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August 2017

Diagnosis Please: It Pays to be Specific!

Diagnosis Please: It Pays to be Specific!

By ASC Management, Revenue Cycle Management No Comments

Payors often update their clinical policies in ways that modify how ambulatory surgery centers and physicians must document their interactions with, and sometimes even how they treat, their patients. Staying informed of these updates is crucial to an ASC billing team’s success in obtaining the expected reimbursements. As surgical procedures proliferate, payors are demanding an increased focus on diagnosis specificity. Physicians, surgery schedulers, coders, and billing departments all have a role in expeditiously implementing payor clinical policy changes to ensure reimbursement losses are minimized when policies change.

For example, Aetna’s Clinical Policy Bulletin #0673 changed how ASCs approach meniscectomy cases – procedures billed via CPT codes 29880 and 29881. From Aetna’s perspective, meniscectomies billed without a current injury diagnosis are deemed experimental and investigational (not reimbursable). Therefore, at time of scheduling facility personnel should be able to anticipate whether the meniscectomy case will result in payment or denial based on the patient’s history. Surgeons who add time parameters and other adjectives to the patient’s post-operative notes can clarify the type of tear to ensure medical records and letters of medical necessity do not need to accompany the claim.

The time parameters acute, chronic, acute on chronic, and recurrent are important documentation factors in ICD-10-CM. The difference between billing a specified and an unspecified code may rely on one of these time parameters. Additionally, the distinction in the operative note between an old and a new injury assist coders with proper diagnosis specificity. The indications heading of the operative note is the ideal section to include details regarding injury, trauma, acute, chronic, recurrent, or degenerative conditions.

For example, without knowledge of the patient’s medical history, the postoperative diagnosis “right knee medial meniscus tear” is coded as “M23.231 – Derangement of other medial meniscus due to old tear or injury, right knee.” According to ICD-10-CM coding guidelines, if acute or chronic is not specified, the default diagnosis – chronic – must be assigned. Your surgery center coders should query the physician to obtain greater diagnosis specificity and to gain access to the History & Physical or other parts of the patient’s medical record that clarify the condition.

Ideally, a stand-alone diagnosis reads “medial meniscus tear of right knee, current injury” with a sentence in the indications section of the operative note such as: “The patient is an 18-year-old male who suffered an acute injury to his left knee while playing basketball.” This example yields diagnosis code “S83.231A – Complex tear of medial meniscus, current injury, right knee, initial encounter.”

Other key descriptive words to include about meniscus tears in post-operative documentation are:

  • Lateral, medial, bucket handle
    • Complex, peripheral, bucket handle

Sample key descriptive words to include in post-operative documentation about rotator cuff tears include:

  • Complete, incomplete, traumatic, non-traumatic, capsule

On average, it takes payors two weeks to issue a claim response (payment or non-payment). When the diagnosis specificity in the operative note is lacking and the carrier requests medical records, an additional 30-60 days is tacked onto the carrier’s payment processing time.

To improve claims processing efficiency, maintain open, direct communication between the patient’s record keepers and the ASC billing department. Regularly review medical necessity denials in the context of clinical policies and operative note documentation. Doing so ensures you are well apprised of payor clinical policy updates and minimizes reimbursement losses.

Bethany Bueno, Director of Billing Operations

What is Your Surgery Center’s Online Reputation?

What is Your Surgery Center’s Online Reputation?

By ASC Management No Comments

Trista Sandoval, Director of Business Development & Physician Relations, expands on an excerpt from PINNACLE III’s February 2017 White Paper “Looking Ahead: 10 ASC Trends to Watch in 2017.”

How is your online reputation management coming along this year? This question may seem intrusive. For those of us who have done nothing, it may seem flat out invasive. Many of us started the year with great intentions, perhaps even creating an initiative to develop an online reputation strategy, launch a program, or reach a target number of views or responses. For many, those objectives have fallen by the wayside, long forgotten whilst putting out day-to-day fires, onboarding new physicians, developing new service lines, or implementing new software.

Unfortunately, allowing online reputation to fall off our radar has negative ramifications. Why? Let’s start with what online reputation management is.

