For the purpose of this project and analysis there are two types of surgical procedures. Updated Sep 2021.
| Facility OR office-based | Facility-Only | |
| 1 | Those that can be performed in the office or a facility (ASC, hospital outpatient department [HOPD] or hospital). | Considered “Facility-Only”. |
| 2 | There is a Site of Service Differential. Physician compensated for use of office surgical suite. | No Site of Service Differential. No compensation for office surgical suite. |
| 3 | Facility PE (Practice Expense) RVUs and Non-Facility PE RVUs are different. | Facility PE RVUs and Non-Facility PE RVUs are the same. |
| 4 | The office overhead reimbursement is included in the NON-FAC PE. This is essentially a “facility fee” for the office (POS=11). | The facility reimbursement is separate from the FAC PE. ASC, hospital outpatient, or hospital are paid separately. |
| 5 | Applies to both 90-day and 10-day procedures; 10-day procedures generally have lower RVU’s. | More 90-day procedures (but not all). Procedures are generally more complicated or risky. |
| 6 | These can be routinely performed in the office. There is no issue. | Not routinely performed in the office. Our focus is on these procedures. The issue is migrating procedures traditionally performed in an ASC to the office. |
“Facility-only” procedures are typically more complex, have higher total RVUs, require regional or general anesthesia, and have a higher level of risk (patient safety). Some are more apparent than others. Exceptions abound. Some complex procedures have a Site of Service Differential and some minor procedures do not. An office-based surgery (OBS) is submitted on one form, the CMS-1500, by the physician; when performed in the facility, two claims are submitted: the CMS-1500 form by the physician and a UB-04 claim form by the facility for facility fees.
An example is given below. Open carpal tunnel release has a Site of Service Differential and is therefore considered an office or facility procedure. Endoscopic carpal tunnel release is considered “facility-only” and there is no Site of Service Differential (the Facility PE and the Non-Facility PE are the same). While the procedure may be reimbursed if performed in the office, there would be no compensation for the use of the office surgery suite.
29848: Endoscopy, wrist, surgical, with release of transverse carpal ligament (ECTR)
Procedure 29848 priced for 1/29/2021 (No Site of Service Differential)
| Procedure 29848 priced for 01/29/2021 | Atlanta GA | ||
| Medicare Facility | Medicare Non Facility | ||
| Global | Allowed | $521.78 | $521.78 |
| Reimbursement | $417.42 | $417.42 | |
| After Sequest | $409.08 | $409.08 | |
| RVUw | 6.39 | 6.39 | |
| These are the same | RVUpe | 7.51 | 7.51 |
| RVUm | 1.23 | 1.23 | |
| RVU total | 15.12 | 15.12 | |
| Global period: 90 days |
In the Table above we see the Work RVU’s (RVUw), the Practice Expense RVU’s (RVUpe), and the Malpractice RVU’s (RVUm). Together these are total RVU’s for the procedure.
The Facility reimbursement and Non-Facility reimbursement PE RVUs, above are the same (7.51). This amount is what the clinic needs to negotiate, individually, with all of your main carriers. The ASC facility reimbursement, for CPT code 29848 is roughly $713 and paid separately to the ASC.
There are 1,174 orthopedic procedures that fall into this “facility-only” category. A complete list is available on the website. There is also a shorter list of 97 hand-and-wrist procedures that might lend themselves to WALANT.
64721: Neuroplasty and/or transposition; median nerve at carpal tunnel
Procedure 64721 priced for 1/29/2021
| Procedure 64721 priced for 01/29/2021 | Atlanta GA | ||
| Medicare Facility | Medicare Non Facility | ||
| Global | Allowed | $443.98 | $451.64 |
| Reimbursement | $355.18 | $361.31 | |
| After Sequest | $348.08 | $354.09 | |
| RVUw | 4.97 | 4.97 | |
| Different Values | RVUpe | 6.9 | 7.13 |
| RVUm | 1 | 1 | |
| RVU total | 12.87 | 13.1 | |
| Global period: 90 days |
There is a Site of Service differential for OCTR but it is only $6.14 (.24 RVU’s)! The ASC facility reimbursement, for CPT code 64721 is $796.79 or over 10X the amount. One could question why is the OCTR facility reimbursement higher than ECTR facility reimbursement? I don’t know the answer. In this case, there is compensation for performing the procedure in the office (Non-FAC PE) but it is very low. There are 471 orthopedic codes with a positive SOSD. But there are over a thousand with a zero SOSD.
The challenge is to work with clinics, surgeons, and professional associations to negotiate proper Non-FAC PE (overhead/facility fee) reimbursement from the insurance company for office-based (ECTR)(short-term) and lobby the AMA and Medicare to establish NON-FAC PE’s for ECTR (long-term). There are dozens of orthopedic procedures that fall into this category.