ASC Professional Fee

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PMROralBoards

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Question for those who are hospital employed but do procedures at an ASC (who then pass the pro fee to the hospital)-

What is your wrvu productivity for placing two SCS leads during an implant? I was under the impression that 63650 would be billed twice in addition to the one 63685. Hospital administration is telling me that while they can double charge for the procedure, they cannot double the wrvu credit.

This doesn’t make sense to me- am I in the wrong here?

Thanks
 
That’s insane. I’m hospital employed, I do my procedures at the hospital and not an ASC so I don’t meet the exact criteria you’re referencing, but all my SCS are absolutely 63650 x 2. They’re absolutely getting paid for both leads, and you should be too.
 
A lot of the big hospital systems do 63650 x 1.5 for trials. So only about 10.5 wrvu and less than 15 for an implant. There is some logic to it if you look into it. We get x2 in the office to compensate for the price of the leads which isn’t an issue anymore as they cost very little. The professional component pays probably only $550 for a Medicare trial. It looks like I get $718 for a Medicare with a secondary implant. This is well less than 10.5 wrvu for a trial and 15 wrvu for an implant converts out to typically.

The unique thing is your hospital employer allows you to work at an ASC they might have 0 ownership in or at most 55%. They may be getting no benefit or some benefit from the ASC pro fees. I assume you either own or expect to own in the future some of the ASC. I don’t think this is the hill you want to die on. They are likely trying to let you have the best of both worlds. Sweet, beautiful RVU’s that well outpace pro fee earned - clinic overhead with no risk, no RAC audits, no hr problems, and a bit of ASC facility involvement to keep you engaged in the business of medicine.
 
Hospital gets the same facility fee whether you use one lead or 4. ASC Medicare will allow you to add up the 63650’s. Some commercial plans pay the same for one or 4. BCBS for sure is the same.
 
BobBarker said:
Hospital gets the same facility fee whether you use one lead or 4. ASC Medicare will allow you to add up the 63650’s. Some commercial plans pay the same for one or 4. BCBS for sure is the same.
Click to expand...
The hospital has other sources of revenue from me like the ridiculous SOS facility fee for patients I bring to the OR who are not stable enough for an ASC or the 20 fluoro procedures a week I do in the hospital clinic.

Not an owner yet, but I was going to buy in partially later this month. My contract doesn’t have any clause that says they can choose which cpts generate wrvus once they’ve billed and been paid for them. I’m hoping this is just a misunderstanding.
 
They need to treat the RVU’s the same no matter where they are done. I’m not sure if that is what you are are talking about with the “clause” line. I’m sure they are doing that, though.
 
BobBarker said:
They need to treat the RVU’s the same no matter where they are done. I’m not sure if that is what you are are talking about with the “clause” line. I’m sure they are doing that, though.
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The work RVUs are the same for a given procedure unless there’s a billing restriction. For example, I cannot perform a three-level kyphoplasty at the ASC because reimbursement is limited to two levels. However, that same procedure performed in the hospital OR would be reimbursed for all three levels.

What I’m referencing in the contract clause is that I’m paid based on productivity, specifically wRVUs. If the billing department is submitting and collecting on services—especially since most of my patients have Medicare with supplemental coverage—there should be no justification for arbitrarily reducing the wRVUs credited. For instance, if two units of CPT 63650 were billed and paid, I should be credited for both. If only 1.5 units were reimbursed, I would understand a reduced credit—but not when full reimbursement for both units was received.

If the hospital would like to restrict the procedures I do in order to eliminate less profitable ones, I am all for a transparent policy. Otherwise, it does not seem right to take productivity away from one procedure in order to make up for another one. I might as well just place one lead per implant and tell the patients that the hospital does not want to pay me to place the second one.
 
you are going to get yourself fired with your line of thinking. It is a give and take with the hospital and typically they give much, much more than a private practice employer will.
 
BobBarker said:
They only get 1.5x for 63650 x2 pro fee only.
Click to expand...
I’m not sure what you mean by this. The email from the admin person said they can/do double bill for the pro fee. What’s the point of productivity based compensation when the productivity values are arbitrary?
 
That’s not quite right. Most of the time they are getting around 1.5x. My implants only pay around $720. If they give 20 wrvu for an implant they would be giving you over 2x your professional fee with no overhead taken out on a case that you did at an ASC that you are an owner in. That isn’t going to work.
 
BobBarker said:
That’s not quite right. Most of the time they are getting around 1.5x. My implants only pay around $720. If they give 20 wrvu for an implant they would be giving you over 2x your professional fee with no overhead taken out on a case that you did at an ASC that you are an owner in. That isn’t going to work.
Click to expand...
Thank you for your input—I really do appreciate it. I know you don’t owe me an explanation, but if you’re willing, could you help me understand this in simple terms?