Online reputation management is the practice of crafting strategies that shape or influence the public perception of an organization, individual, or entity on the internet. It helps drive public opinion about a business and its services. Undeniably, it influences, and is influenced by, your overall reputation.

What happens when your reputation is tainted? Simply put, you lose business – and customers. In a market where the competition is high and physicians are known for being highly competent, experienced, certified professionals with proven track records, there is no room for a tainted reputation. Further, healthcare entities are beginning to favor models in which the patient experience is prioritized and continuously enhanced based on patient feedback.

Patients gravitate to their preferred provider through engaging websites, mobile-optimized scheduling features, healthcare portals where they can access their recent visit information, and pay-your-bill online features. With patients more responsible than ever for satisfying upfront co-pays and deductibles, they are more willing to research top healthcare options to obtain the highest quality, most cost-effective care.

In a study from Nielsen Report Global Trust Advertising and Brand Messages, consumers were asked to what extent they trust various forms of advertising. Ninety-two percent (92%) of individuals surveyed indicated they completely trust recommendations from people they know. Seventy percent (70%) responded that they completely trust consumer opinions posted online. This is significant, telling information on how our consumers perceive our brands and who influences their choices. It is no wonder healthcare organizations are prioritizing the patient experience and improvements based on patient feedback.

Every healthcare entity should be focused on learning how to better communicate with patients and how to better gain their trust when it comes to helping with surgical care needs.

If you find yourself in the category of most individuals who have completed little to no online reputation management efforts this year, or have put in limited effort, all is not lost. Start now!

First, identify what is being said about you. Managing reviews or creating operational changes that enhance your patients’ experience requires knowing exactly what your customers are relaying to others. Review top consumer resources – Google, Facebook, Yelp, etc. – to gauge the status of your online reputation. Take a moment to evaluate how your current online reputation differs, and aligns, with your online reputation goals.

Second, identify the platforms on which most of your patient reviews are being posted. This will be helpful in determining which platforms are most utilized and warrant efforts to improve your reputation as well as which platforms are under-utilized. You can then create your strategic initiatives based on how you want to tackle each platform.

Here are some helpful hints to remember when managing your online reputation:

1. Use Google Alerts to notify you when your brand is mentioned on the internet. You can also use the same method to alert you when your competition is mentioned to compare your popularity.

2. Respond timely to any negative reviews. Show customers you care about their experience and you value their input.

3. Remain factual. Ensure you carefully craft your responses.

4. Capitalize on bad reviews by improving your processes.

5. Avoid sharing protected health information (PHI), including pictures of patients or staff members.

6. Monitor your online platforms and identify potential pitfalls. If this is not your area of expertise, reach out to a trusted expert for guidance.

It is important you and/or your third-party advisor understand your market, industry, strategy, and goals. Define these in the early stages of your strategic planning.

Online reputation management is a process. There is no better time than now to start protecting and enhancing your brand in the digital world.

To uncover more ASC Trends in 2017, visit our white paper page.

Trista Sandoval, Director of Business Development & Physician Relations

We all Wear Many Hats – An ASC Staffing Guide

We all Wear Many Hats – An ASC Staffing Guide

By ASC Management, Leadership No Comments

Ambulatory surgery centers (ASCs) are cost effective because they employ a highly efficient staffing model. In addition to traditional roles various employees and departments perform, ASC administrators and facility staff assume other non-traditional responsibilities. Every staff member wears many hats on any given day. When hiring ASC personnel, it is imperative to outline for candidates all the duties expected of them, many of which often go beyond solely providing direct patient care. ASC leaders know staffing a surgery center requires flexibility and careful consideration.

How do you devise a staffing plan that incorporates the multiple roles staff will be expected to perform while ensuring your facility remains cost effective and efficient? In this post, we highlight some of the diverse functions your surgery center staff perform to help you visualize a plan for effectively allocating your ASC’s operational responsibilities among them.


A registered nurse is typically solely responsible for patient care. However, in an ASC, one or more nurses may also be tasked with facility infection prevention and/or monitoring the center’s adherence to the infection control program. Ensuring nurses complete infection control duties requires building sufficient time into the schedule. Infection control may occur during non-clinical hours, on slower days when the schedule permits, or by scheduling an extra nurse on certain days to allow infection control tasks to be routinely completed.

