Wiki DRG - ASC - Work Comp

[574coding]

Hello,
We bill for an ASC and the provider will do some procedures that are considered to be in-patient codes per the APC book. We have been asked to figure out how much a hospital will bill and be reimbursed for the procedure in order for a LOA to be signed by the adjuster / case manager for payment to the ASC. Does anyone have any experience with this?
Thank you

 

[MarcusM]

You could look at the CMS fee schedule or the AAPC Coder tool for the specific CPT codes in your locale and work up an amount from that.

 

[574coding]

Wouldn't that give me the Medicare allowed amount at a ASC and not what the hospital would be paid?

 

[MarcusM]

http://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

This gives allowables for facility and non-facility services. You will need to do a cost analysis to determine all the fixed costs and the variable costs associated with a specific procedure/service for your facility and work with the allowables to give you an idea to present to the carrier for the LOA to provide specific services at a specific price/reimbursement. Essentially you are bidding for a contract to provide quality medical services at a rate lower than the hospital rates but you also need to make sure you cover all of your overhead costs and not lose money.