Wiki Outpatient surgery billing/reimbursement

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GretchenC123

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I am wondering if outpatient surgery centers get reimbursed for each cpt code. For example, for someone who goes in for multiple injections on different regions, such as cervical MBBB, Lumbar ESI, and Stellate Ganglion injection with MAC do outpatient surgery centers get reimbursed for each procedure billed separately? Or do they bundle like surgery centers? I am doing a bill review on a patient who had multiple injections and the bill type is 831. Thank you.
 
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In general, yes, OP surgery centers are subject to the same coding guidelines as other sites of service. The question is what the payment methodology is listed in the provider's contract with the insurance company. Are they on a fee schedule which is based on the procedure codes billed, is the contract allowance based on the APC methodology or is the provider reimburse based on a case rate?

It is hard to answer this question without knowing what the provider's contract states the payment methodology is.
 
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CBLENNIE said:
In general, yes, OP surgery centers are subject to the same coding guidelines as other sites of service. The question is what the payment methodology is listed in the provider's contract with the insurance company. Are they on a fee schedule which is based on the procedure codes billed, is the contract allowance based on the APC methodology or is the provider reimburse based on a case rate?

It is hard to answer this question without knowing what the provider's contract states the payment methodology is.
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I know and I apologize for the vague question. I do not have access to that information because all I have access to is the bills with codes. I do auditing for a 3rd party liability company for personal injury cases and we are at the mercy of valuing the billing based on UCR figures. Does that make sense? In general, it seems that OP surgery centers as opposed to ASCs bill higher and cost more due to more overhead costs.
 
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CBLENNIE said:
In general, yes, OP surgery centers are subject to the same coding guidelines as other sites of service. The question is what the payment methodology is listed in the provider's contract with the insurance company. Are they on a fee schedule which is based on the procedure codes billed, is the contract allowance based on the APC methodology or is the provider reimburse based on a case rate?

It is hard to answer this question without knowing what the provider's contract states the payment methodology is.
Click to expand...
I know and I apologize for the vague question. I do not have access to that information because all I have access to is the bills with codes. I do auditing for a 3rd party liability company for personal injury cases and we are at the mercy of valuing the billing based on UCR figures. Does that make sense? In general, it seems that OP surgery centers as opposed to ASCs bill higher and cost more due to more overhead costs.
 
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Just to clarify when you refer to an "outpatient surgery center" are you referring to an outpatient hospital surgery center (or an outpatient surgery center operated by a hospital) because in general an outpatient surgery center is the same thing as an ASC so I'm confused on what type of facility you would be considering an outpatient surgery center.

If the outpatient surgery center you are referring to is affiliated with or operated by a hospital, then yes, the fees are typically higher and an ASC. If you are referring to some other type of facility as an outpatient surgery center, then I don't have an answer for you because I'm unfamiliar with what an outpatient surgery center is.
 
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CBLENNIE said:
Just to clarify when you refer to an "outpatient surgery center" are you referring to an outpatient hospital surgery center (or an outpatient surgery center operated by a hospital) because in general an outpatient surgery center is the same thing as an ASC so I'm confused on what type of facility you would be considering an outpatient surgery center.

If the outpatient surgery center you are referring to is affiliated with or operated by a hospital, then yes, the fees are typically higher and an ASC. If you are referring to some other type of facility as an outpatient surgery center, then I don't have an answer for you because I'm unfamiliar with what an outpatient surgery center is
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It sounds like a physician owned hospital, which are typically less expensive than OP hospitals facilities but more expensive than ASCs. This is likely why you are seeing higher charges from the OP surgery center compared to an ASC. In actually, an OP surgery center which is a physician owned facility should not be substantially more than an ASC as they operate in much the same way so I don't know why their services would be so much more than an ASC. A search of the NPI registry (NPI # 1710595996) shows that their primary taxonomy code is for an ASC but they also have taxonomy codes for a multi-specialty group, a neurological surgery and a clinical lab.

1697144734984.png

According to the following blurb on their website they are an ASC but are also calling itself an OP Surgery Center. I think they may just charge more than other facilities in your area.

1697144961190.png
 
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CBLENNIE said:
It sounds like a physician owned hospital, which are typically less expensive than OP hospitals facilities but more expensive than ASCs. This is likely why you are seeing higher charges from the OP surgery center compared to an ASC. In actually, an OP surgery center which is a physician owned facility should not be substantially more than an ASC as they operate in much the same way so I don't know why their services would be so much more than an ASC. A search of the NPI registry (NPI # 1710595996) shows that their primary taxonomy code is for an ASC but they also have taxonomy codes for a multi-specialty group, a neurological surgery and a clinical lab.

View attachment 6492

According to the following blurb on their website they are an ASC but are also calling itself an OP Surgery Center. I think they may just charge more than other facilities in your area.

Thank you so much for helping me. What I see are providers who jack up the prices of procedures and office visits because it is a personal injury case. I work in the field of 3rd party liability insurance. I see fraudulent billing and practices because these cases are litigated and the patients are represented by plaintiff's attorneys, so they can technically bill whatever they want.
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