What billing challenges stifle outpatient spine migration? 2 surgeons' insights

Carly Behm -   Print  |
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The migration of some spine surgeries to ASCs is well underway, but evolving CMS rules and payer regulations still pose some roadblocks.

Two spine surgeons told Becker's Spine Review what they thought were the biggest coding and billing obstacles in outpatient migration.

Note: Responses were edited for style.

Question: What billing challenges pose the biggest threat to outpatient spine migration?

Kern Singh, MD. Midwest Orthopaedics at Rush (Chicago): CMS’s elimination of the “inpatient only” list for many spine-specific codes coupled with the trend to move towards site neutral payments between ASCs and HOPDs, the shift to outpatient spine migration in the next few years will continue to march forward. However, as the outpatient spine surgical environment matures, certain challenges will need to be addressed. As CMS continues to modify healthcare payment models with a trend towards bundled payments, it will be incumbent on physicians to effectively preoperatively stratify patients by risk to prevent higher episodic costs under a bundled payment model.

It is estimated that 30 percent to 45 percent of patients will be covered under bundled payments within a few years. As spine surgeries are relatively more heterogeneous with greater cost variation and penalties for “outliers” to fully capitalize on the shift to outpatient spine, delineating all controllable costs and stratifying patients for the appropriate setting of care will be paramount.

Issada Thongtrangan, MD. Microspine (Scottsdale, Ariz.): Spine surgeries, beyond interventional procedures, are now migrating to the ASC setting of care. In the past several years, Medicare has allowed more procedures, not only simple decompressions but also fusion surgery, in the OP or ASC setting. Many spine surgeons utilized minimally invasive techniques and got great outcomes similar to when the surgery was done in the hospital setting.

Coding standards that are primarily designed for Medicare complicate the coding pathways that must be adopted into outpatient/private payor contracts. Differing payment methodologies for OP and ASC facilities require that surgeons and facilities communicate and provide relevant coding pathways for services and devices they use in more complex spine surgeries.

Another issue is that in some payers or plans, there is no pre-authorization required for the same surgery if it is being done in the ASC versus in the hospital. However, many ASCs and surgeons won’t take the risk as they might not get paid for the service.

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