ASC vs. HOPD - CMS rules

[MedZeppelin]

Question:
With the Medicare changes regarding prior auth requirements and frequency for basic procedures such as MBB, RFA, ESI, etc., quick question...

Is there any difference in performing these procedures in an ASC vs. HOPD facility?

The reason I ask is that I currently practice in HOPD facility, but have and opportunity to move my procedures to an nearby ASC. If that would help to avoid some of the CMS LCD requirement nonsense, it would be worth it!

Thoughts?
Thanks,

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[Agast]

@jsaul

 

[paindoc007]

My understanding is no

 

[Ducttape]

one of the insurers i am aware is much more lenient with approving ASC over HOPD procedures.

with this one, its a game. you still have to ask for auth, but for the ASC the answer for bread and butter procedures is "no auth required if done in ASC".

a certain poster would find is great you are doing them in ASC because of SOS differential, though he might comment that office is even better.

 

[drusso]

one of the insurers i am aware is much more lenient with approving ASC over HOPD procedures.

with this one, its a game. you still have to ask for auth, but for the ASC the answer for bread and butter procedures is "no auth required if done in ASC".

a certain poster would find is great you are doing them in ASC because of SOS differential, though he might comment that office is even better.

 

[jsaul]

@jsaul

Medicare does not.require preauth for facet procedures unless they are done in an hopd
The preauth process for novitas is ridiculous
Therefore I now do rfa at asc instead of hopd. For your sanity I would recommend to go to the asc

 

[Taus]

Medicare does not.require preauth for facet procedures unless they are done in an hopd
The preauth process for novitas is ridiculous
Therefore I now do rfa at asc instead of hopd. For your sanity I would recommend to go to the asc

What makes it so difficult?

 

[Laryngospasm]

I’ve been fighting this battle.. I’m wondering if it’s just me or what.. I can document everything correctly and still get denied. I’m hopd I had a feeling it was related to this.

 

[jsaul]

I’ve been fighting this battle.. I’m wondering if it’s just me or what.. I can document everything correctly and still get denied. I’m hopd I had a feeling it was related to this.

Yes you can document everything perfectly and then you send it via fax to novitas and then wait up-to 2 weeks for an answer. they will deny more often than not due to a nitpicking issue. Again this is just for hopd rfa. No.need for preauth for asc or office. All you hopd docs that think this is not an issue for you, think Again when you see that a lot of of your Medicare rfa's that were scheduled are not getting paid

 

[BobBarker]

Yes you can document everything perfectly and then you send it via fax to novitas and then wait up-to 2 weeks for an answer. they will deny more often than not due to a nitpicking issue. Again this is just for hopd rfa. No.need for preauth for asc or office. All you hopd docs that think this is not an issue for you, think Again when you see that a lot of of your Medicare rfa's that were scheduled are not getting paid

It usually won’t affect them. Most hospitals pay the units earned no matter what. It is their problem if they don’t get paid, don’t get auth, etc. It is part of the deal and they typically accept it without issue.

 

[Laryngospasm]

They accept up to a point.. whe it becomes an issue we have a major problem. My hospital has lost so much money they have now stopped doing any procedures that aren’t approved.

 

[jsaul]

It usually won’t affect them. Most hospitals pay the units earned no matter what. It is their problem if they don’t get paid, don’t get auth, etc. It is part of the deal and they typically accept it without issue.

It's.got to catch up at some point. The hopd.admin don't like losing money on procedures not getting paid while the doc gets rvus for those procedures. At some point comes judgement day

 

[DOctorJay]

There are some pretty significant issues with the documentation being scrutinized now. I had a patient who started with an 8/10 pain and documented immediate post procedure pain as a 6 but the 15 minute mark through the next few hours the patient had greater than 80% relief. Patient was denied their second MBB because of this and now we're having to appeal it.

 

[Laryngospasm]

This is the kind of stuff I’m dealing with.. had one mbb denied after I documented 6 weeks of PT but in didn’t put the exact dates of every PT visit.

 

[BobBarker]

Probably should just send out all of the mbb’s and rfa’s to the office based docs.



😂


But for real though…

 

[SSdoc33]

i am also seeing denials for not documenting a disability scale at baseline.

is everybody doing this on essentially every patient? i dont want to do an ODI on every patient if i dont have to. and i dont want to deal with it AFTER i have done my assessment

 

[Laryngospasm]

We’ve started doing them on all Medicare patients for this reason

 

[SSdoc33]

We’ve started doing them on all Medicare patients for this reason

is there any sort of add on code to bill for this? im strongly guessing no.

