Ambulatory Surgery Billing in 2025: Unlocking Smarter Strategies for Maximum Reimbursement
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 Conduct automated eligibility checks during scheduling and 48 hours before surgery. Implement a rules engine that identifies “Authorization Required” for GI, pain management, and cardiology CPT codes. Show authorization status in the surgery schedule for visibility to all staff. 24-Hour Claim-Out Rule Dictate operative notes on the same day. Utilize voice-to-text technology to relay details directly to coders.