Current Challenge in Ambulatory Anesthesia: Cost-Containment

Here are is one of the challenges affecting ambulatory anesthesia, and advice from experts for handling it effectively. The full story, “5 Current Challenges in Ambulatory Anesthesia,” appears in the Jan. issue of Becker’s ASC Review.

If anesthesia is truly committed to the success of your facility, it will do all it can to ensure business efficiencies.

“Anesthesia should critically look at the delivery of anesthesia to continually address the cost of anesthesia per case,” says David Shapiro, MD, CPHRM, LHRM, CHC, chair of the Ambulatory Surgery Foundation and chair-elect of the ASC Association. “In some cases, nothing can be changed, because you need to maintain patient safety, but in other cases, you can find unnecessary or excessive use of disposables, or that a generic drug can be used.”

Stanford Plavin, MD, an anesthesiologist, managing partner of Ambulatory Anesthesia of Atlanta and board member of Georgia Society of ASCs, agrees, and offers that saving money doesn’t have to mean hardship for anesthesia providers.

“For example, if you switch to generic anti-emetics, not only are you spending $1.50 per dose compared with $15 or $20, but you can afford to offer it to more patients and cut down on post-op nausea, which leads to more efficiency overall,” he says.

Use of propofol for sedation is another strategy for saving money and enhancing patient care and efficiency.

“Using propofol improves efficiencies; if, instead of doing 13 or 14 cases by 5 p.m., you can do 18 cases by 3 p.m., that’s big money,” says Dr. Plavin. “In a GI center, at a $450 facility fee per procedure, you’re looking at millions in revenue annually. Not to mention the ability to schedule more efficiently – something that will increase surgeon satisfaction and patient satisfaction, because they don’t have to spend a month worrying before they are scheduled.”

A lot of these efforts begin in materials management, so anesthesia, not just surgeons, needs to be kept in the loop on purchasing, notes Dr. Shapiro. This also circles back to the concept of consistency among the anesthesia providers in the ASC setting.

“Surprises are bad in the ASC, and having anesthesia involved in many facets of the center can help eliminate those,” says Dr. Shapiro. “When anesthesia is involved in purchasing, it contributes to cost-containment efforts. When anesthesia is involved in scheduling and pre-op processes, you don’t end up cancelling a case on the operative day and wasting a pack or other supplies.”

10 Steps to an Easier ICD-10 Transition

There is no doubt that the U.S. healthcare system will transition to ICD-10. Whether it happens in 2011, as proposed by the Centers for Medicare & Medicaid Services (CMS), or at a later date, it is coming.

The potential benefits for ASCs from the transition to the expanded code set are fairly significant and include more accurate payments, fewer rejected or improper claims and better understanding of new procedures. However, to realize those benefits, ACSs will need to invest heavily in systems and training.

For those ASCs that lack formal coding processes or systems to fall back on, the transition will be that much more complex. That is why you need to be aggressively proactive in planning for ICD-10, in part by implementing the following 10 steps to ease the pain of the transition and begin realizing the benefits of the new system more quickly.

1. Establish a transition team

Because of its granular nature, the move to ICD-10 will affect more than just your coding and billing staff. That is why it is imperative to put together a well-rounded transition team made up of representatives from coding, clinical, finance and information technology. The team should have a working knowledge of ICD-10 and how it differs from ICD-9, as well as the expected short- and long-term financial and personnel impact of the transition.

Communication is especially critical to a successful transition. As such, the transition team should commit to regular meetings, as well as establish communication channels to provide senior management and affected staff members with status reports to keep them updated on progress, next steps and any issues that arise throughout the process.

2. Develop a transition plan

The first task of the transition team is developing a transition plan and timeframes. The plan should identify specific actions and assign responsibilities and deadlines for achieving them, including any changes to processes, policies and procedures, as well as education needs. It is important to also identify any need for increased staffing or consulting services to assist with coding backlogs, monitoring of coding accuracy, etc., as well as system upgrades or changes necessary to accommodate the new code set.

The plan should establish a budget for accomplishing the transition and estimate the financial impact the expected loss of productivity and disruptions in cash flow will have. This is particularly important given the costs associated with completing the transition. Nachimson Advisors estimates that a small physician practice (three physicians and two impacted staff members) will spend more than $83,000 and a large practice (100 providers and 64 coding staff) will spend in excess of $2.7 million.

3. Identify the impact on key business processes

To understand the impact ICD-10 will have on key business processes, including health plan contracts and coverage determinations, the team should conduct a detailed assessment. This should identify any contract modifications that may be necessary to accommodate the greater specificity required for ICD-10 and any resulting adjustments to payment terms. Additional documentation requirements and new diagnostic codes may also cause revisions in coverage determinations.

4. Assess adequacy of existing documentation

Because of the higher level of specificity required under ICD-10, it is important to ensure your clinical documentation contains enough detail to support code assignment under the new system. This can be accomplished by evaluating random samples of medical records to identify areas where documentation is lacking, as well as diagnoses and procedures that will require a higher level of detail.

By assessing existing documentation, areas of weakness can be identified and addressed prior to the transition. The documentation improvement strategies identified in the assessment can also serve as the foundation of staff education programs.

5. Design staff education programs

The transition to ICD-10 is more than a simple code-set replacement. Because ICD-10 is more granular and detailed, even professional coders and billing specialists who are very comfortable with ICD-9 will require specific training to become proficient with the new diagnostic codes and documentation requirements. Further, because few ASCs have a dedicated coding staff, responsibility for ensuring accurate documentation and code assignment will typically fall to billing clerks who rarely have specific coding expertise, which makes training and education all the more critical.

However, education cannot focus solely on coding and billing staffs. If electronic documentation and coding systems are not utilized, physicians and nurses will need training on capturing the appropriate level of information in procedure documentation to support coding under ICD-10. The IT staff will also need to be educated on the difference between ICD-9 and ICD-10 to determine whether current systems and interfaces need to be built or modified in any way.

6. Meet with payers and billing vendors

Just like providers, health plans must also transition to ICD-10. In addition to upgrading their own systems to accommodate the new coding formats, payers will need to revamp coverage determinations and reimbursement rates. As such, it is important to sit down with payers early in the process to gain a clear understanding of what they will be looking for under ICD-10, establish when they will be ready to begin receiving claims coded under the new system and determine what, if any, interim plans they have.

Further, for those ACSs that utilize a billing service or clearinghouse, it is important to meet with those vendors to ascertain their plans for rolling out ICD-10. Discussions should also focus on how billing vendors will support the ASC during the transition period.

7. Establish procedures to accommodate coding in both environments

Because it is very likely that payers will make the transition to ICD-10 at different paces, establishing a process to accommodate coding in both environments ensures that ASCs can submit claims and receive reimbursements in a timely manner. This will be a difficult manual process if you aren’t working with some sort of electronic documentation system before the transition.

You’ll need to determine the length of time both systems will need to be supported, and any additional storage capacity that may be necessary. For internal IT representatives, you’ll need to know how long the ICD-9 system will be accessible and by whom. For example, anyone responsible for data analysis will likely require access to the old system for longer than coding and billing personnel. The billing department may also require longer access to ICD-9 to process older claims and for any re-billing.

8. Evaluate existing documentation, coding and billing systems

A thorough evaluation should be conducted of any IT applications that will potentially be impacted by the change to ICD-10, including practice management, scheduling, billing, documentation, coding and/or electronic medical record systems. In most cases, software modifications will be needed to accommodate format changes, new diagnostic codes, etc. For example, ASCs that utilize superbills will need to make significant changes to accommodate the expanded number of codes contained within ICD-10.

Software modifications will likely include expanding field sizes, changes to alphanumeric composition, decimal use, redefining code values and interpretations, edit and logic changes, table structure modifications, etc. It will also be necessary to determine if you’ll need to modify or redesign any reports or forms, as well as to determine any changes to other applications that will be impacted by the new code set.

This step will consume a significant portion of the ICD-10 budget. According to Nachimson Advisors, changes to the superbill alone will range in cost from nearly $3,000 for a small practice to $99,500 for a large practice. IT system changes will range from $7,500 for a small practice to $100,000 for a large practice, while increased documentation costs will range from $44,000 for a small practice to nearly $1.8 million for a large practice.

That is why, for those ASCs that have not already done so, now is a good time to consider making the investment into procedure documentation and coding systems. Doing so will ease the transition to ICD-10 and allow ASCs to take advantage of the increased revenues and streamlined workflow processes made possible by automating these processes.

9. Meet with system vendors

Software vendors, particularly those whose applications link directly to the documentation, coding and billing processes, should play a key role in easing the transition for their ASC customers. In fact, system vendors should ideally take on the “heavy lifting” by providing clients with upgrades that allow them to automatically produce coder-ready documentation appropriate for ICD-10, and also to accommodate the dual-coding environment that will likely be necessary during the early days of deployment. However, not every vendor will be willing or able to do so. That is why it is important to meet with them early in the process to ascertain exactly what role they will play in the transition process, any support they can or will provide and any costs for them to do so.

Key issues to discuss include vendor readiness and timelines for upgrading software to new coding systems and whether or not upgrades are covered by existing contracts. It will also be necessary to coordinate any software or upgrade installations and testing.

10. Designate a monitor

CMS may have issued its mandate regarding the transition to ICD-10, but that does not mean there won’t be rule changes between now and then. For example, will CMS fully embrace ICD-10, including both CM and PCS, or will they continue to utilize CPT codes? What are the HIPAA implications of ICD-10? By designating one individual to monitor any changes to the mandate, an ASC can ensure they are making the most appropriate use of resources to achieve compliance in a timely manner.

Making the transition to ICD-10 will be neither easy nor cheap. By getting a transition plan in place now and following the steps outlined above, you’ll be able to move past the expected productivity and revenue losses far more quickly and realize a more rapid return on investment into the new systems and processes required to comply with ICD-10.

– Sean Benson ( sean.benson@provationmedical.com ) is co-founder and vice president, consulting, with ProVation Medical (www.provationmedical.com), which provides procedure documentation and clinical decision support solutions for hospitals and ASCs. ProVation Medical is part of Wolters Kluwer Health, a leading provider of information and business intelligence for students, professionals and institutions in medicine, nursing, allied health, pharmacy and the pharmaceutical industry.

In the News: California’s South Bay Hospitals See Elective Procedures Shift to Surgery Centers

Hospitals in the South Bay region of California are reporting decreases in elective surgeries while surgery centers are reporting increases, according to a report from the Silicon Valley/San Jose Business Journal.

Good Samaritan Hospital in Los Angeles, Regional Medical Center in San Jose and O’Connor Hospital in San Jose all report declines, with hospital executives attributing some of the drop to a shifting of procedures to ASCs, according to the story.

Meanwhile, Los Gatos Surgical Center reports an increase in business and is projecting a strong finish to the year.

Read the Silicon Valley/San Jose Business Journal report on the shift of South Bay outpatient surgery.

Top 8 Reasons For Monetizing Healthcare Real Estate From Bruce Bright of The Sanders Trust

Here are the top eight reasons Lt. Col. Bruce Bright, director of business development for Birmingham, Ala.-based The Sanders Trust, cites for selling healthcare real estate.

1. Current market presents opportunities. Lt. Col. Bright says while the economy has battered the stock market, those changes may help his sector of the industry.

“Hospitals and health systems are more interested now in deriving cash value from their bricks and mortar. It’s the same thing for ambulatory surgery centers and medical office buildings,” he says. “When capital needs go up, real estate offers an opportunity to put money back into their core businesses. The return on investment (ROI) of capital in a surgery center or hospital is always higher than the ROI for bricks and mortar real estate. They can monetize real estate and take that money and pump it back into use into for equipment, staff or services.”

2. Add cash to balance sheet. He says hospital CEOs are not focused on maximizing their real estate investments.

“They’re in the “caring for patients business,” he says. “And they have lots of capital tied up in real estate that isn’t delivering for them. Remember that adding cash to the balance sheet while preserving debt capacity is always good.”

3. Greater credit. Lt. Col. Bright says analysts assign greater credit to cash than to property plants and equipment combined with debt.

“If you have cash on balance sheet, credit writing agencies will always assign greater credit,” he says.

4. Breakdown barriers. Selling the medical office building resolves uncomfortable conflicts that arise when hospitals act as landlords to physician tenants. Lt. Col. Bright says relations improve when physicians and hospitals focus on clinical and patient relationships and don’t allow touchy financial connections to impinge on those crucial relations.

5. Avoid legal ramifications. He says selling the property eliminates potential Stark law issues.

“I don’t have Stark liability, but hospitals and doctors do. Physicians and hospitals can never refer me any patients,” Lt. Col. Bright says.

6. Maintain control. Lt. Col. Bright reassures healthcare providers that their greatest fear in selling medical real estate – that competitors will locate on their campus and steal their patients as soon as they sell – is highly unlikely.

“The sellers can maintain control of their facilities and include prohibitions against renting or selling to competitors,” he says.

7. Remove personal debt guarantees. He says that monetizing real estates also can eliminate personal debt guarantees associated with real estate mortgages, freeing doctors to practice medicine without committing their homes and property to back guarantees.

8. Dispute resolution. Lt. Col. Bright says selling healthcare real estate assets can resolve problems between physician real estate owners in ASCs, clinics and medical office buildings and their non-participating physician business co-owners.

“Inevitably there are disputes when some of the partners are writing rent checks out to other partners, usually older ones,” he says. “Selling the property obviates those disputes.”

Lt. Col. Bright ( bbright@sanderstrust.com), a former Marine fighter pilot and infantryman, is an expert in commercial and investment real estate for The Sanders Trust, a national medical real estate investment firm. Learn more about The Sanders Trust.

From the VMG Health 2008 Intellimarker: 10 Interesting Ophthalmology Statistics and Figures

According to the VMG Health 2008 Intellimarker, here are the average revenues per case for ophthalmology procedures.

1. Ophthalmology makes up an average of 15 percent of case volume for ASCs nationwide.
2. Regional case volume average: West – 13 percent; Southwest – 18 percent; Midwest – 15 percent; South – 17 percent; Northeast – 11 percent.
3. Average national gross charges per case – $4,813.
4. Average national net revenue per case – $1,409.
5. Average national discount to charges per case – 66.9 percent.
6. West region: average gross charges per case – $4,846; average net revenue per case – $1,164.
7. Southwest region: average gross charges per case – $5,293; average net revenue per case – $1,269.
8. Midwest region: average gross charges per case – $3,319; average net revenue per case – $1,087.
9. Southeast region: average gross charges per case – $4,173; average net revenue per case – $1,098.
10. Northeast region: average gross charges per case – $3,649; average net revenue per case – $1,123.

Learn more about VMG Health. To receive a copy of the VMG Health Intellimarker, go the the VMG Health Web site.

7 ASC Trends from Medical Architect Raymond Fox of Raymond Fox and Associates

Here are seven observations from medical architect Raymond Fox of Raymond Fox & Associates about what he expects to see in the ASC market in the near future.

1. More dermatology focused ASCs. “Dermatologists have grown more prolific and come on stronger as ASCs expanded services to incorporate the need for dermatology ASCs and are now building more ASCs for themselves and their specialties,” Mr. Fox says.
2. More gastrointestinal ASCs. “GI ASCs started growing about five years ago and continues to grow despite the drop in reimbursements in that specialty,” he says.
3. Bigger, rather than smaller ASCs. “We’re seeing physicians building bigger buildings, in spite of the economy,” he says. “We’re particularly seeing that in smaller markets where they have captive audiences. A physician in Rollins, Wyo., doesn’t face the same kind of competition that a doctor in Dallas does. We’ve seen a ton of these in small communities around the country at the same time physicians in big markets are trying to consolidate.”
4. More ASCs built within Certificate of Need (CON) states with a single specialty. “About half the remaining states that have CONs do allow physician groups to build single specialty (ASCs),” Mr. Fox says, citing Pennsylvania and Washington as two states seeing a lot of ASC construction activity. “That’s a way for CON boards to bridge the gap. They’re not trying to be hospitals.”
5. Fewer pain management ASCs. “Pain management as a specialty has taken a beating over last few years,” Mr. Fox says. “It’s not going away, but the reimbursements have fallen and that component [has become] smaller and is less of a cash cow than it used to be.”
6. More spine-focused ASCs. “As more orthopedic surgeons and neurologists perform more arthroscopic procedures, they will grow more comfortable doing them in outpatient settings such as ASCs,” says Mr. Fox, who said that reimbursement and technology will also drive the migration. “Spinal procedures in surgery centers will explode in the next few years in ASCs and I think we’ll see the same thing with knees and hips.”
7. Improved aesthetics. “We’re seeing more user-friendly and patient-friendly new products coming out, new flooring and cabinetry that make ASCs look homier,” he says. “You can build an ASC now that looks like somebody’s living room, still with commercial grade materials, but looking much more residential and less institutional We expect that to grow.”

Mr. Fox says the actual flow and design of ASCs haven’t changed much since he entered the business 31 years ago. “They might vary by specialty and types of surgery performed,” he says. “And the lights and surgical equipment may have improved. They are power users and there’s strong need for filtration. The plumbing, electrical and mechanical systems are so large and based on capacity that it seems to be going in the opposite direction of the green movement. So much of it is dictated by building code, which necessitates using more energy. It’s not a place where you can incorporate a lot of energy conservation.”

Raymond Fox ( ray@raymondfox.com ) is a medical architect whose San Diego-based firm, Raymond Fox & Associates, has designed more than 600 ASCs.

Understanding the Implications of Physician/Hospital Joint-Venture ASCs

One of the biggest changes I have seen in my many years working in the ASC sector has been the move toward more hospitals and surgeons joining forces in establishing and operating surgery centers as partners. Back when I first started in working with surgery centers in 1997, the idea of doctors working in partnership with the local hospital on a surgery center was unrealistic. The hospital administrators were outraged that the doctors had the audacity to open a surgical facility and the doctors were directly competing as hard as they could.

Fast forward to 2008 and the majority of clients I work with through my company (ASC Strategies) are surgery centers that are owned by a partnership of hospitals and physicians. While we are engaged to help them work through operational issues or to find opportunities for increased profitability, for the most part they are already successful partnerships. They are just looking for a third party to give them a little advice and direction.

As the number of these physician/hospital partnerships continues to grow, it is worthwhile to examine what this joining of two different cultures means for all of the parties affected and understand why a partnership with a hospital might be worth exploring for your ASC.

Patients

While the patients like the efficiency and friendliness of having their procedures in a freestanding surgery center, they seem to have an increased sense of comfort knowing there is a connection to the main hospital campus. Whether it is perception or reality (since all freestanding ASCs have the capacity for transfer to a hospital if needed), patients and their families like knowing the hospital – with both its reputation and all of its emergency equipment – is standing behind the services offered at the surgery center. Also, if the partnership is working, there is the opportunity for less duplication of outpatient surgical services and the expenses that accompany it; this reduces healthcare costs and allows the hospital to possibly add more complex services that can benefit the community.

Staff

One of the hardest groups to let go of the past and understand these partnerships is the employees that work in the surgery center. Many of them still hold on to the “us vs. them” mentality that has been the hallmark of relationships between the physicians and the hospital, especially if the employee has a long history working for one or the other partner. They have to be encouraged to remember that everyone is now on the same team. Not the hospital team or surgeon team, but the surgery center team.

Soon they see that having a hospital as a partner can facilitate sharing of equipment, supplies etc. And when you have physicians who are owners, they tend to start their cases on time and move cases through more quickly with fewer demands placed on the staff.

Surgeons

Even though some physicians come to these partnerships kicking and screaming, many surgeons who have had the opportunity to participate in a partnership with the hospital through a surgery center are pleased with the relationship. It is universal that most surgeons do not want the hospital administration to manage the center, but they do understand the value that the hospital administrator’s healthcare management expertise and clout with vendors and payors can bring to the surgery center. The biggest hurdle that the surgeons need to get over is exactly how much control the hospital will have over the operations of the center. If this issue is discussed early and honestly, we often see little conflict in making everyone comfortable with the roles.

Hospitals

It used to be a very hard sell to convince a hospital CFO that it is smart business for the hospital to support moving surgical cases into a lower reimbursing facility and split the revenue with surgeons performing the cases. But more and more sophisticated hospital leaders understand the value of partnering with their physicians in outpatient surgery centers, both as a way of solidifying relationships and decreasing expenses. The hospital administrators of successful joint-ventured surgery centers understand that they can be more successful in the long run when they partner with their surgeons instead of competing with them.

Hospital leaders across the country are now aggressively trying to find ways to partner with their medical staff in outpatient surgical ventures. Whether it is buying into existing physician-owned centers or opening new surgery centers and surgical hospitals in partnership with their physicians, it is rare to find a hospital or hospital system without some sort of joint-venture initiative in their strategic plan.

A scenario that can benefit all parties

From the early days of the surgery center industry, the main reason the surgeons took money out of their pockets to invest in a surgery center was not for a large return, but to create a more efficient and surgeon-friendly surgical environment to work in. With the changes in reimbursement, the need to see more patients and the tightening of available capital, that is even more the case today. Surgeons need an efficient place to work and hospitals need a lower cost environment for those cases which are seeing their reimbursement shrinking. One of the best models for everyone, (patient, staff, surgeon and hospital) is a surgery center where everyone is working together, honestly, and contributing their individual and diverse strengths to partnership and where everyone works to keep the interest of the partnership and the patients before their own.

Ms. Nantz ( jnantz@ascstrategies.com ) is co-founder of ASC Strategies, a privately-held ASC consulting company that works with hospitals, physicians and other professionals to help them develop and operate surgery centers. Learn more at www.ascstrategies.com.

Top Surgical Specialties in Surgery Centers by Procedure Volume

Here is an analysis of the mix of specialties in ASCs by procedure volume, with gastroenterology accounting for the greatest volume of procedures, according to the 2008 Outpatient Surgery Center Market Report.

• Gastroenterology – 42 percent
• Ophthalmology – 16 percent
• Pain management – 9 percent
• Orthopedic – 8 percent
• Plastic surgery – 5 percent
• ENT – 4 percent
• Gynecology – 3 percent
• General surgery – 3 percent
• Urology – 3 percent
• Podiatry – 2 percent
• Other – 5 percent

Source: SDI’s 2008 Outpatient Surgery Center Market Report.

Best Practices for Correct Coding and Billing of 5 GYN Procedures

Here are best practices and guidelines for the correct coding and billing of five common gynecology procedures performed in ASCs.

1. Laparoscopy procedures

Here are the guidelines for locating the correct/most precise laparoscopy code.

• Begin by looking up “laparoscopy” in your CPT manual’s index.
• Review the choices for the body area/organ/system the procedure examined or treated.
• If you can’t find a code, look up the codes in the area of the CPT book for similar procedures done in an open fashion and see if there are any scope-applicable codes in that section. Look for codes which contain the descriptor suffix of “-oscopy.” Do not code an “open” procedure code for a scope procedure.
• If questions remain about correct coding, verify the code with the surgeon.
• If no appropriate code can be located, use an unlisted laparoscopy code, file the claim as a paper claim and include the operative report with the claim.

If the patient has two unrelated laparoscopic procedures performed during the same operative session, both may be coded and billed. Check your CCI unbundling guidelines and if the procedures are unbundled but were performed in different areas, append a -59 modifier to the code that is unbundled.

Always remember that a diagnostic laparoscopy is included in a surgical laparoscopy and is not separately-billable.

2. Laparoscopic lysis of adhesions

Laparoscopy procedures often include lysis of (incidental) adhesions, which are not separately billable most of the time. The only time the lysis of adhesions procedure would be separately billable from other laparoscopic procedures (from which the lysis procedure is unbundled according to your CCI unbundling guidelines) would be if the lysis of adhesions procedure is performed for a different medical reason (with documented separate medical necessity, i.e., a different diagnosis) than the laparoscopy, the lysis procedure was performed in a different area than the other laparoscopy and the surgeon documents in the operative report that he/she spent a significant amount of time performing the lysis procedure.

If all of these circumstances are met, you can bill the lysis of adhesions procedure using the -59 modifier if it is unbundled from the other laparoscopy procedure.

3. Sling/TVT tape procedures

The sling operation for stress incontinence performed laparoscopically is coded 51992. Use the 57288 code if the procedure is performed as an open procedure. According to the AMA’s CPT Assistant newsletter, CPT code 57288 describes the placement of fascia or other materials at the urethrovesical junction to encircle and suspend the urethra for treatment of stress incontinence. The ends of the sling are pulled toward the symphysis pubis and fastened to the rectus abdominus sheath. This procedure is for a combined anterior vaginal and abdominal approach.

In the laparoscopic procedure (code 51992), the endopelvic fascia is opened and a tunnel is dissected between the urethra and vaginal mucosa; sling material (cadaver or synthetic) is then passed through the tunnel and secured to Cowper’s ligament bilaterally. If tape is used in the procedure, don’t forget to bill for the TVT tape – the C1771 HCPCS code can be used to bill for the sling supply to some payors, if the payor reimburses for implants. However, don’t use C-codes to bill implants to Medicare. Other possible codes to use instead (depending upon the payor) include L8699 or 99070.

4. Hysteroscopy procedures

Here are the guidelines for proper coding of hysteroscopy procedures.

• Use code 58555 for a diagnostic hysteroscopy which would not be billable if a more extensive procedure is performed hysteroscopically. This code is designated as a “separate procedure” according to CPT guidelines.
• When a hysteroscopy procedure includes a biopsy or polypectomy, and is performed with or without dilation and curettage, it is coded 58558.
• When Essure, NovaSure, or similar implants are used for birth control, use code 58565 for the placement of these devices performed using a hysteroscope. Don’t forget to bill for the implant supply with codes L8699 or 99070.
• Use code 58563 for an endometrial ablation procedure performed under hysteroscopic guidance (by endometrial resection, electrosurgical ablation, or thermoablation).
• Use code 58353 for a thermal endometrial ablation procedure performed without hysteroscopic guidance.

5. Myomectomy/Fibroid excision procedures

Myomas are growths in the uterus, which are more commonly referred to as “fibroids” or “fibroid tumors,” and they are the most common growth of the female genital tract. These tumors are benign and they are usually characterized as round, firm masses of the muscle wall of the uterus. Myomas are composed of smooth muscle and connective tissue, they can grow to be quite large, and are very common, as they affect as many as 30 percent of women. The growth of fibroid tumors is thought to be stimulated by estrogen. Common symptoms of fibroids include dysfunctional uterine bleeding, cramps, abdominal pain and pressure.

According to the CPT Assistant, there are several different types of uterine fibroids, which are classified based upon their location.

• Intracavitary myomas are fibroids that are located inside of the uterus.
• Submucous myomas are fibroids located partially in the uterine cavity and partially in the wall of the uterus.
• Intramural myomas are fibroids usually located in the wall of the uterus. Their size can range from microscopic to larger than a grapefruit.
• Pedunculated myomas are fibroids connected to the uterus by a stalk.

Coding of these procedures is based on the method of approach to remove the fibroids, the number of myomas removed and the total weight of the tissue removed.

• Use code 58140 for an open myomectomy procedure involving the excision of 1-4 intramural fibroid tumor(s) of the uterus with a total weight of 250 grams or less and/or removal of surface myomas, performed via an abdominal approach.
• Code 58145 for a myomectomy procedure involving the excision of 1-4 intramural fibroid tumor(s) of the uterus with a total weight of 250 grams or less and/or removal of surface myomas, performed via a vaginal approach.
• Code 58146 for an open myomectomy procedure involving the excision of 5 or more intramural fibroid tumor(s) of the uterus with a total weight greater than 250 grams, performed via an abdominal approach.
• Code 58545 is for a laparoscopic myomectomy with the excision of 1-4 intramural myomas with a total weight of 250 grams or less and/or the removal of surface myomas.
• Code 58546 is for a laparoscopic myomectomy excision of five or more intramural myomas with total weight greater than 250 grams.

Note: CPT codes are copyrighted by the AMA.

Ms. Ellis ( sellis@ellismedical.com ) is president of Ellis Medical Consulting (www.ellismedical.com), a healthcare consulting firm providing chart audits for coding and documentation issues, business office operational assessments, research of coverage issues, fee and coding revisions, litigation support, reimbursement research, coding/billing training, and the development and implementation of billing compliance programs for healthcare providers.

Case Study: Resyndication Leads to Successful Hospital/Physician Joint-Venture

In this case study, a health system collaborated with an existing ASC and its physicians through resyndication. Learn how the health system, with market assessment, strategic planning, feasibility analysis and financial planning expertise from Health Inventures, was able to make this its project a success.

HealthEast Care System is the largest healthcare provider in Minnesota’s Twin Cities’ East Metro area. HealthEast Care System has four hospital campuses in the St. Paul metro area: Bethesda, St. John’s, St. Joseph’s and Woodwinds.

In March of 2007, HealthEast met with Health Inventures (HI) to review and plan for the system’s future ambulatory joint venture strategy. During the meetings, the group identified seven opportunities for hospital-physician collaboration. The opportunities included existing ASCs and potential de novo opportunities at HealthEast ambulatory sites.

HI conducted a comprehensive market assessment in April of 2007. Maplewood Surgery Center, an existing, licensed ASC, was identified as the most immediate opportunity for collaboration. Maplewood was 100 percent owned by HealthEast Diversified Services, a subsidiary of HealthEast. Maplewood is a four-OR, one-procedure room ASC, operating at 73 percent capacity in a 12,678 usable square foot facility. The ASC is attached to St. John’s hospital in the Maplewood Professional Building owned by HealthEast Properties.

Wellspring Partners, an independent valuation firm, arrived at a fair market value based upon a multiple-approach valuation method and a minority ownership offering. HI conducted extensive physician interviews and generated financial projections based on the current facility operations and physician feedback. The Minnesota Department of Health re-approved the facility as an ASC at the state and federal levels in July 2007.

A steering committee of interested physicians, hospital representatives, HI representatives and attorneys met several times from May through July to review and approve the Operating Agreement, Private Placement Memorandum (PPM) and Subscription Agreement.

In September 2007, HealthEast and HI had a kick-off meeting to open the offering to physician investors. The offering closed with 14 physician investors from six medical groups. Sixty-two physician units (or 10.3 percent) were issued ownership. A management board of six voting managers was elected by the owners. HealthEast Diversified elected three of the managers, the physician owners elected two managers and Health Inventures elected a manager. Maplewood has entered into a long-term management services agreement with HI while payor-contracting services were purchased from HealthEast.

Learn more about Health Inventures.

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