Surgical Technician.

A surgical technician takes charge of preparing operating rooms, ensuring all the necessary equipment is prepped and assembled. Due to the nature of their role, your ASC’s surgical technician may also function as your materials coordinator. Organization and prioritization are paramount for this dual role. As materials coordinator, the surgical technician will need to order supplies, check on special orders, receive products, document purchases, account for shipments received, and remain on hand to cover procedures. Specific ordering days can be established to ensure supplies are effectively managed. Consider adding an additional staff member on ordering days, or scheduling ordering on slower procedure days. Other team members may also assist with putting away received supplies and restocking supply areas.

Nurse Manager.

A nurse manager is expected to contribute to direct patient care while also attending to their administrative duties. A facility’s nurse manager typically maintains managerial authority over the entire clinical staff. As the title suggests, the nurse manager needs to possess expertise in both clinical and administrative duties, including direct patient care and staff management, respectively. An effective nurse manager is organized and competently harnesses the assistance of facility personnel to accomplish daily, monthly, quarterly, bi-annual, and annual tasks.

A clinical nurse manager can help alleviate some of the administrator’s burden by handling the administrative and hiring responsibilities of clinical staff, as well as monitoring the use of implants and corresponding reimbursement. This delegation works particularly well because nurse managers are often in close conversation with physicians where they can adeptly advocate for the use of more cost-effective implants. Train these leaders to manage their staff members and implants, and to operate with autonomy.

Clinical Staff.

There are many other roles your clinical staff will be expected to perform in addition to their direct patient care duties. Quality assessment and control, managing safety protocols, pharmacy ordering, and data input are a few examples. The person responsible for quality assessment and control will need allocated time to run reports, conduct research, compile items for meetings, assist with staff education, etc. The safety officer will need to conduct audits, assist with staff education, and compile items for meetings, among other tasks. Clinical staff must fulfill many important roles. They can accomplish smaller tasks between patients or as the schedule starts to slow down.

Front Office Personnel.

These employees wear multiple hats every day and many times in a day. They can be responsible for reception, registration, medical records, scheduling, verification and authorization of benefits, and patient collections. They may perform some HR functions assisting the administrator with onboarding, benefits administration, personnel file maintenance, and payroll. The unique skills they possess should not be overlooked when special projects or mini-task force committees arise.

The size of your facility and the processes you put into place will determine how many hats you need and who will wear them. Try to allocate tasks based on employee strengths.

Make a list of the crucial roles, then designate each role to a specific title (e.g., RN). Doing so will help you identify what type of person you may need to hire or move into each role.

Hire personnel who are willing to function in multiple roles. Understand this multiple role mindset may be a departure from an employee’s previous environment. Set expectations accordingly.

Incorporate time to achieve these multiple roles into your staffing schedule. Take advantage of low volume times. Set aside staffing time for special tasks/projects. Use flexible hours to effectively staff for projects and clinical time on the floor.

To employ the use of an efficient flexible staffing ASC model, ASC administrators and leadership teams must ensure staff have comprehensive job descriptions with clearly defined responsibilities that collectively cover the entirety of an ASC’s operational responsibilities.

These steps will help unleash the power of your ASC team.

Kelli McMahan, Vice President of Operations

Leadership Defined – Best Qualities of an ASC Leader

Leadership Defined – Best Qualities of an ASC Leader

By ASC Management, Leadership No Comments

Jennifer Post’s article, 11 Ways to Define Leadership, published in the leadership section of Business News Daily on March 29, 2017, listed qualities of highly effective leaders alongside relevant quotes from current leaders and business founders. I found many of the viewpoints on the definition of leadership useful for the ambulatory surgery center (ASC) industry. The author’s main point also struck a chord. She maintains leadership is subjective, but its foundation is formed from one thing – the ability to build consensus and establish a following among individuals and teams.

I have been fortunate to learn from highly effective ASC leaders. Those I admire possess a variety of styles, but at the core, they all build momentum around common clinical and business-related goals.

