Wiki Office-based procedures vs. ASC

[ksobota]

Our physician has been doing lipoma removals in the office. Recently we have had one pay and is now going to recoup and another flat out denial because it was not done in an ASC. The procedures are soft tissue excisions.

He would like a list of these procedures or a way to verify before hand what he can do in the office and for the life of me (and my associate) we can not figure out how to determine this. She's scoured books and I've scoured the internet looking for a list from Medicare or anything to show me what procedures can and can not be performed in the office.

Does anyone know of a resource that can help us? Or are we missing a sign somewhere?

 

[DiMuchow]

office vs ASC

I think the next thing you can do is check with ALL your payers and review your contracts with them to see if there is anything there that will tell you whether these will be paid. You might want to include something in the future if the physician plans to do a lot of these procedures.

If you have a rep with each payer that you work with, they should be able to help you. Why did the one payer tell you it has to be done in ASC? Unfortunately, some insurance claims reps are simply going off written rules, and they know very little medical terminology, etc. They've probably always seen these come through from an ASC so they think it has to be done there! You might have to have a discussion with a medical director to explain why/how the procedures are being safely done in the office, or pursue it through medical review. Sometimes the determining factor may be something like "conscious sedation has to be done in ASC". And, I know Medicare has "secret" edits they don't make public until you stumble across one and it results in a denial.

Hopefully, someone with direct experience in something like this will step up and give you some insight. Good luck!

Diane Muchow, CPC
Adjunct Instructor
Computer Systems Institute