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One of the things I'd been curious about for awhile is - how are ASC/facilities reimbursed for podiatric procedures.
www.medicare.gov
*The above link has a search tool at the bottom of the page, but you can simply change the address to a different procedure code and the page will update
Interestingly, Medicare runs a website that provides an approximation of the physician and facility reimbursement with separate values for ASCs and Hospitals/OPPS. I'm strongly under the impression there is a regional component similar to localities as I've seen documents from individual MACs like Novitas spelling these out. Hospitals are obviously reimbursed higher than ASCs. The physician component listed likely matches the "National Value" that is provided in the Physician Fee Schedule Lookup tool.
For the CPT procedures we do - you can essentially match the underlying facility reimbursement ie. $1500, $~4500, $9000 to the procedure's APC (Ambulatory Payment Classification).
APC - 5113 - a myriad of straight forward procedures. ie. hammertoes, some bunion codes- 28296, 28289, 28292. However, an ankle scope with extensive debridement is probably a 5113, but the secondary repair of the ligaments code is a 5114. In the Medicare search tool these procedures at ASCs appear to reimburse $1518... which is probably considered pretty bad. Gastrocnemius recession, amputations, plantar fascial releases all fall here. There are codes that are lower still ie. 28232, 11750 reimburse even less and likely don't fall here..
APC - 5114 - 1st MPJ fusion. Some bunion codes - Akin, historically lapidus. Repairs of things like Achilles or ankle ligaments. These codes usually show ASC values of $4300-4700.
APC - 5115 - ankle fusion, multi-joint fusion, subtalar joint fusion. As of 2025 - 28297 and 28740 now fall here, but its not yet updated in the search engine. These codes usually shows ASC values in the range of $9000-10,000. Obviously we don't perform them, but hip and knee replacement fall here and these are being performed at ASCs now.
APC - 5116 - total ankle replacement. From what I can tell - ankle, shoulder, and elbow replacement are 5116. As noted above, hip/knee are 5115. Looking around the internet I've seen values in the $12-16,000 range for 5116. Pantalar also falls here.
This file from Zimmer Biomet below gives example CPT codes with their associated APC.
A certain hardware company had in the past described how certain combinations of procedures associated with APCs with a J1 code (another associated code tied to APCs that indicates intensive hardware requirement) can cause an increase in a procedure's APC code to the next level ie. 5114 increasing to 5115, but I believe this was hospital only. Increasing a 5114 to a 5115 generated several thousand in extra reimbursement which made the cost of expensive hardware more tolerable for surgery centers.
I was recently asked to perform a bread and butter peer review for another physician and at the front of the chart was the billing. The patient had Medicare and the surgery had already processed/finalized and been paid.
#1 - 28310 - reimbursed at a bit shy $4K
#2 -28285 - reimbursed just shy of $700 - interestingly, this appears to represent a 50% reduction for the second procedure
#3 - 28285 - reimbursed just shy of $350 - 3rd procedure, so apparently 75% reduction.
Interestingly the 3 procedures together - essentially an Akin and 2 hammertoes came out to about $5000 in reimbursement.
The Medicare fee schedule value (top link) above suggests the 28310 should be worth $4300 and the 28285 should be worth $1518. I've historically reviewed my "locality" against others on the Medicare fee schedule and I'm definitely in a lower quartile so the mismatch between these values did not surprise me.
1. Everything I've shown above is for Medicare/CMS. I'm strongly under the impression Medicare reimburses lump sum. What you see is what you get.
2. I have no idea how hospital Diagnosis Related Groups (DRGs) are accounted for ie. a toe amputation performed during a hospitalization may simply be part of the lump sum for the DRG as opposed to a separate reimbursement.
3. Insurance companies negotiate their own fee schedules with ASCs/hospitals and obviously the values will be different with the possibility of a lot of variability.
4. If this example above is still relevant then BCBS at least has some of their values fairly similar to Medicare though obviously that's an old example.
5. Hospitals collect more from procedure as I've noted above. I'm sure its more complicated than that though. What's interesting though is the difference is probably greatest for 5113s. The 5114/5 values definitely are larger for hospitals but they might not be gigantically higher than an ASC. So a toe amp goes from $1500 to $3000. That said, that might not be interesting to a hospital where heart procedures and big joints are being performed. The greater value is likely collecting the DRG from the hospitalization and allowing an early discharge of the patient.