 

[Laryngospasm]

No that I know of.. we have the nurses give them a scale to fill out on paper and send it in with the auth requests. Part of the intake papers.

 

[drusso]

Probably should just send out all of the mbb’s and rfa’s to the office based docs.



😂


But for real though…

It would be cheaper for everyone,

 

[buddababa]

i am also seeing denials for not documenting a disability scale at baseline.

is everybody doing this on essentially every patient? i dont want to do an ODI on every patient if i dont have to. and i dont want to deal with it AFTER i have done my assessment

yup started doing it on everybody because it was just easier

 

[buddababa]

is there any sort of add on code to bill for this? im strongly guessing no.

no code, sadly just more work

 

[jsaul]

this is what I am saying. If you don't document the dates of PT if you don't document pain relief the exact way they want, if you don't document disability scales at all visits . any little nitpicky thing -- they will deny. Its just a mess and not worth this nonsense. All you hopd docs if you are not being told of denials you probably are then doing the procedures without pre-auth and the hospital is not getting paid and then your day of reckoning will come.

 

[bedrock]

Unfortunate for the HOPD folks.

A better solution for Medicare is to maybe decrease the insanely high HOPD facility fees, but then not nitpick regarding the auth to do Medicare MBB/RFA.

 

[SSdoc33]

this is what I am saying. If you don't document the dates of PT if you don't document pain relief the exact way they want, if you don't document disability scales at all visits . any little nitpicky thing -- they will deny. Its just a mess and not worth this nonsense. All you hopd docs if you are not being told of denials you probably are then doing the procedures without pre-auth and the hospital is not getting pain and then your day of reckoning will come.

no, they are catching on.

my problem is that even if you document everything correctly -- and all of the requirements are onerous -- they STILL will sometime deny

that is the frustrating part.

RF is probably our best procedure and a high percentage of them are medicare. plus, it pays well. its not like we can avoid this battle. just really sucks

 

[Ducttape]

Aren't you guys giving patients back exercises?

I document that patients have been doing physician directed exercises as of the last appointment date, which seems to work well.

Mind you, I usually have to document this conservative therapy because most patients I see have not had imaging, and given the ages of these patients, for the most part I do like to get MRIs.

The one area of concern I do have I documenting disability. Besides asking what patients can't do, I haven't had a good solution. We do not have enough staff to do scales such as ODI....

 

[jsaul]

no, they are catching on.

my problem is that even if you document everything correctly -- and all of the requirements are onerous -- they STILL will sometime deny

that is the frustrating part.

RF is probably our best procedure and a high percentage of them are medicare. plus, it pays well. its not like we can avoid this battle. just really sucks

Yes no matter how perfect your note is they will find a reason to deny, It has happened to me this way so I gave up.

 

[Taus]

this is what I am saying. If you don't document the dates of PT if you don't document pain relief the exact way they want, if you don't document disability scales at all visits . any little nitpicky thing -- they will deny. Its just a mess and not worth this nonsense. All you hopd docs if you are not being told of denials you probably are then doing the procedures without pre-auth and the hospital is not getting pain and then your day of reckoning will come.

This sounds fing terrible…. Perhaps worth it if you are RVU based, but if seeing professional fee only… Forget it.

 

[Ronin1]

You guys need better templates. Like this

 

[cowboydoc]

i am also seeing denials for not documenting a disability scale at baseline.

is everybody doing this on essentially every patient? i dont want to do an ODI on every patient if i dont have to. and i dont want to deal with it AFTER i have done my assessment

Every patient gets an ODI documented in their CC: by the nurse, auto populated into note. Done.

 

[cowboydoc]

You guys need better templates. Like this

The templates are getting stupid long, but ever new check box adds a line.

Make sure pain is always 1 or 2 post procedure and at least 80% improved for expected duration of local anesthetic…

Had to change my PE template recently to clarify “reproduction of typical axial pain,”

 

[DOctorJay]

The templates are getting stupid long, but ever new check box adds a line.

Make sure pain is always 1 or 2 post procedure and at least 80% improved for expected duration of local anesthetic…

Had to change my PE template recently to clarify “reproduction of typical axial pain,”

I need to coach my nurses on that immediate post procedure number

 

[SSdoc33]

Every patient gets an ODI documented in their CC: by the nurse, auto populated into note. Done.

That ODI takes time and manpower.

The like the idea of only doing it for Medicare patient with LBP tho

 

[bedrock]

That ODI takes time and manpower.

The like the idea of only doing it for Medicare patient with LBP tho

PEG is very quick. I got the idea here and now every patient gets it.