Understanding facility reimbursement

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SpineandWine

SpineandWine

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Looking at Medicare procedure price look up, 64635 has facility fee of 1.8k for HOPD

- if you mod 50, does facility also get 1.5x 1.8k
- what if you add additional level 64636- the site doesn’t have info on additional levels
 
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facility should be getting 1 set fee. the equipment doesnt really change (ie fluoroscopy, use of procedure suite, etc).

i dont do 64636, as it is generally not covered by Medicare and those that follow Medicare guidelines. i suspect there is no additional reimbursement.
 
Depends on payer/contract but we get 1.5x pro and facility. Facility only gets paid on 1st level though.

1.8k is good, way higher than ASC or office. Needles don't cost that much, I'd consider good margin.
 
RoloTomassi said:
Depends on payer/contract but we get 1.5x pro and facility. Facility only gets paid on 1st level though.

1.8k is good, way higher than ASC or office. Needles don't cost that much, I'd consider good margin.
Click to expand...
Assuming half hour for bilateral RFa

Similar to two slots of 15 minute epidurals bilateral TFESi
 
ASCs don’t get a higher fee for more levels, I imagine the hospitals aren’t much difference. Medicare also doesn’t reimburse for equipment used.
 
SpineandWine said:
TKA CPT 27447 facility is 12k. Assuming 6k for implant cost
6 k margin for 1.5 hours
RFA comes close


Better than joints is 2 level ACDF, hard to beat/time
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How do you get HOPD facility rates?
 
SpineandWine said:
Just trying to understand theoretically

- - -

Is there another site for facility fee for Medicaid?
Click to expand...
No one asks about Medicare and Medicaid facility reimbursements out of “theoretics”

The vail of anonymity on a social media forum should be good enough for you…

“Show yourself” what gives?
 
Does office work same way?
So let’s say pricing for facet one level for office ablation let’s say at 1k

When people do bilateral L5-S1 ablation, do office people get 1.5k?
 
RoloTomassi said:
Yes
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real world medicare reimbursement in the office is more like 500 for bilateral L345 RFA. just checked some of my 1/2024 #'s. when I do the same procedure at an ASC that I do not own, its down to ~300 for the same procedure. ugh. this stone has nearly bled out
 
SpineandWine said:
Anyone finding in ortho group find this to be true? Are pain docs top producer or above median?
Click to expand...

I’ve been in two ortho groups. I work hard but do well. 14,000 wRVU

In my first job in a 5 man group I made more than half of the surgeons and less than the other half.

In my current 8 man group I bring in more $ than 5 of the orthopods and but less $ than 2 of the orthopods.
 
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There are several surgeons in my group that I cannot hope to compete with under any circumstance.

We have a few outliers that do insane numbers of totals, and two hand guys who do ridiculous numbers as well. Overall, we are 22 or 23 guys and I’m in the upper half.

Our practice is basically set up for the guys doing totals.
 
MitchLevi said:
There are several surgeons in my group that I cannot hope to compete with under any circumstance.

We have a few outliers that do insane numbers of totals, and two hand guys who do ridiculous numbers as well. Overall, we are 22 or 23 guys and I’m in the upper half.

Our practice is basically set up for the guys doing totals.
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Are you talking top half professional or facility?
 
Did a 3 level Intracept on a Cigna commercial patient last month at ASC — net profit for them on the case was 11K.
 
Taus said:
Unlikely to top busy total joint and spine docs…. All else is fair game and doable.
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A general orthopedist can not hang with a moderately busy pain doctor who is mostly doing clinic procedures, with some ASC.

Not all orthopedists do well BTW, especially trauma (they eat **** on collections, but make up for it with call pay). Too many cases in the hospital IMO, and the payor selection often sucks when they do cases in our surgical centers. Sports is not great either, but many sports guys supplement sports with general ortho cases and that helps.

In my group, if you separate out facility fees and compare me against everyone else, I am very competitive and the only thing that makes it close with a lot of my colleagues are the DME they Rx day in/out. Braces all day, and post op PT.

I do virtually zero DME, so their ancillary collections added into their nonfacility clinic collections adds a huge boost to what they collect.

If I am doing 200-240 spine injections per month, and I am doing roughly 37% of those in an ASC (I own 4% of that 100% physician-owned ASC and do not have a clinic procedure space at that location). I do around 500-600 patient encounters per month (6300 last year), and those numbers put me in the top half of my group before you add in facilities.

End of Feb this year, I was set to end the year around 7000 total patient encounters and have a huge year, but we went live with Athena in March, and this has literally sabotaged my practice. I am F'd right now, but I'll figure out how to fix it.

I'm doing 37% of my procedures in an ASC, but even with just that number of procedures/cases in the ASC I'm competitive. If all of my procedures were ASC I'd be extremely competitive in the facility numbers because of the fact some people seem to forget that collections are just that - collections. That does not include the cost for a case. Ortho cases are expensive.

It's when you add in the outrageously efficient total joint and hand guys that I fall way behind, and I cannot imagine how a pain guy could keep up with them. Bob and GDub sound like they're outliers capable of cranking huge amounts of volume, but I do NOT believe my practice would be able to keep up with that.