In evaluating the day-to-day behaviors of these effective surgery center leaders, I identified the things they did that were most inspiring to me. I paired each tenet of a good leader with relevant quotes on leadership from Ms. Post’s article. I created the following as a guide for myself in hopes I can integrate these leadership traits into my daily interactions with my surgery center teams.

Step 1: Care

Leadership is about people serving people, inspiring people, and caring about people. You must show you care through your daily actions.

Our surgery centers often lean on staff to be excellent in a fast-paced environment, which is what we are known for. However, this can leave staff feeling the pressure to keep up. It is important to provide our presence, support, education, and creative tools so staff feel equipped to deal with the day-to-day operations of their departments.

“Leadership is serving the people that work for you by giving them the tools they need to succeed . . . [Team members] should be looking forward to the customer and not backwards, over their shoulders, at you . . . [Give] genuine praise for what goes well and lead by sharing in the responsibility early and immediately if things go bad.” –Jordan French, founding CMO, BeeHex, Inc. 3D Food Printing

Step 2: Communicate

When a leader does not communicate well, team members don’t feel valued. Good communication involves listening, truly understanding, and respecting others’ opinions. ASC staff members must be critical thinkers and doers. Impromptu conversations with staff member about problems in the center can result in some of the best ideas to resolve them. This requires leaders to have conversations, ask for input, listen, and think before throwing out an idea.

“Any time you work with a group you should expect disagreement. You should embrace dissent. Teamwork isn’t about going along. It’s about hearing all views, admitting mistakes, and sharing risks and rewards jointly.” – Gary Kelly, CEO, Southwest Airlines

“In my experience, leadership is about three things: to listen, to inspire and to empower. Over the years, I’ve tried to learn to do a much better job of listening actively making sure I really understand the other person’s point of view, learning from them, and using that basis of trust and collaboration to inspire and empower.” –Larry Garfield, president, Garfield Group

Step 3: Have Character

Over-prepare, admit weaknesses, and allow others to assist you. This builds a culture where team members feel valued and fulfilled.

“Adversity does not build character, it reveals it.” –James Lane Allen, novelist

“Leadership is the ability to see a problem and be the solution. So many people are willing to talk about problems or can even empathize, but not many can see the problem or challenge and rise to it. It takes a leader to truly see a problem as a challenge and want to drive toward it.” –Andrea Walker-Leidy, owner, Walker Publicity Consulting

Step 4: Be Competent

Effective leaders know their business and their team. A competent leader is reflected in a competent team. Encourage and help your team gain certifications or specialized training that will make your facility better by providing staff members with gratification and betterment of themselves. Promote from within your organization to your leadership roles. Create your own OR nurses using peri-op 101. Hire clinical directors with the intent of nurturing them in ways that will allows them to assume administrator roles.

“To me, leadership is about playing to strengths and addressing weaknesses in the most productive and efficient way possible. It’s about knowing your team and yourself, and doing your best job to set both up for success.” –Samantha Cohen, co-founder, Neon Bandits

Step 5: Have Courage

As many times as things go right, they go wrong. Leaders need to be the ones sitting in front of a board owning up to mistakes made. However, if a leader can take the situation, apply corrections, and discuss that process, blame is removed so the problem can be fully dissected. If we look at every issue as a potential opportunity to prevent its recurrence, people stop avoiding the issues.

“A leader is someone who has the clarity to know the right things to do, the confidence to know when she’s wrong, and the courage to do the right things even when they’re hard.” –Darcy Eikenberg, founder,

Every leader has his or her own style and strategy, and every company its unique challenges. Recruiting and retaining talent in healthcare is a financial and intellectual investment. Effective leadership helps ensure we get the most out of the time and money we spend finding and training team members, because effective leaders build and retain top talent.

“There is no one-size-fits-all approach, answer key or formula to leadership. Leadership should be the humble, authentic expression of your unique personality in pursuit of bettering whatever environment you are in.” –Katie Christy, founder, Activate Your Talent

Jovanna Grissom, Vice President of Operations

1Business News Daily article March 29, 2017 11 Ways to Define Leadership

Managing difficult employee behavior

Help! My Employees are Keeping Me Awake at Night!