6. In Texas, BCBS is trying to encourage physicians to perform cases at ASCs rather than at hospitals.
7. Yes, a toe amputation performed at a hospital is worth more than a 28296 performed at an ASC.
8. Yes, doing more procedures does appear to be worth more, but within reason ie. in my hammertoe example case there's a fairly substantial reduction from 50% on the second to 75% on the 3rd. I have no idea how things reduce after that.
9. I initially labeled this thread as "28296 has low facility reimbursement." I've changed it, but lets touch on this.
$~1500
28295 is 5113 - HV Proximal 1st ray Osteotomy
28296 is 5113 - HV Distal 1st ray osteotomy
28308 is 5113 - Angular osteotomy 1st ray
$~4000
28298 is 5114 - HV + proximal phalanx osteotomy of hallux
28310 is 5114 - Angular Osteotomy of Great toe
28299 is 5114 - HV Double Osteotomy
From some limited online reading - apparently procedures move between APCs related to the expenses associated with them -I don't know the specifics, but there's a formula that takes into account some sort sort of variation of whether they exceed 2x geometric mean cost or something like that. You can read more about it here (below link) in the federal register (search 2897) - this shows a discussion in 2023 of moving 28297/28740 to 5115 although it was rejected at that time.
That said - if you are simply performing isolated 28296 codes on Medicare patients at your nice little ASC - you are probably not generating a lot of revenue for these facilities. A 28113, a plantar fascial release, a gastrocnemius recession, a hammertoe etc - procedures that take 5-10 minutes - are all apparently in the same reimbursement category as an osteotomy/Austin based on what I'm seeing. I'm somewhat amused/confused that an Akin reimburses higher than an Austin. I assumed that a 28299 ie. a double, reimbursed higher because 29299 could also be used for a proximal and distal osteotomy and that perhaps we were "exploiting" something but apparently the Akin component is already a 5114 and a proximal 1st ray osteotomy is actually still a 5113.
Interestingly, unless the 28296 somehow upgrades to a 5114 by adding enough procedures (which I think only happens with hospital J1s) - you are starting deeply in the hole based on my example above even if you add hammertoes or more procedure. Consider that 28296 + 28285 x 2 is $1500 + 1500/2 + 1500/4 is $2600 (jokingly, still less than a toe amp in a hospital). Less than that in my area. The same patient with a 28750 or 28299 is essentially $4500 + 1500/2 + 1500/4 - $5600.
I'm not telling you to always do an Austin+Akin or to do one so your facility gets more money. I would say I'm simply sharing my surprise that adding an osteotomy to the hallux appears to literally double or more the reimbursement for the procedure. I'm also simply somewhat surprised that a procedure(28296) that requires honestly a fair amount of care and work simply reimburses so poorly. ie. technically this procedure has a number of components built into it compared to just removing the 5th metatarsal head. There are all sorts of people trying to come up with expensive hardware to add to 1st ray osteotomies and its clear to me this is a procedure code without a lot of meat left on the bone for hardware expense if its done on a Medicare patient at an ASC.
A different take still is that you often hear of "specialties that ASCs have to have" or "profitable specialities". The guy with a main procedure that takes an hour and is worth $1500 of Medicare facility dollar isn't going to be a star contributor.
I've said this elsewhere, but 28740/29207 being a 5115 code is fairly amusing ie. that's the same APC that a knee/hip replacement is in.
Anyway. Hopefully someone will find this relevant or educational. I've had some reps say ridiculous things to me through time ie. use my products, your facility gets so much money for this procedure. I once had a rep tell me they were sure a procedure was worth $17,000 to the facility so I should definitely use their hardware. Maybe a hospital could get that from a commercial insurance, but its interesting to see the spread across Medicare.
Last of all - I'm sort of under the impression a lot of facilities are now having to straight subsidize their anesthesia costs. You can see that on the anesthesia forum ie. they know they are worth $350-500/hr and they know Medicare reimburses them jack crap. The money for their hourly wage is coming out of the facility fee.