Every time I bring a new "thing" to our practice it has a been nightmare. I'm rolling out Intracept now, and this has been quite smooth this time around. Our old ASC director was an ignorant *****, but she's gone.
 
MitchLevi said:
A general orthopedist can not hang with a moderately busy pain doctor who is mostly doing clinic procedures, with some ASC.

Not all orthopedists do well BTW, especially trauma (they eat **** on collections, but make up for it with call pay). Too many cases in the hospital IMO, and the payor selection often sucks when they do cases in our surgical centers. Sports is not great either, but many sports guys supplement sports with general ortho cases and that helps.

In my group, if you separate out facility fees and compare me against everyone else, I am very competitive and the only thing that makes it close with a lot of my colleagues are the DME they Rx day in/out. Braces all day, and post op PT.

I do virtually zero DME, so their ancillary collections added into their nonfacility clinic collections adds a huge boost to what they collect.

If I am doing 200-240 spine injections per month, and I am doing roughly 37% of those in an ASC (I own 4% of that 100% physician-owned ASC and do not have a clinic procedure space at that location). I do around 500-600 patient encounters per month (6300 last year), and those numbers put me in the top half of my group before you add in facilities.

End of Feb this year, I was set to end the year around 7000 total patient encounters and have a huge year, but we went live with Athena in March, and this has literally sabotaged my practice. I am F'd right now, but I'll figure out how to fix it.

I'm doing 37% of my procedures in an ASC, but even with just that number of procedures/cases in the ASC I'm competitive. If all of my procedures were ASC I'd be extremely competitive in the facility numbers because of the fact some people seem to forget that collections are just that - collections. That does not include the cost for a case. Ortho cases are expensive.

It's when you add in the outrageously efficient total joint and hand guys that I fall way behind, and I cannot imagine how a pain guy could keep up with them. Bob and GDub sound like they're outliers capable of cranking huge amounts of volume, but I do NOT believe my practice would be able to keep up with that.

Every time I bring a new "thing" to our practice it has a been nightmare. I'm rolling out Intracept now, and this has been quite smooth this time around. Our old ASC director was an ignorant *****, but she's gone.
Click to expand...
So I find myself doing tons of procedures (mostly LESI, TFESI, SI joint) ~70%
15-20% mbb/RF
1 kypho on average/week

Very little stim and advanced procedures

~~

Hard to build when most of my referral is spine asking for injections to then surgerize
- they don’t like SCS so I don’t do on their patients

~~
 
I don’t do kyphos, but if you’re in an ortho group your stim numbers should be pretty good.
 
drrosenrosen said:
1 kypho a week in office will bring it at least $255k/yr on it's own. At medicare rates.
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How many ppl do that though? I know office kyphos are routinely performed, but how often does someone do that many in the clinic?
 
Working in ortho doesn’t necessarily mean lots of stim. Depends on the spine surgeon. I’ve seen MIS fanatics and fusion happy dudes but rarely a good balance. I’m now in my second ortho practices and neither of them generated a lot of stim.
 
Dr. Ice said:
Working in ortho doesn’t necessarily mean lots of stim. Depends on the spine surgeon. I’ve seen MIS fanatics and fusion happy dudes but rarely a good balance. I’m now in my second ortho practices and neither of them generated a lot of stim.
Click to expand...
Same. I rarely do stim. Chronic opioid population is the best way to get stims
 
Dr. Ice said:
Working in ortho doesn’t necessarily mean lots of stim. Depends on the spine surgeon. I’ve seen MIS fanatics and fusion happy dudes but rarely a good balance. I’m now in my second ortho practices and neither of them generated a lot of stim.
Click to expand...
I could do 2-3 per week if I wanted. I see failed back daily.
 
My group has an ASC but it’s 51% owned by a national chain (apparently due to payor contracts the partners actually made a lot more after selling out). Buy-in is individual though, and I do almost all my procedures in office including a lot of RF. Trying to decide whether it would be worth it for me to move enough of my RFs to the ASC to qualify for shares. If I’m reading the safe harbor rules correctly it’s possible if I moved about 1/3 of my RFs and SCS cases there I could qualify. Anyone think that would actually pencil out?
 
SSdoc33 said:
one man's stim candidate is another man's "no effing way" candidate
Click to expand...
Exactly the reason I am the way I am. I could get authorization for tons of stimulators but I don’t bc I think it’s a very limited therapy that only works for a small number of diagnoses.
 
MitchLevi said:
Not sure what you mean but I see pts post spine surgery all day every day
Click to expand...
Me too but I don’t see that many great SCS candidates. Lots of adjacent segment disease, degenerative foraminal stenosis, etc, but not so much of the “hurts all the time” back and leg nerve damage type of pain. Maybe it’s a function of the local surgeons? They’re all pretty conservative, very reasonable guys.
 
callmeanesthesia said:
Me too but I don’t see that many great SCS candidates. Lots of adjacent segment disease, degenerative foraminal stenosis, etc, but not so much of the “hurts all the time” back and leg nerve damage type of pain. Maybe it’s a function of the local surgeons? They’re all pretty conservative, very reasonable guys.
Click to expand...
I always end up seeing some adjacent level disease, then fusion extension if failed TFESI
 
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