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brendahealy

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We are a neurosurgery practice thinking of adding on-site pain management services with a physician who is Board Certified in Anesthesiology with Subspecialty Certification in Pain Medicine.

We have several questions...

Will our clinic be considered an ASC since procedures are being performed at our office location? If so, how do we bill these services? Would we be reimbursed by Medicare from the ASC reimbursement schedule or simply the Part B Physician reimbursement schedule?

Lastly, would any of you be willing to speak with me directly?

Thanks!!
 

dwaldman

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Performing the epidurals and other pain managment procedure in an office setting would not generate a facilty fee. Medicare for example has a site of service differential which you would bill the procedure such as 62311 and the drug such as J1040 and the non-facilty reimbursement in office setting would be higher to cover the practice's expense of providing the location, staff, supplies. Reviewing this difference can give you idea if this would be adequate to be able to take it on.
The below consulting firms website has reimbursement amounts and displays facility versu non facility payment

http://www.mowles.com/Euseful_links.html

Below can describe the difference of distinction between 24 and 11 POS

Special Consideration for Ambulatory Surgical Centers (Code 24)
When a physician/practitioner furnishes services to a patient in a Medicare-participating ASC, the POS code 24 (ASC) will be used.
NOTE: Physicians/practitioners who perform services in a Medicare-participating ASC will use POS code 24 (ASC). Physicians are not to use POS code 11 (office) for ASC based services unless the physician has an office at the same physical location of the ASC which meets all other requirements for operating as a physician office at the same physical location as the ASC – including meeting the “distinct entity� criteria defined in the ASC State Operations Manual that precludes the ASC and an adjacent physician office from being open at the same time -- and the physician service was actually performed in the office suite portion of the facility. That information is in Appendix L of that manual which is at http://www.cms.gov/manuals/Downloads/som107ap_l_ambulatory.pdf on the CMS website.



If performed in an office setting you would be place of service 11

If the location is considered an ambulatory surgical center, there would be an accrediation process to be able to receive payment as ASC and NPI for the ASC would be provided.

Below is from the CMS Claims processing manual/ASC State operations manual that describes similiar to above that within an ASC, they do not let a physcian office and ASC share waiting rooms and other areas while operating during overlapping hours.

Page 34

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//som107ap_l_ambulatory.pdf


Distinct Entity
An ASC satisfies the criterion of being a “distinct� entity when it is wholly separate and clearly distinguishable from any other healthcare facility or office-based physician practice. The ASC is not required to be housed in a separate building from other healthcare facilities or physician practices, but, in accordance with National Fire Protection Association (NFPA) Life Safety Code requirements (incorporated by cross-reference at §416.44(b)), it must be separated from other facilities or operations within the same building by walls with at least a one-hour separation. If there are State licensure requirements for more permanent separations, the ASC must comply with the more stringent requirement.
An ASC does not have to be completely separate and distinct physically from another entity, if, and only if, it is temporally distinct. In other words, the same physical premises may be used by the ASC and other entities, so long as they are separated in their usage by time. For example:
• Adjacent physician office: Some ASCs may be adjacent to the office(s) of the physicians who practice in the ASC. Where permitted under State law, CMS permits certain common, non-clinical spaces, such as a reception area, waiting room, or restrooms to be shared between an ASC and another entity, as long as they are never used by more than one of the entities at any given time, and as long as this practice does not conflict with State licensure or other State law requirements. In other words, if a physician owns an ASC that is located adjacent to the physician‟s office, the physician‟s office may, for example, use the same waiting area, as long as the physician‟s office is closed while the ASC is open and vice-versa. The common space may not be used during concurrent or overlapping hours of operation of the ASC and the physician office. Furthermore, care must be taken when such an arrangement is in use to ensure that the ASC‟s medical and
administrative records are physically separate. During the hours that the ASC is closed its records must be secure and not accessible by non-ASC personnel.
Permitting use of common, non-clinical space by distinct entities separated temporally does not mean that the ASC is relieved of the obligation to comply with the NFPA Life Safety Code standards for ASCs, in accordance with §416.44(b), that require, among other things, a one-hour separation around all physical space that is used by the ASC and fire alarms in the ASC.
It is not permissible for an ASC during its hours of operation to “rent out� or otherwise make available an OR or procedure room, or other clinical space, to another provider or supplier, including a physician with an adjacent office.
 
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