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Answer: This is a common problem with interventional radiology practices but, unfortunately, there is no encouraging answer about separate payment for supplies. Perhaps the most frequently performed in-office procedures are breast biopsies, while similar services such as insertion of PICC lines, paracentesis, thoracentesis, thyroid and liver biopsies, and insertion of chemotherapy and dialysis lines are becoming more common. During these procedures, medical supplies such as biopsy needles, surgical trays, catheters, dressings, sutures, guides, scalpels and puncture sets are used.
These and similar costs are reimbursed separately when the procedures are performed in a hospital outpatient setting or through an ambulatory surgical center. Even though HCPCS Codes exist for many of these items (e.g., A4550 for a surgical tray), they generally are not separately paid by most payers when done in an office.
While this seems discriminatory against offices, there are two fee schedule amounts for these types of procedures one for hospital and one for office settings. The office-setting schedule amount is higher and designed to cover the cost of all the drugs, supplies and equipment used during an in-office service. For example, in South Carolina, for 36489 (placement of central venous catheter [subclavian, jugular, or other vein] [e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2) Medicare reimburses $74.75 in the hospital setting and $142.62 in the office setting. Practices should set their fees high enough to allow these costs to be fully captured from Medicare (i.e., if a practice in South Carolina is charging less than $142.62, they would only recoup the amount billed, not the allowed $142.62).
Because the HCPCS codes exist, radiology practices may certainly submit them even though they wont get paid. This raises a second issue. According to most states unfair-trade-practices legislation, claims submitted to and subsequently denied by an insurer must then be charged to the patient. This practice, in essence, will increase the out-of-pocket expenses incurred by patients and probably damage your relationship with them.
One additional complication exists: Practices lose even their opportunity to bill and collect from Medicare patients if those patients have signed an advanced beneficiary notice (ABN). Under Medicare rules, an ABN alerts patients that they might be liable for a portion of the charges if Medicare denies the service as not covered. Medicare generally denies payment for supplies used during in-office procedures, however, because it considers them to be already included in another service, which is considered not covered by the language in the ABN.
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