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Office Procedures

Discussion in 'Pain Medicine' started by PainDr, Mar 12, 2006.

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  1. PainDr

    PainDr

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    For those of you doing procedures in the office, how is such a system set up. You'd have to have a pre/post procedure area. If you have a 3-4 bay holding area, plus 1-2 procedure rooms, how is this any different than a small ASC? What kind of regulatory/accreditation requirements are there? Also, in such a system, are you using RNs or CRNAs for sedation. Thanks.
  2. drpainfree

    drpainfree

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    any answer for these questions?

    what's the difference between this office set-up vs. ASC?

    what regulation/accreditation is required
  3. algosdoc

    algosdoc algosdoc

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    For the most part, offices not rendering any sedation or conscious sedation only (patient still responding verbally) are unregulated, and you don't need recovery bays and pre-op areas. For offices giving sedation, the regulation is state by state using "Office Anesthesia Regulations" that were developed after the 13 deaths due to surgical (not anesthesia) complications in Florida several years ago. The naive regulators believed the problem was anesthesia when the issues was dumb surgeons doing massive liposuction causing hypotension and cardiac arrest while giving their own sedation. Typical surgeons....blamed the sedation. Thus, several states bought into the hysteria and developed office anesthesia rules when they really needed brain-dead surgeon rules.
    The office anesthesia rules typically involve a set up similar to an ASC but with less stringent requirements. Several states now require one of the national certifying agencies such as the AAAHC, AAAASF, JCAHO, etc to survey and certify office anesthesia, but really are certifying the office as safe for surgery. They have many rules and requirements that have nothing to do with office anesthesia...a fact probably known to the state regulators who are doing an end around and de facto expansion of the state sanctioned regulation authority. Nevertheless, the certification process can be expensive requiring some structural modifications, acquiring or creating the required documents and office policies, and paying for surveying. The least expensive survey/certification cost is around $6500 every 3 years (AAAHC) while the more expensive agencies may charge $10,000/year.
    Our office anesthesia unit is but a few steps away from a surgery center but we elected to NOT go with a surgery center due to duplication of paperwork for procedures, ever falling revenue, and the fact that our population (2/3) has Anthem or Medicare which pays us a site of service differential making it a wash for office vs surgery center.
  4. facets

    facets

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    I'll give you a short answer because I'm nowhere near as smart as Algos, (Thats real, I've seen him at conferences). Most states, including mine will not allow you to give sedation unless you have full code cart, oxygen, suction, ventilator, etc. Why do we need a ventilator? God knows it has something to do with lipo deaths. If you have ANY complication and the attorney/state board/ nazis find out you have a crna giving anesthesia in your office without proper equipment, policies and certifications you are in a bad spot, to put it mildly. The last surgeon who tried this was arrested at the airport
  5. Jcm800

    Jcm800

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    keep in mind with the above post, there is a distincton between SEDATION and ANESTHESIA...
  6. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    When I had my solo office, I had my own fluoro, could see pts and decide then and there to do a fluoro procedure, could do it right away or schedule it for later. It was I and my office manager in the fluoro room, sometimes a 3rd office worker. Pts were monitored for 15 minutes and then let go. Documentation and billing were easy and it paid well.

    Now I go to an ASC 95% of the time, next door to us and owned by the orthopods in my practice. Medicare rules prohibit us from scheduling a pt the same day except in an emergency, due to the requirement that they get 24 to review documentiation about possible physician financial involvement in the ASC (of which I have none). A full H&P must be present for every patient. Nurses have a 3-4 page document to fill out, essentially duplicating the H&P. 2 RNs are required to be present (although recently they hired a CRNA to see how that goes, and they put her in there, but she's not allowed to do much). A dictated report must be done within 24 hours, and everything has to be signed and dated. Every year brings additional forms, additional surveys, and an incredible amount of rules.

    ASC pays me less since I don't own the fluoro and since Medicare wants all ASCs to go under, there is a site-of-service differential as well. I'd kill for an in-office fluoro, but it's not my decision. There has been recent hope that I might finally get one after 6 years.
  7. drpainfree

    drpainfree

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    There are four reimbursement fees available on ASIPP website:

    ASC
    HOPD
    Physician Fee NonFacility
    Physician Fee Facility (ASC/Hospital)

    So for example, for 64483, Lumbar TFESI,

    ASC: 295.98
    HOPD: 485.3
    Physician Fee NonFacility: 257.50
    Physician Fee Facility (ASC/Hospital): 106.98

    If you do the procedure in ASC or hospital, you get reimbursed for professional components only, $106.98.

