Many physicians are drawn to the idea of simply converting their existing office into an ambulatory surgery center for the purpose of facility fee reimbursement. This idea for many appears to be driven from The Centers for Medicare and Medicaid Services 2014 Final Payment Rule which includes a significant payment cut to some specialties especially in the field of pain management. For instance, cuts in pain management professional fees for the office site of service differential to epidural injections, spinal cord stimulation and many other common pain procedures performed are so deep that it looks to be impossible for physicians to continue to perform these procedures in an unlicensed facility.
This idea of conversion crosses over into many other specialties that are performing in-office procedures, such as plastics, podiatry, cardiology and vascular procedures.
"There has never been, or will never be, an office with a procedure room that will meet the physical environment requirements as is," says Amy Mowles, President and CEO of Mowles Medical Practice Management.
Quite simply, "If you want to be paid a facility fee, you must be designated as a provider of surgical services, (Certified)," says Ms. Mowles. "A prerequisite is state licensure and that drives the strictest requirements on the physical environment. Even in a state like California that does not license most ASCs, all ASCs that are Medicare Certified still have to meet the Medicare physical environment requirements. This means compliance with Chapter 20 of NFPA 101, 'Life Safety Code,' and NFPA 99 (emergency power always, and piped medical gases sometimes-per level of Anesthesia or state requirement) states that have adopted the design standard of the 'Guidelines for Design and Construction of Health Care Facilities;' American Institutes of Architects; Facility Guidelines Institute; will require the ASC space to be at minimum 2,500 square feet to 3,500 square feet per anesthesia allowed. This would include all required minimum spaces, plus important others — public and administrative, public toilets, waiting and reception, business support, records, pre-procedure changing and prep, procedure core including ORs, clean and soiled utility, staff changing, etc., as well as semi-restricted areas including recovery acute post anesthesia and lounge/stage 2, ancillary and support, power, gases, receiving, trash removal, etc."
The ASC itself must be a distinct entity and separated by a one hour rated fire wall by any other entity, even from a physician's affiliated practice. "If you want to run the ASC and a physician's office concurrently, the two can't commingle. You can't have nurses that have duties in the office and ASC at the same time," says Ms. Mowles. Most physicians with an office-based procedure suite are not accustomed to this idea.
Once the ASC is constructed, there are whole host of rules and regulations that apply to acquire and maintain license, certification and accreditation. "Most physicians who are currently doing procedures in their own office will find the regulations very onerous."
Pre- and post-procedure phone calls, pre-procedure H&P, patient and site verification and marking and a full "time-out" before each procedure are just a few examples of how different an ASC is from a typical physician's practice. ASCs are also required to have a legal governing board, quality assessment and improvement programs, a staff member trained in infection prevention, emergency disaster preparedness, formal credentialing as well as clinical protocol for drugs and biologicals, sterilization parameter and a whole host of environmental logs to include OR/procedure room temperature, humidity and air pressure.
"I look at State Licensure and Medicare Certification regulations as 100 percent absolute, while accreditation can be viewed as compliance within reason as accepted standards of care for what it is that you are doing," says Ms. Mowles. "The best advice I can give physicians in a current office is to enlist the expertise of a seasoned ASC medical facility design planner who can assist in identifying the regulated functional/operational aspects of an ASC and whether this will work in your existing space. There are zoning rules that apply to both single- and multi-story buildings as well as fire protection."
Physicians who are unable to convert their current space into an ASC are considering a move to a new location better suited to meet these new requirements. Either option requires a significant financial commitment from the physician owners of the group, leaving some to wonder whether converting to the ASC will bring a return on investment.
"It is worth it," says Ms. Mowles. "It will quadruple their income. But they need to commit to it. The amount of resources necessary depends on whether they are remodeling or moving. The fastest I think it could be done is eight months; it could take as long as a year before the physician can begin performing procedures in an operational ASC."
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