By ASC Management, Leadership No Comments

Lately, when faced with a work situation that taxes my emotional reserve and keeps me awake at night, I turn it on its head. I view the issue from a different perspective; change the tape that’s repeatedly playing in my brain by altering the order of the words.

For example, when I hear, “I’ve got a difficult employee and I don’t have a clue what to do,” I reframe the problem and respond with, “Let’s talk about the difficult behavior this person is exhibiting that is creating frustration for you in the workplace.” Shifting our dialogue to focus on the behavior rather than the person, creates a much-needed level of objectivity that allows for more effective problem solving.

Let’s face it, as leaders, we are bound to encounter employees who exhibit behaviors that are difficult to manage. An employee who simply fails to show up to work on time can create havoc in a facility. Being met with resistance when asked to perform a task in a specific way can derail a surgery center team’s attempts to ensure patient safety.

If you’re like most people, you don’t enjoy confrontation. So, you chalk the behavior up to “a bad day” or, when the behavior rears its ugly head consistently, excuse it with, “That’s just how Marianne operates. She’s not interested in hearing feedback.” But, it’s your job to deal with these behaviors effectively to minimize the ripple effects. The harsh reality is, if you don’t deal with difficult behaviors, the problems will only get worse. And, if you don’t document your actions, it is as if you never responded.

When you find yourself wondering why an employee is being so difficult, avoid succumbing to “stinkin’ thinkin’.” In other words, avoid personalizing the behavior.

Here’s an example. Tom, your receptionist/registrar, reports to the surgery center 10 to 15 minutes late every morning. He is responsible for checking patients in promptly. If he’s not there, patients either end up waiting for him to arrive or his co-workers must stop what they’re doing to perform his job. This is annoying enough on its own. But he has the nerve to saunter in with a Starbucks coffee in hand, jovially greeting everyone on the way to his workstation. The patients love him. They have no idea he’s the one who created the tension they sensed upon their arrival. As he settles into work, capably completing the tasks his co-workers have started for him, you overhear a steady stream of employees filing past your office muttering, “Really? He does this every day. Why does he insist on making everyone miserable? I’m tired of doing his job. Doesn’t he recognize we’ve got our own tasks to perform to ensure surgeries start on time?”

Tom, contrary to what is now popular belief, likely does not wake up every morning planning to upset everyone. He’s laid back – a strong suit when it comes to interacting with patients nervously anticipating their planned procedure – and approaches everything in stride, including sleeping through his alarm, a long line at Starbucks, and having to circle the parking lot three times to find an empty spot.

To deal effectively with Tom’s tardiness, it’s important to accurately identify the problem behavior. On the surface, it might appear the problem is slacking – showing up late because Tom wants others to perform his job. After all, that’s what his co-workers have surmised. However, after talking with Tom, you realize he is on a completely different wavelength. He truly is unaware his behavior negatively impacts the start of everyone else’s day.

Now that you’ve identified the true difficulty, you can effectively manage Tom’s future behavior by having a conversation with him. People who are on a different wavelength, need clearly defined communication that outlines expected results.

Your conversation may proceed along these lines. “Tom, I need you to be at your workstation ready to check in our first patient on time each morning. I expect you to clock in at 5:45, then immediately report to your desk to ensure you are prepared for 6:00 a.m. arrivals. Adhering to this regimen will serve our patients well. The value you bring to our organization will be enhanced when your co-workers realize they can rely on you to greet patients and get them checked in promptly. Our physicians will recognize a change in how quickly they are able to get started each morning. I’m going to document our conversation today as a coaching session. Now that you recognize how important it is for you to be on time to perform an essential requirement of your job, I’m confident you will figure out how to report to work promptly every day.”

I recognize this is only one example of dealing with a difficult behavior. And, more importantly, I’ve assumed the conversation went well. You talked to Tom, he saw the light, he altered his behavior, and being late to work is not something that occurs anymore. I’m aware, however, that’s not always the case.

My point is this: when you separate the person from the behavior, accurately identify the problem, and promptly address with the employee how their behavior impacts the organization, you have a much greater chance of achieving a successful outcome. Those successful outcomes will not only lead to a happier, more united facility, they will allow you to sleep much better at night!

Kim Woodruff, VP of Corporate Finance & Compliance