Edited: to correct some spelling issues, add some links/clarity
Procedure Price Lookup for Outpatient Services | Medicare.gov
Use official Procedure Price Lookup tool to compare national average to Medicare costs in ambulatory surgical centers, hosptial outpatient departments
Interestingly, Medicare runs a website that provides an approximation of the physician and facility reimbursement with separate values for ASCs and Hospitals/OPPS. I'm strongly under the impression there is a regional component similar to localities as I've seen documents from individual MACs like Novitas spelling these out. Hospitals are obviously reimbursed higher than ASCs. The physician component listed likely matches the "National Value" that is provided in the Physician Fee Schedule Lookup tool.
For the CPT procedures we do - you can essentially match the underlying facility reimbursement ie. $1500, $~4500, $9000 to the procedure's APC (Ambulatory Payment Classification).
APC - 5113 - a myriad of straight forward procedures. ie. hammertoes, some bunion codes- 28296, 28289, 28292. However, an ankle scope with extensive debridement is probably a 5113, but the secondary repair of the ligaments code is a 5114. In the Medicare search tool these procedures at ASCs appear to reimburse $1518... which is probably considered pretty bad. Gastrocnemius recession, amputations, plantar fascial releases all fall here. There are codes that are lower still ie. 28232, 11750 reimburse even less and likely don't fall here..
APC - 5114 - 1st MPJ fusion. Some bunion codes - Akin, historically lapidus. Repairs of things like Achilles or ankle ligaments. These codes usually show ASC values of $4300-4700.
APC - 5115 - ankle fusion, multi-joint fusion, subtalar joint fusion. As of 2025 - 28297 and 28740 now fall here, but its not yet updated in the search engine. These codes usually shows ASC values in the range of $9000-10,000. Obviously we don't perform them, but hip and knee replacement fall here and these are being performed at ASCs now.
APC - 5116 - total ankle replacement. From what I can tell - ankle, shoulder, and elbow replacement are 5116. As noted above, hip/knee are 5115. Looking around the internet I've seen values in the $12-16,000 range for 5116. Pantalar also falls here.
This file from Zimmer Biomet below gives example CPT codes with their associated APC.
A certain hardware company had in the past described how certain combinations of procedures associated with APCs with a J1 code (another associated code tied to APCs that indicates intensive hardware requirement) can cause an increase in a procedure's APC code to the next level ie. 5114 increasing to 5115, but I believe this was hospital only. Increasing a 5114 to a 5115 generated several thousand in extra reimbursement which made the cost of expensive hardware more tolerable for surgery centers.
I was recently asked to perform a bread and butter peer review for another physician and at the front of the chart was the billing. The patient had Medicare and the surgery had already processed/finalized and been paid.
#1 - 28310 - reimbursed at a bit shy $4K
#2 -28285 - reimbursed just shy of $700 - interestingly, this appears to represent a 50% reduction for the second procedure
#3 - 28285 - reimbursed just shy of $350 - 3rd procedure, so apparently 75% reduction.
Interestingly the 3 procedures together - essentially an Akin and 2 hammertoes came out to about $5000 in reimbursement.
The Medicare fee schedule value (top link) above suggests the 28310 should be worth $4300 and the 28285 should be worth $1518. I've historically reviewed my "locality" against others on the Medicare fee schedule and I'm definitely in a lower quartile so the mismatch between these values did not surprise me.
1. Everything I've shown above is for Medicare/CMS. I'm strongly under the impression Medicare reimburses lump sum. What you see is what you get.
2. I have no idea how hospital Diagnosis Related Groups (DRGs) are accounted for ie. a toe amputation performed during a hospitalization may simply be part of the lump sum for the DRG as opposed to a separate reimbursement.
3. Insurance companies negotiate their own fee schedules with ASCs/hospitals and obviously the values will be different with the possibility of a lot of variability.
4. If this example above is still relevant then BCBS at least has some of their values fairly similar to Medicare though obviously that's an old example.
5. Hospitals collect more from procedure as I've noted above. I'm sure its more complicated than that though. What's interesting though is the difference is probably greatest for 5113s. The 5114/5 values definitely are larger for hospitals but they might not be gigantically higher than an ASC. So a toe amp goes from $1500 to $3000. That said, that might not be interesting to a hospital where heart procedures and big joints are being performed. The greater value is likely collecting the DRG from the hospitalization and allowing an early discharge of the patient.