My contract guarantees a set compensation per wRVU, determined by the hospital. The majority of my patients have Medicare with supplemental coverage. If Medicare assigns a specific number of wRVUs to a CPT code for the professional fee, and the hospital is billing and being reimbursed accordingly, I’m struggling to understand how applying those wRVUs to my productivity and compensating me at the agreed rate results in a financial loss.

I realize the hospital may not be generating profit from each individual case. Some commercial payers may reimburse above the Medicare rate, and Medicaid may pay less—but overall, this is the compensation model I was hired under.

I also want to emphasize that I work in a small community hospital in a rural area where it can be difficult to recruit younger physicians. By providing these services locally, I’m helping keep patients within the system instead of having them travel hours to larger cities for care.
 
Always with employed pain docs, the hospital ends up in the hole as the wrvu x conversion factor is always going to be less than the pro fee generates and much less than pro fee - clinic overhead. But that is the deal the hospital signs as it it worth it due to the facility fees, MRI’s, PT, surgical referrals as you alluded to earlier.

But all that matters is the contract, and the hospital wants to adhere to the contract as much as you do. Remember they wrote it.

Most procedures and surgeries, the largest wrvu procedure will get full reimbursement by Medicare then the lower reimbursing procedures will get only reimbursed at 50% their base rate. This can and does happen on the 2nd lead for an scs trial done in a facility. This is in regards to pro fee only.

The math works out where everyone is happy when the cases are done at the hospital. If they are being done at another facility (the ASC) the model breaks down and the hospital loses a large amount of money on every case done at the ASC.
 
BobBarker said:
Always with employed pain docs, the hospital ends up in the hole as the wrvu x conversion factor is always going to be less than the pro fee generates and much less than pro fee - clinic overhead. But that is the deal the hospital signs as it it worth it due to the facility fees, MRI’s, PT, surgical referrals as you alluded to earlier.

But all that matters is the contract, and the hospital wants to adhere to the contract as much as you do. Remember they wrote it.

Most procedures and surgeries, the largest wrvu procedure will get full reimbursement by Medicare then the lower reimbursing procedures will get only reimbursed at 50% their base rate. This can and does happen on the 2nd lead for an scs trial done in a facility. This is in regards to pro fee only.

The math works out where everyone is happy when the cases are done at the hospital. If they are being done at another facility (the ASC) the model breaks down and the hospital loses a large amount of money on every case done at the ASC.
Click to expand...
Thank you for the explanation—I really appreciate you taking the time to clarify.

As I mentioned earlier, I would completely understand receiving only partial or no wRVU credit if the hospital were truly being reimbursed at 50% or not at all for the second lead. However, the leadership team has indicated that they are billing for both leads at 100%.

In that case, do you still believe it would be appropriate for me to receive wRVU credit for only one lead? I’m genuinely trying to understand the reasoning, especially since my contract is based on productivity and wRVUs—not margin or profitability.

While I recognize that the hospital may or may not be generating a strong margin on each case, managing those margins isn't my responsibility. My role is to provide care and be compensated according to the terms of the agreement the hospital itself created.
 
I think their is miscommunication. They are getting paid on both leads, yes. But they are not getting a full 63650 x 2. They are probably doing 63650 and 63650-59 and getting paid on both lines but that only yields 10.725 wrvu.



They certainly should not only be giving you 63650 x 1 for a two lead trial
If that is the case, I see why you are upset.
 
BobBarker said:
I think their is miscommunication. They are getting paid on both leads, yes. But they are not getting a full 63650 x 2. They are probably doing 63650 and 63650-59 and getting paid on both lines but that only yields 10.725 wrvu.



They certainly should not only be giving you 63650 x 1 for a two lead trial
If that is the case, I see why you are upset.
Click to expand...
That is exactly what I am saying. I am only getting the professional fee wrvu for one lead in both trials and implants despite them collecting the pro fee for two leads (MPPR or not).

I am also sent perms and revisions from surrounding practices with pain docs who come up one day every other week to do trials, epidurals, and ablations. I trial/revise/implant probably 10 per month.
 
Last edited:
that needs to be corrected and they will have to go back and give you units from when you started. The minimum it can yield is 10.725/13.32 trial/implant using modifier 59


All of that activity makes you the biggest hitter by far at the ASC and you absolutely need to buy in as long as it is otherwise a sound business.
 
BobBarker said:
That’s not quite right. Most of the time they are getting around 1.5x. My implants only pay around $720. If they give 20 wrvu for an implant they would be giving you over 2x your professional fee with no overhead taken out on a case that you did at an ASC that you are an owner in. That isn’t going to work.
Click to expand...
I’ve been having issues recently finding hospitals for my >40 bmi implant pts and they are saying for financial reasons, do you have any thoughts on that? Im not doing the trial there
 
Eterna/Inceptiv are quite expensive on most hospital GPO’s and the hospital may not be making any money due to that. You need to work with your reps to make a carve out, a baby bundle (3 implants), a unique package, etc to bypass the crappy GPO pricing.