    If you do the procedure in office, you get paid $257.50 (no distinction of professional component vs. technical component, just one fee?)

    If you do the procedure in ASC, you get paid $106.98 + $295.98.

    What separates an office-suite for interventional pain procedure from ASC? Obviously, there's enough financial incentives to make an office into ASC.

    From what algo said, it sounds like if you are not giving sedation, or giving only conscious sedation, you can basically set up an office suite for injection with a fluoroscopy.
  8. Tenesma

    Tenesma Senior Member

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    while your math sounds seductive - you cannot leave out the significant difference in overhead between office based procedures and ASC procedures.

    Just to put up an ASC you have invest about 1.4-1.6 million for a 2 room ASC (minimum)... just to cover the codes for evacuation/fire safety/ventilation etc... these are not costs needed for office based procedure suite... then you have to have the costs of running the ASC with its higher over-head/logistics/compliance etc... ie: you need an RN to actually/physically get your meds... in the office it doesn't matter.

    so ASC is not always more profitable than an office based procedure suite...

    the difference is if your share of ownership in the ASC is more than the amount of time you spend in the ASC which means you are skimming facility fees off other surgeons/proceduralists...
  9. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    And you need a full time manager who does nothing but keeps up with the regulations and insures that everything is running to code - CMS, AAAHC, etc.

    Then you need someone who can insure everyone is credentialed correctly - all staff that has access to the ASC has been properly credentialed, background checks, licenses, insurance.

    Then the ASC needs it's own malpractice insurance, not to mention business insurance, as it needs to be run as a separate corporation from your clinic. Then if they occupy the same space, the IRS may deny the incorporation.

    Our ASC has 2 surgical rooms and a procedure room (no anesthesia in that room). We have 8 pre- and post-op bays. Ours is a Certificate of Necessity state, so it took a lot of money and time to get that. We have about 12 surgeons and 2 physiatrists actively using it, with full time staff of about 10 nurses, and 6-8 part-time nurses, plus a supply clerk, housekeeping who does sterilization also, front desk, schedulers and the manager. Operational costs probably exceed $1M per year. It cost $4-5M to build 5 years ago.

    It is an incredible amount of work and money and unlikely that a small office can effectively run one on their own.
  10. Jcm800

    Jcm800

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    and its just amazing all of the added work to do a 10 minute procedure compared to the office...

    i dont own any ASC, but even if i did, i think i would like it better in the office... Maybe not if the money was as good as it was. Keyword, was...
  11. bedrock

    bedrock Member

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    Algos,

    A wash becaue of site of service differential? Does this mean that Medicare and Anthem pay a really low ASC facility fee, but the average in office fee, such as the $257 for the 64483?

    i.e. the days of making money from setting up ASCs have come and gone and the odds of recovering your money from setting up an ASC are much slimmer than they used to?

    I finished fellowship a year ago and have a nice in-office procedural setup, but wonder if investing or starting an ASC is just too risky at this point since I graduated 10 years too late......
    Last edited: Nov 29, 2010
  12. kdlymes

    kdlymes Hero Member

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    It would be cheaper to start from scratch setting up the ASC compared to
    reconstructing a current office set-up. The firewalls would mean complete teardown, etc.

    In the long run, if your the owner it can become quite profitable, and pay for itself in a year.
  13. algosdoc

    algosdoc algosdoc

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    At this time, in a competitive environment with other pain docs in your area that are willing to accept the predominant insurances in your area, it is unlikely a new grad building a surgery center for one doc could make any significant profit and would most likely incur significant losses. The overhead costs for a surgery center are huge, your income from physician fees for Anthem and Medicare are 1/3 that of doing the procedures in your office, and the hassle factor is enormous. There is also a change that is occurring in insurance that is not much appreciated: the deductables are escalating rapidly and many patients have $2500-5000 deductables now...which means 1/4-1/3 of their entire yearly take home pay would go to pay the deductable for your procedures. Some insurances now have maximum yearly coverages of $5000 and some are hybrids that have large deductables and then are fully covered up to a certain amount, then no coverage. Obamacare may change all this, but the recent federal wage freeze and his statements that we all have to give something are omnious since physicians have not been hit with any reductions (yet). Not a good sound financial environment to be building a surgery center, unless you are in a larger group to share risks and overhead.
  14. PainHelp

    PainHelp

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    All procedures are done without sedation in the office
  15. pjuer

    pjuer New Member

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    If you do the procedure in an ASC- you get $106.98, the ASC gets the $295.98
  16. Jcm800

    Jcm800

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    in your office maybe (and in mine) but not in everyones...

    read the posts above. office sedation is very common

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