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Regulatory and Compliance Issues

By: Juan Arredondo and Bri Driggers

In part three of our free webinar series, Regulatory & Compliance Issues, RCCS President Melody W. Mulaik took the lead to discuss the nuances and challenges of opening and operating an outpatient-based IR lab (OBL) from a regulatory and compliance viewpoint. In this online webinar, Raif Erim and Sheila Sferrella joined her to discuss valid points for those considering an OBL versus an ambulatory surgery center (ASC). 

This blog summarizes the important points mentioned in the online webinar such as advantages and disadvantages from a compliance standpoint, reimbursement differences, documentation, tax requirements, and much more. Learn why now is a critical time to consider OBL opportunities in the market.

Key Takeaways

  • Coding for ASC/OBL is different from other coding and proper training is needed.
  • Depending on your anticipated procedures and physician specialists involved in your ASC/OBL, you must complete an in-depth and detailed strategic plan before launching.
  • In the documentation process, it is crucial to report what services were offered and who provided the services. Structured reporting is an effective way to properly document these.

What procedures can be done in an ASC vs. OBL?

One of the first questions that someone might have when considering an OBL is: what procedures can be performed in an OBL and/or ASC? To properly answer this question, our experts recommend that you analyze the list of available procedure codes for the services the physicians will perform in the facility. The reality is that a wide variety of procedures can be safely performed in an outpatient setting. The trick is understanding how a practice can generate the appropriate and greatest revenue for those procedures. This is a crucial step that must be completed prior to launch because of reimbursement requirements and payment structures. 

A market assessment could help estimate the projected services for that demographic area and the facility’s performance. Keep in mind that every facility is different. One of the main differences between billing for services at an OBL vs an ASC is for an ASC there is a facility charge and procedures are typically reimbursed under an ASC fee schedule whereas at an OBL the procedures would be billed globally under the physician practice tax ID. Understanding which procedures are reimbursed under which setting is critical.

Can you use the same billing and coding staff for an OBL or ASC?

Medical billing and coding play a key role in ensuring procedures are fully reimbursed but coding for an OBL or ASC is distinct from general coding. To successfully bill for an OBL or ASC depends on the skillset of the staff and the systems in place. For example, an OBL or freestanding ASC is billed on a CMS 1500, but a hospital-based ASC has different requirements that will be billed on a UB-04 form. It is possible for someone to be skilled in both, but it is not guaranteed. It is recommended that an organization invests in proper training for their staff to be skilled in both areas.

Are different tax IDs required for an OBL or ASC?

OBLs have been around for a while, but they became a hot topic because of their declining reimbursements for the professional services provided by physicians in a hospital setting. Historically interventional radiology procedures brought a lot of revenue into a hospital but current reimbursement has made it difficult to justify a full suite of IR procedures when the IR physicians aren’t reimbursed enough to justify their dedicated presence on the hospital campus. Radiology groups have found a lot of success developing outpatient IR Labs (OBLs) where they bill for the entire procedure under the tax ID of the physician practice, enabling them to benefit from the global reimbursement for the work they perform.

Setting up an ASC is a whole other process. The group or organization is required to create a new Tax ID number and apply for all the necessary Medicare IDs and credentials in order to bill for procedures at the facility. 

Note that when a new tax ID number is created, it is required to negotiate new payer contracts under the new ID and there are no guarantees that potentially favorable rates for a particular practice or provider will translate to those same favorable rates under the new ASC’s Tax ID.

Billing for procedure supplies in an OBL or ASC

From an OBL perspective, only a few additional things are added. It is important for groups to decide what they are trying to properly capture to avoid overbilling. The Y90 radioembolization or Selective Internal Radiation Therapy (“SIRT”) procedure is a notable example because the Y90 isotope itself is very expensive and there is a difference in reimbursement between commercial payers and Medicare. If the supply of the Y90 is not coded, documented, and billed correctly, there could be significant reimbursement being missed which causes that procedure to be performed at a loss. 

Contacting payers becomes important because sending patients to an OBL or ASC may be more cost-effective than to a facility. There will also be significant differences in reimbursement for supplies, drugs, and other necessities. Note that it will be hard to get reimbursement for procedures that are beyond the scope of procedure codes. It is advised to understand payer requirements and what is appropriate in all scenarios.

Something else to consider with ASCs is the increase of HCPCS codes (C codes) created by CMS for ASC procedure coding and billing. NCCI edits, particularly MUEs on those C codes, are important to review for coding and billing purposes. Make sure your staff understands the difference in reporting codes for physicians vs facilities.

The difference in documentation between an ASC and an OBL

All procedures must be documented. It is important to note what services are offered and who is providing the services to determine what the documentation will look like. No matter what services are performed, the reports must support the documentation captured. Structured reporting is a way to ensure that physicians document all the services provided appropriately to avoid regulatory and compliance issues. Structured reporting is a fantastic way to walk the physician through the prompts on how to do it. The Society of Interventional Radiology (SIR) provides this for its members.

Can you use your existing RIS and PACS for an ASC?

From their experience in the field, our experts have found ASCs usually use a dedicated and specialized ASC EMR because of the many nuanced items that must be documented. Billing for an ASC procedure is not the same as billing for an OBL procedure. In an OBL, the RIS system for the radiology group is usually sufficient to document all the necessary patient and procedure information for accurate billing. In an ASC, there is an entirely different process that requires different documentation and verification. The documentation systems are similar to operating room documentation rather than a traditional imaging report. As such, there are specialized vendors that have streamlined the patient intake, registration, and procedural processes in order to ensure more accurate coding and billing, assuming the workflow is set up appropriately for your facility.

What does accreditation look like for an ASC?

Attaining accreditation for an ASC is like getting Joint Commission accreditation for an outpatient imaging center or getting ACR accreditation for imaging modalities. It is time and work-intensive but not necessarily difficult. But it requires particular attention to detail so that nothing is missed. There are several commercial payers you cannot contract with if you do not have Joint Commission accreditation.

Just like any other accreditation process, there are going to be life safety and documentation reviews. It is not that different from any other accreditation except for the surgical procedures you provide. One of the appealing things about an ASC is having potential physician partners in other specialties share the space. It is possible to set up an ASC that is only utilized 2 days a week because you are setting up an OR that can do anything from podiatry to ophthalmology.

If you have additional questions about setting up or operating an OBL or ASC, contact our team to get the assistance you need!