In 2005, only five percent of outpatient spine cases were done in the ASC setting, said Deb Yoder, RN, CNOR, director of clinical services and HIPAA and compliance officer of Surgical Management Professionals in Sioux Falls, S.D. Over the course of 10 years, that number has grown to nearly 45 percent of cases performed in an outpatient setting. While the procedures themselves haven't changed, the medical community is equipped with better technology, instrumentation, pharmacological agents and techniques in surgery centers.
Ms. Yoder discussed the finer points of developing a spine program at an ASC, during a presentation titled, “Developing a Spine Program at an ASC” at Becker's 14th Annual Spine, Orthopedic and Pain Management-Driven ASC Conference + The Future of Spine in Chicago.
There are several considerations before adding a spine program to an ASC. Long-term vision, such as the sustainability of a spine service line at an ASC, and taking into account whether the ASC is properly equipped to add a new service line, are two main factors to consider. There's also incentive for physicians, such as financial gain, efficiency, less travel, patient cost savings, added control over implants and less chance of infection when adding a spine service line.
Physicians may want to consider several key items prior to adding a spine service line to an ASC. First, are regional needs. Physicians need to know the type of spine services being offered in the region, as well as which procedures other physicians are currently covering.
Financially, successful physicians will understand the costs of startup capital (type of bed, microscope, C-arm, etc.) and facility needs (adequate space to do additional procedure, security for overnight patients, etc.). Other factors to consider include marketing, food services, staff and startup operational inventory.
On the line of revenue cycle and reimbursement, physicians need to consider contracts with all payers, whether to be in-network or out-of-network, carve outs and regional payer mix. Physicians may also want to consider negotiating with large employers to help drive patients to the ASC.
It's also important for physicians to look at team involvement. "Give me what I need, not what I asked for," Ms. Yoder said, when discussing the physician/surgeon relationship in the procedure room. The physician team can also help with patient selection, such as evaluation and anesthesia criteria, patient education and ensuring Medicare patients meet specific criteria.
Adding a new service line involves some risks. Physicians should consider if they're ready to add another service line to the ASC, as well if all the ASC physicians (not just spine) are on board. Physicians also may want to consider any liability changes to the facility's insurance plan and how the hospital-ASC relationship (only for those ASCs in partnership with hospitals) will change by adding another service line.
Another factor to consider is the nine new CMS approved spine codes for Medicare, which were first added in October 2014. According to the ASCA, the nine spine codes are:
- 22551 Neck spine fuse&remov bel c2
- 22554 Neck spine fusion
- 22612 Lumbar spine fusion
- 63020 Neck spine disk surgery
- 63030 Low back disk surgery
- 63042 Laminotomy single lumbar
- 63045 Removal of spinal lamina
- 63047 Removal of spinal lamina
- 63056 Decompress spinal cord
The addition of the Medicare codes increases both the number of healthy young Medicare patients and the number of coffers in the Medicare fund. "It doesn't just help us with spine, it helps us with all cases," said Ms. Yoder.
There could be some issues physicians may run into during the development stage. The CMS payment will be less than the private payers, and while there is still profitability, the ASC needs to make sure all implant costs are under control, because implants are a large percent of case costs and can cut into profit margins.
Most importantly, says Ms. Yoder, "don’t go it alone." It's imperative that everyone at the ASC is on the same page and willing to work together to achieve the same goal.