# office based surgical suite vs outpatient and inpatient hospital



## j.monday7814 (Mar 9, 2015)

My vascular surgeons have been performing office based surgeries for over a year and a half with great success. Now they are interested in submitting a paper to the SVS (Society of Vascular Surgeons) demonstrating their results and the cost savings to the payer. Unfortunately it is extremely difficult to get a side-by-side comparison of office payment vs outpatient or inpatient hospital payment. I've reached out to a couple of our local hospitals but they won't respond. Anyone have experience with hospital billing that may be able to help me do an accurate comparison? Or does anyone have any references or sources that would help?

Thanks in advance.


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## eagendj (Mar 9, 2015)

I would start with looking up the Medicare fee schedule.


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## j.monday7814 (Mar 9, 2015)

eagendj said:


> I would start with looking up the Medicare fee schedule.



that doesn't give a side-by-side comparison of claims and potential payment. It only provides the "facility" fee for the the CPT codes.


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## j.monday7814 (Mar 17, 2015)

I could really use some expert advice and guidance with this issue please....


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## mitchellde (Mar 17, 2015)

woldnt the fee schedule be exactly what youy need. What the actual total fee if performed in the facility is the facility fee plus the physician fee in either the POS 22 or 21.  and if performed in the office is only the provider fee POS 11.  Soyou will need to look up the facility fee plus the physician fee from the Medicare fee schedule but then the physician fee schedule is broken down to the different POS.  I know of no other way to do this.


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## j.monday7814 (Mar 17, 2015)

for the outpatient comparison that is as far as I can get as well. But I've heard that even on the outpatient setting that the hospital can bill for certain supplies that we (office-based surgery) cannot. Also, the inpatient comparison seems extremely difficult because that large DRG payment is meant to encompass many more services than would ever be performed in an office based surgical center, correct?

Also, if we stick to outpatient vs office-based comparisons only and base it off of the fee schedule than outpatient hospital is reimbursed the exact same as office-based, correct? as an example, we bill 37227, 75716, 75625 for a "typical" lower extremity intervention and I need to know exactly how that same claim would translate to an outpatient hospital reimbursement.


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## mitchellde (Mar 17, 2015)

I know what you are getting at , however, (bear with me now) if you are wanting to prove that the office based procedure can go head to head with either outpatient or inpatient based then from a cost comparison all the expenses that make up the DRG is what you are going up against.  Your trying to make an argument that this procedure can be safely and more cost effectively be performed in the physician office setting.  So you will have to take the entire DRG reimbursement on head to head. As far as outpatient goes.. When the facility is reimbursed it is for the overhead cost of providing the space, personnel, and supplies for that procedure.  This is why the procedure codes must match.  So the total cost of a procedure performed in the outpatient setting is the facility fee plus the physician fee in the POS 22.  Again you will have compare this total to the physician fee in a POS 11.  Head to head.


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## j.monday7814 (Mar 17, 2015)

alright, so I must have been over estimating or over calculating the comparison. so as far as the insurance company's total payment is concerned there is no financial difference between billing this service outpatient hospital or office-based surgery.

as for the inpatient comparison, it won't be easy or fair by any means. inpatient procedures are for higher risk patients and we only perform procedures on low risk patients so trying to compare our payments will not be easy. Or we could compare them only to inpatient DRG w/o MCC...but that still isn't a fair comparison.


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## mitchellde (Mar 17, 2015)

Correct there should be little to no difference between billing the same service as outpatient vs physician office.  The inpatient issue there is no way to compare the severity of the patient in terms of being reimbursed for a procedure.  The best you can get is by the provider qualifying that on those patients with certain other issues they would never consider office based as an option.  They would need to list out what those qualifying conditions would be.    I am not sure what the purpose of this paper is to be so it is hard to imagine the point.  If this procedure is currently not allowed in an office setting, then how have you been paid for those performed over this last year.  If this procedure can be performed in the office or outpatient or inpatient, then what point is being made with the paper?


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## j.monday7814 (Mar 17, 2015)

These procedures have been allowed in the office setting and we've been reimbursed as expected. The paper will be presented during an SVS conference and the physicians would like to demonstrate the cost savings to the healthcare system, patient safety and overall higher satisfaction. This was motivated by an article in the New York Times about physicians abusing "office-based" surgeries and putting patients at risk for increased complications while pocketing a higher profit. Apparently the cost savings is not as extreme as we had imagined. The interesting part though is that there have been articles published about the cost savings benefit but it is not clear where that data came from.


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## mitchellde (Mar 17, 2015)

Ah I see.  It helps to know the motivation.  I don't think you will find the dollars you are wanting.  They may be looking only at the hospital DRG and not the outpatient figures.  I wish I could have been more helpful.


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## j.monday7814 (Mar 18, 2015)

not at all, that info was plenty helpful. thank you


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