6. In Texas, BCBS is trying to encourage physicians to perform cases at ASCs rather than at hospitals.
7. Yes, a toe amputation performed at a hospital is worth more than a 28296 performed at an ASC.
8. Yes, doing more procedures does appear to be worth more, but within reason ie. in my hammertoe example case there's a fairly substantial reduction from 50% on the second to 75% on the 3rd. I have no idea how things reduce after that.
9. I initially labeled this thread as "28296 has low facility reimbursement." I've changed it, but lets touch on this.
$~1500
28295 is 5113 - HV Proximal 1st ray Osteotomy
28296 is 5113 - HV Distal 1st ray osteotomy
28308 is 5113 - Angular osteotomy 1st ray
$~4000
28298 is 5114 - HV + proximal phalanx osteotomy of hallux
28310 is 5114 - Angular Osteotomy of Great toe
28299 is 5114 - HV Double Osteotomy
From some limited online reading - apparently procedures move between APCs related to the expenses associated with them -I don't know the specifics, but there's a formula that takes into account some sort sort of variation of whether they exceed 2x geometric mean cost or something like that. You can read more about it here (below link) in the federal register (search 2897) - this shows a discussion in 2023 of moving 28297/28740 to 5115 although it was rejected at that time.
That said - if you are simply performing isolated 28296 codes on Medicare patients at your nice little ASC - you are probably not generating a lot of revenue for these facilities. A 28113, a plantar fascial release, a gastrocnemius recession, a hammertoe etc - procedures that take 5-10 minutes - are all apparently in the same reimbursement category as an osteotomy/Austin based on what I'm seeing. I'm somewhat amused/confused that an Akin reimburses higher than an Austin. I assumed that a 28299 ie. a double, reimbursed higher because 29299 could also be used for a proximal and distal osteotomy and that perhaps we were "exploiting" something but apparently the Akin component is already a 5114 and a proximal 1st ray osteotomy is actually still a 5113.
Interestingly, unless the 28296 somehow upgrades to a 5114 by adding enough procedures (which I think only happens with hospital J1s) - you are starting deeply in the hole based on my example above even if you add hammertoes or more procedure. Consider that 28296 + 28285 x 2 is $1500 + 1500/2 + 1500/4 is $2600 (jokingly, still less than a toe amp in a hospital). Less than that in my area. The same patient with a 28750 or 28299 is essentially $4500 + 1500/2 + 1500/4 - $5600.
I'm not telling you to always do an Austin+Akin or to do one so your facility gets more money. I would say I'm simply sharing my surprise that adding an osteotomy to the hallux appears to literally double or more the reimbursement for the procedure. I'm also simply somewhat surprised that a procedure(28296) that requires honestly a fair amount of care and work simply reimburses so poorly. ie. technically this procedure has a number of components built into it compared to just removing the 5th metatarsal head. There are all sorts of people trying to come up with expensive hardware to add to 1st ray osteotomies and its clear to me this is a procedure code without a lot of meat left on the bone for hardware expense if its done on a Medicare patient at an ASC.
A different take still is that you often hear of "specialties that ASCs have to have" or "profitable specialities". The guy with a main procedure that takes an hour and is worth $1500 of Medicare facility dollar isn't going to be a star contributor.
I've said this elsewhere, but 28740/29207 being a 5115 code is fairly amusing ie. that's the same APC that a knee/hip replacement is in.
Anyway. Hopefully someone will find this relevant or educational. I've had some reps say ridiculous things to me through time ie. use my products, your facility gets so much money for this procedure. I once had a rep tell me they were sure a procedure was worth $17,000 to the facility so I should definitely use their hardware. Maybe a hospital could get that from a commercial insurance, but its interesting to see the spread across Medicare.
Last of all - I'm sort of under the impression a lot of facilities are now having to straight subsidize their anesthesia costs. You can see that on the anesthesia forum ie. they know they are worth $350-500/hr and they know Medicare reimburses them jack crap. The money for their hourly wage is coming out of the facility fee.
Edited: to correct some spelling issues, add some links/clarity
Last edited:
