Reimbursement Advisor

Is discount unfair for outpatient ablation?

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Q Our ObGyn providers perform endometrial ablations in the outpatient department of our local hospital. Medicare and some other major carriers state we are to be reimbursed at the facility fee reimbursement rate. We disagree with this reduction in payment and would like some guidance on how to dispute this discount.

A The payment level is determined by the place of service, not the category of health care professional performing the surgery.

In the office setting the practice expense portion of the relative value assigned to a procedure is higher than when the procedure is performed in an outpatient setting, which does not incur the expense of supplies, treatment room, anesthesia, and equipment. The physician is still reimbursed the same for the physician work and malpractice elements of the procedure’s relative value, but the total RVU is less because the practice expense portion is less.

A physician would be paid at the lower RVU level for a facility setting, for performing a procedure in a hospital outpatient department, under Medicare rules, since the outpatient facility has incurred the expenses of staffing the procedure as well as the expensive disposable equipment.

The only exception to this rule is when a procedure performed in this setting does not appear on the ambulatory surgical center (ASC) list of procedures. In that case, the higher nonfacility fee allowance would be reimbursed. Unfortunately, both codes for an endometrial ablation—58353 (endometrial ablation, thermal, without hysteroscopic guidance) and 58563 (hysteroscopy surgical; with endometrial ablation)—appear on the ASC list.

Ms. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

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