In-office surgical suite

Klynch49

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Can anyone help with the coding/billing for a new in-office surgery suite? I have googled this but am not having any luck with guidance.
i.e can it be billed with POS 11 and can we get a facility fee
 

SharonCollachi

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If you are not licensed as an ASC (Ambulatory Surgical Center), then you cannot bill facility fees.

You will handle billing the same way you do for office visits. POS 11. Bill for medications, supplies not normally included in the procedure, fluoroscopy if you are using it and paying for it (meaning the fluoro company is not doing their own billing, but you are paying them a flat fee for the day, for instance), ultrasound guidance if you use it and it is not already included in the procedure code (make sure you keep the images or you cannot bill for it), moderate sedation if you are doing that, etc. All wrapped up in a written report.
 

Klynch49

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Thank you! We are not licensed as an ASC, but licensed by the State of Florida as a Level III in-office surgery suite. Would this make a difference?
 

SharonCollachi

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Becker's Healthcare Review states this:

Accreditation for Office Based Surgery vs. Ambulatory Surgery Centers: Frequently Asked Questions

Office-based surgery accreditation:

Twenty-six state health departments plus D.C. have jurisdiction on office based surgery meeting various thresholds. The most common specialties performing office based surgery are pain management, plastic surgery and GI. The requirement is typically based on the levels of anesthesia used and/or complexity of procedure performed. For instance, New York and Pennsylvania refer to pain management as "invasive and complex" regardless of whether anesthesia or moderate sedation is used with the procedure. The twenty-six health departments include Alabama, Arizona, California, Colorado, Connecticut, DC, Florida, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Mississippi, Nevada, New Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia and Washington. Delaware will implement by the end of 2012. Accreditation by a third party is the most typical way of satisfying the office based surgery state regulation. A few states however, require their own survey. In either case, both the state regulations and the accreditation standards will have governance.

Frequently asked questions:

Q: Once accredited, can I bill facility fees?
A: Office-based accreditation is NOT an avenue to receive facility fees
. Local and state law, and third party payer policies (commercial and workers' comp) typically require the facility to be licensed and certified in order for facility fees to be paid. There have been cases of what the prosecution labeled as wire and mail fraud for billing facility fees outside of the ASC program. Insurance companies have also visited office-based surgery practices in an attempt to show a scheme to defraud the insurance company.

Q: I see the Medicare standards listed in the accreditation manual. Does that apply since our office based surgery practice treats Medicare beneficiaries?
A:
No. CMS is the authority having jurisdiction for ambulatory surgery centers only. CMS does not govern office-based surgery. The standards shown in accreditation manuals are for those ASCs seeking deemed status Medicare surveys from the accreditation body. The Medicare conditions of participation, also known as the state operation manual, are regulations that all ASCs must meet in order to be recommended for participation in the Medicare program as a provider of surgical services (certification).

More here.

*******************************************************************************************************************

A lot of info from the Florida Public Health Department, to show what types of procedures can be done:
Q: What are the different levels of office surgery?
A:
Level I office surgery includes, but is not limited to, the following:
  1. Minor procedures such as excision of skin lesions, moles, warts, cysts, lipomas and repair of lacerations or surgery limited to the skin and subcutaneous tissue performed under topical or local anesthesia not involving drug-induced alteration of consciousness other than minimal pre-operative tranquilization of the patient.
  2. Liposuction involving the removal of less than 4000cc supernatant fat is permitted.
  3. Incision and drainage of superficial abscesses, limited endoscopies such as proctoscopies, skin biopsies, arthrocentesis, thoracentesis, paracentesis, dilation of urethra, cysto-scopic procedures, and closed reduction of simple fractures or small joint dislocations (i.e. finger and toe joints).
  4. Pre-operative medications not required or used other than minimal pre-operative tranquilization of the patient; anesthesia is local, topical, or none. No drug-induced alteration of consciousness other than minimal pre-operative tranquilization of the patient is permitted in level I Office Surgery.
  5. Chances of complication requiring hospitalization are remote.
Level II Office Surgery is that in which peri-operative medication and sedation are used intravenously, intramuscularly, or rectally, thus making intra and post-operative monitoring necessary. Such procedures shall include, but not be limited to: hemorrhoidectomy, hernia repair, reduction of simple fractures, large joint dislocations, breast biopsies, colonoscopy, and liposuction involving the removal of up to 4000cc supernatant fat. Also, includes any surgery in which the patient is placed in a state which allows the patient to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and/or tactile stimulation. Patients whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than encompassed by this definition.

Level III Office Surgery is that surgery which involves, or reasonably should require, the use of a general anesthesia or major conduction anesthesia and pre-operative sedation. This includes, but is not limited to, the use of:
  1. Intravenous sedation beyond that defined for Level II office surgery;
  2. General Anesthesia: loss of consciousness and loss of vital reflexes with probable requirement of external support of pulmonary or cardiac functions; or
  3. Major conduction anesthesia.
Only patients classified under the American Society of Anesthesiologist’s (ASA) risk classification criteria as Class I or, II, are appropriate candidates for Level III office surgery.


