you can:
- Gain immediate access to certified ASC billing professionals.
- Enhance clean-claim rates through the use of advanced technology and skilled personnel.
- Decrease accounts receivable days with focused follow-up and denial management.
- Reduce cost-to-collect by eliminating the necessity for additional full-time hires.
- Ensure your ASC remains compliant with changing payer rules and regulations.
For numerous centers, outsourcing is not intended to replace staff but rather to augment them with additional expertise and technology.
Conclusion
It requires a proactive and structured strategy that mitigates denials before they occur. This methodology accelerates claims submission and guarantees adherence to evolving regulations. Ambulatory surgery billing is crucial for revenue generation and timely surgeon payments. By focusing on core practices, implementing accelerators, and committing to continuous improvement, denial rates can be maintained below 5%, with accounts receivable days averaging in the low 20s as the norm.
By applying the five fundamental billing principles and incorporating the seven accelerators into everyday operations, ASCs can enhance their cash flow. Whether managing billing internally or with the assistance of specialized outsourcing partners, the implementation of these strategies enables your ASC to remain competitive, compliant, and financially robust.
Frequently Asked Questions (FAQs)
Q1. What makes ASC billing different from hospital or physician billing?
ASC billing stands out because it requires specific claim forms (like UB-04), unique place-of-service codes (POS 24), and a solid understanding of bundled CPT codes. Plus, it involves juggling both facility and professional claims, which adds layers of complexity in terms of compliance and accuracy compared to standard hospital or physician billing.
Q2. How long does it typically take for an ASC to receive payment after submitting a claim?
On average, ASCs can expect to wait around 35 to 50 days for payment. However, the top-performing centers manage to bring that down to under 35 days, with first-pass payments often arriving in just 15 to 21 days.
Q3. What exactly is the ASC Covered Procedures List (CPL), and how frequently is it updated?
The CPL is a list curated by CMS that outlines which procedures are eligible for reimbursement in the ASC environment. It gets updated every quarter, so it’s crucial to check the latest CPL before billing to steer clear of any denials.
Q4. What new compliance risks should ASCs be aware of in 2025?
Here are some key items to keep an eye on:
- NCCI Edits v31.2: This includes over 1,400 new code pairs and fewer modifier overrides.
- No Surprises Act (2025 update): This brings tighter timelines for good-faith estimates and dispute resolution.
- CMS 2026 Proposed Rule: Changes are coming regarding device offsets, site-neutral payments, and the procedure list.
- California Medi-Cal Manual Pricing: Manual rates that will require written verification.
Q5. How can ASCs stay financially competitive in 2025 and beyond?
To remain competitive, ASCs should focus on implementing the five billing fundamentals, adopt at least five of the seven accelerators, keep up with compliance updates, and be open to outsourcing or integrating new technology. This approach can help them:
- Keep denials below 5%
- Maintain accounts receivable days in the low 20s
- Ensure quick and accurate payments
- Lower administrative costs