You can also see about doing older technology like Proclaim XR or Vanta. They are cheaper and with a big patient they have plenty of room for the large IPG.
 
PMROralBoards said:
Question for those who are hospital employed but do procedures at an ASC (who then pass the pro fee to the hospital)-

What is your wrvu productivity for placing two SCS leads during an implant? I was under the impression that 63650 would be billed twice in addition to the one 63685. Hospital administration is telling me that while they can double charge for the procedure, they cannot double the wrvu credit.

This doesn’t make sense to me- am I in the wrong here?

Thanks
Click to expand...

They are lying to you. They can do whatever they want. Ask them to think outside the box.
 
BobBarker said:
Always with employed pain docs, the hospital ends up in the hole as the wrvu x conversion factor is always going to be less than the pro fee generates and much less than pro fee - clinic overhead. But that is the deal the hospital signs as it it worth it due to the facility fees, MRI’s, PT, surgical referrals as you alluded to earlier.

But all that matters is the contract, and the hospital wants to adhere to the contract as much as you do. Remember they wrote it.

Most procedures and surgeries, the largest wrvu procedure will get full reimbursement by Medicare then the lower reimbursing procedures will get only reimbursed at 50% their base rate. This can and does happen on the 2nd lead for an scs trial done in a facility. This is in regards to pro fee only.

The math works out where everyone is happy when the cases are done at the hospital. If they are being done at another facility (the ASC) the model breaks down and the hospital loses a large amount of money on every case done at the ASC.
Click to expand...

What you are describing is "site of service arbitrage." It's the oldest trick in the book.
 
drusso said:
What you are describing is "site of service arbitrage." It's the oldest trick in the book.
Click to expand...
Bless you drusso. Don’t you just get tired of it all..fighting the uphill battle, trying to convince people..kudos to you man, I couldn’t do it..I sold out like one of those who just succumbed to getting bit by the vampire..
 
Dr. Ice said:
Bless you drusso. Don’t you just get tired of it all..fighting the uphill battle, trying to convince people..kudos to you man, I couldn’t do it..I sold out like one of those who just succumbed to getting bit by the vampire..
Click to expand...

...Chapter 12 from The Book of Drusso...

What Scaevola Teaches Us About Persistence​

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This painting hangs in the Kimbell Art Museum across the street from my medical school in Fort Worth, Texas. I know it well because I've spent hours pondering it. A copy hangs on the wall in my bedroom--It is the last thing I see at night before I close my eyes and the first thing I notice in the morning. The image is seared into my retinas, and the story echoes in my brain.

The subject of this painting is taken from Livy's account of the Etruscan siege of Rome. Gaius Mucius, a young Roman nobleman, infiltrated the enemy camp to slay the Etruscan King Porsenna, but mistakenly killed the king's treasurer (you see him lying on the ground in the background).

At center stage is Gaius, who defiantly turns his head and dagger toward Porsenna, warning him that he is one of many youths sworn to assassinate him. Demonstrating his resolve, Gaius unflinchingly holds his hand in the hot embers until it is burned away. Porsenna was so impressed by this action that he freed the young hero and concluded peace with Rome. Afterward, Gaius Mucius was known as Mucius Scaevola (the left-handed).

It's a story about bravery, persistence, and putting everything on the line for a cause you believe in. At some time in our lives, everyone will "hold their hand in the fire," resolving to endure whatever pain is required rather than succumb to defeat. Porsenna knows that he can kill this boy, but legions of others like him will be encouraged by his bravery. Scaevola knows that his actions will leave him permanently scarred and disfigured. Both know that things will never be the same again for either of them from this point forward. In different ways, this event seals their fates.

With its upheaval and tumult, our healthcare system leaves us feeling like we will burn up. Still, as we embrace changes and evolve, we realize that things will never be the same again. We also realize there are principles we can never abandon. The future is going to look different from what we thought it would. Still, our resolve to show up for our patients, stay true to our commitments, and plan accordingly is our way of holding our hands in the fire.

Keep your hand in the fire.
 
PMROralBoards said:
That is exactly what I am saying. I am only getting the professional fee wrvu for one lead in both trials and implants despite them collecting the pro fee for two leads (MPPR or not).

I am also sent perms and revisions from surrounding practices with pain docs who come up one day every other week to do trials, epidurals, and ablations. I trial/revise/implant probably 10 per month.
Click to expand...
for my last stim trial, i put in 2 leads, and got 14.3 wRVU.

at an ASC.
 
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