Q: What should be recorded on the surgical log?
A:
The items required on the surgical log form are:
  • Confidential patient identifier
  • Time of arrival in the operating suite
  • Name of the physician who provided medical clearances
  • Surgeon's name
  • Diagnosis
  • CPT Codes <-------
  • Patient ASA classification
  • Type of procedure
  • Level of surgery
  • Anesthesia provider
  • Type of anesthesia used
  • Duration of the procedure
  • Type of post-operative care
  • Duration of recovery
  • Disposition of the patient upon discharge
  • List of medications used during surgery and recovery
  • Any adverse incidents, as identified in Section 458.351, F.S.
More info here.
 

Klynch49

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Back at this again.....Florida Board of Accreditation of a Level III surgery center, stand alone building with it's own Tax ID and NPI. What place of service code would be used?
 

SharonCollachi

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I love your challenging questions, by the way. I dig the research. One of the positives about being in your position, is that if you have an office that uses the same waiting room as your surgical suite, you can have both open at the same time unless there is a prohibition against it buried deep in the Florida regs (an ASC cannot use shared spaces, including waiting rooms, at the same time that an attached physician's office is open).

Since it the facility is not allowed to bill facility fees, then it stands to reason that it cannot have a place of service for which you would get paid less than in an office. A procedure in an office pays more to the provider than the same procedure in a facility, because in the office, the provider is footing the bill for the overhead, but in a facility, the facility is footing the bill for the overhead.

Having just browsed through the place of service codes, and tossing aside all the ones that designate a facility, I'm going with 11, Office. I wonder, though, if you may get denials for some of what you would bill. For instance, you can do procedures that cannot be done in an office because of the level of anesthesia involved. I did find some other people that are in this same predicament over the last couple of years, and they use POS 11. I also found a presentation by someone whose credentials appear legit (although she IS trying to sell her services in setting up an office-based surgery center for providers, so there's that), and she says it is POS 11.

I just double-checked on that person's data for my area for Medicare, and dang, but I may be recommending this to my own boss! I know your expenses are substantial, because you need staff that have a license level high enough to do an IV, you need someone to monitor anesthesia (cannot be operating surgeron), you need supplies, etc., etc.

22513 - $532 in facility; $7,264 in office (percutaneous vertebral augmentation... using mechanical device (eg, kyphoplasty), 1 vertebral body, includes imaging, thoracic)
37227 - $737 in facility; $15,850 in office (revascularization, endovascular, open, femoral...) - okay, not our specialty
37243 - $592 in facility; $10,527 in office (vascular embolization or occusion.., for tumors, organ eschemia, or infarction) <-- yeah, neither is this one

62321 - $113 in facility; $278 in office (Interlaminar epidural or subaranoid, cervical, or thoracic, with imaging) <-- this is more of what we do, dangit
64510 - $80 in facility; $149 in office (stellate ganglion block) <-- yeah, this one too.
 

Klynch49

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You state that we share a waiting room. This is not the case. The office is located at one address and the surgery center is located at another address in a building built to specifications of an ASC. It contains all the elements of an ASC, just not accredited as an ASC. Also meaning we cannot service Medicare patients. It is accredited by the State of Florida and also AAAASF certified
 

csperoni

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From my experience, if you are not Article 28, you cannot bill/get paid as a facility and your POS is 11. You will get the site of service differential for non-facility, but not a facility fee. The certification you have is for OFFICE based surgery.
Our office had a AAAASF surgical suite. Years ago, some outside "consultants" tried to convince us that we could/should bill separately as a facility (for non-Medicare only) as out of network, but that just didn't sound right to me. My research showed that basically this used to occur all the time. Insurance companies caught onto this practice and adjusted their policies to only pay facility fee if Article 28. Some insurance companies (definitely Aetna, maybe also United HealthCare?) legally went after practices that did this to recoup years of payments, stating it was fraud.
Here's a post by me about the whole situation. https://www.aapc.com/discuss/threads/office-based-surgery-facility-billing.90780/

This is my personal opinion regarding surgical suites that are not Article 28:
You will not make any significant amount of money. You are lucky if you do more than break even.
If possible, become Article 28 and bill facility fees. If you cannot, there are situations where it may still make sense to build out such a surgical suite. Examples would be a large group of physicians where the surgical suite is in use most days. Otherwise, rent it to other physicians, who would need to credential with insurances as an additional office location.
It can also depend on the exact procedures being done. Some procedures have a significant site of service differential that more than makes up for your additional expenses.
 

SharonCollachi

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You state that we share a waiting room. This is not the case. The office is located at one address and the surgery center is located at another address in a building built to specifications of an ASC. It contains all the elements of an ASC, just not accredited as an ASC. Also meaning we cannot service Medicare patients. It is accredited by the State of Florida and also AAAASF certified
I said IF you share a waiting room... just pointing out some of the positives.
 
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