Wiki Room Fee for Out-Patient Surgery

[GinaLea77]

Our procedures are done on an out-patient basis in a office setting. Our provider would like to charge a room fee for these procedures. Is this allowed? If so, how would I bill the room fee to insurance.

Stumped.
Gina

 

[thomas7331]

Our procedures are done on an out-patient basis in a office setting. Our provider would like to charge a room fee for these procedures. Is this allowed? If so, how would I bill the room fee to insurance.

Stumped.
Gina

No, the charge for the room is considered a part of the fee paid for the surgical CPT code - your provider is already getting a fee for performing surgeries in the office that is more than that which would be paid if the procedure was done in a separate outside facility, and the reason that fee is calculated to be higher is because it includes the office's overhead costs.

If the provider feels the charge for the surgery isn't sufficient to cover the costs of the room, then the fee for the surgery can be increased. Of course, for Medicare and any payers with whom the provider has already established contracts, it won't change the amounts of the payments.

 

[csperoni]

Many years ago, my practice used to have a AAAASF certified surgical suite. It was really built for the convenience of the provider, but we did think we would more than break even for it. At the time, there was not a local surgi-center, and when performing minor procedures at the hospital, we were limited by the amount of time the hospital would give us.
Unfortunately, when you factor the additional costs (staffing, equipment, maintenance, certification), we were actually losing money on many procedures. Also, because we were a 1 physician practice, the space was only being used 1 day/week. For us, we decided we would sublet the surgical suite (and employees if wanted) to other local physicians doing similar types of procedures. That additional revenue allowed us to do a little better than break even on the space. There were some shady consultants who suggested we should bill as an ASC and out of network. When I did a little research, 1) many insurances had caught onto this process and were no longer paying, 2) it was just way too suspicious for my comfort. I did reach out to all of our contracted payors and 2 agreed to pay an additional small flat fee for keeping patients out of the hospital for very minor procedures. Most of the carriers simply have a site of service differential that (in theory) pays you for all the additional expenses incurred doing the procedure in office.
Once there was a local ASC and we were acquired by a large hospital system, we decided to discontinue the surgical suite.
I will also note - depending on what type of setup you have, and your state requirements, you MAY (big MAY) be able to get your procedure room certified to bill as an ASC for SOME insurances. It is a very involved legal process and you must follow all state requirements to remain compliant. We looked into it, but for NY, you basically must be an entirely separate space.
Summary:
1) Reach out to your contracted payors to find out IF they will even consider paying additional for in office procedures. For me, it was 2 from dozens of payors.
2) Find out your fee schedule for procedures in office vs in hospital. Decide for each of these procedures whether or not it's cost effective to perform in office. Even if the insurance pays an additional $650, but you must use $700 in disposable equipment, then don't perform that procedure in office.
3) If after doing some research, you believe your state may have very open interpretations for ASCs, then involve experts to confirm this and create all the necessary legal and compliant steps.