This presentation explains the difference between Professional Fees and Facility Fees and compares the three most common facilities: Ambulatory Surgical Center (ASC), Hospital Outpatient Department (HOPD), Hospital Inpatient, A facility means “not an office” and an office (POS=11) can never be a facility--even if you are performing surgeries in your office.

1. Facility Total Fee Comparison
Endoscopic Carpal Tunnel Release
June 5 2021
Jeffrey Restuccio, CPC, COC, MBA
Certified medical coder, auditor, and reimbursement consultant
http://www.IOECTR.com
ritecode@gmail.com
(901) 517-1705

2. The Issues (1)
• Total reimbursement for a surgical procedure includes the surgeons
professional fees (CPT codes/RVU’s / PFSRVU database) and the
facility charges billed separately by the ASC, HOPD or hospital.
• Numerous surgical procedures can now be safely performed in an
Office-Based Surgical Suite (OBSS) instead of an ASC, HOPD or
hospital. When performed in the office there is no separate facility
fee.
• For many procedures there is a Site-of-Service Differential (SOSD)
where the office Practice Expense RVU’s (reimbursement) is higher
than the facility Practice Expense RVU’s. This difference reimburses
the surgeon for both direct and indirect overhead costs of the
OBSS.
• While conceptually the overhead reimbursement are “facility” fees,
an office is never a facility (Place of Service=11) and should never
be referred to as a facility.
www.IOECTR.com 2

3. The Issues (2)
• Many surgical procedures have a status indicator of "NA" in
the “Non-Facility NA INDICATOR” field in the 2021 Medicare
PFSRVU database. This means there is no additional
reimbursement for the OBSS. The Site-of-Service Differential
(SOSD) is zero. There is no reimbursement for the overhead of
direct and indirect expenses that would be billed separately
by the facility.
• There are thousands of procedures with a zero SOSD. At least
97 orthopedic hand-and-wrist procedures, that lend
themselves to an OBSS and WALANT have a SOSD of zero; all
of these would require negotiation for reimbursement with
each carrier when performed in an OBSS.
www.IOECTR.com 3

4. Acronym Explanations
OBSS: Office-Based Surgical Suite. This means not at a facility (ASC,
HOPD, or hospital) and the Place of Service = 11.
OBS: Office-Based Surgery
IOECTR: In-Office Endoscopic Carpal Tunnel Release. This describes
Endoscopic Carpal Tunnel Release performed in an OBSS, typically
under WALANT.
WALANT: Wide Awake Local Anesthesia with No Tourniquet. This is
not a specific code but a new way to perform many hand and wrist
surgeries under local anesthesia.
SOSD: Site-of-Service Differential. This is the difference in
reimbursement for a procedure when performed in an office
(typically higher) versus a facility. Many procedures have zero SOSD.
www.IOECTR.com 4

5. 29848: Endoscopy, wrist, surgical, with release
of transverse carpal ligament (ECTR)
Procedure 29848
priced for 01/29/2021 Atlanta GA
Medicare
Facility
Medicare Non
Facility
Global Allowed $521.78 $521.78
Reimbursement $417.42 $417.42
After Sequest $409.08 $409.08
RVUw 6.39 6.39
Same (SOSD= 0) => RVUpe 7.51 7.51
RVUm 1.23 1.23
RVU total 15.12 15.12
Global period: 90 days
www.IOECTR.com 5

6. Total Reimbursement (MCR): ECTR
• dddBelow are 2021 charges for
www.IOECTR.com 6
Reimbursement Information
Wrist Endoscopy
/ Surgery
CPT™ Code: 29848
PFS Relative Value Units: 15.12
Medicare Allowable (Physician Services Fee): $490.04
Facility Fee Payment Weight: ASC: 14.7803
Facility Fee Reimbursement: ASC: $723.53
Facility Fee Payment Weight: HOPD: 16.9551
Facility Fee Reimbursement: HOPD: $1,419.09
Facility Fee Reimbursement Hospital (MS-DRG=502) $7,957.84
Total Reimbursement ASC (Pro Fee + Facility): $1,213.57
Total Reimbursement HOPD (Pro Fee + Facility): $1,909.13
Total Reimbursement Hospital (Pro Fee + Hospital): $8,447.88

7. Negotiation Strategy
• Note that the total facility costs to the carrier will likely be higher
than you adding up all your actual indirect and direct costs
(disposable blade, gowns, local anesthesia, etc…).
• The simplest negotiating strategy is how your OBSS will save the
carrier money versus performing the procedure at a facility.
• While having an estimate of your actual costs is valuable, you may
not need to present your actual direct and indirect expenses during
the negotiations. Have this information available—just in case.
• In addition, the carrier may not need justification or research data
on the efficacy, post-op time, and safety of WALANT. Have this
information available—just in case.
www.IOECTR.com 7

8. Hold Harmless Statement
• This coding and reimbursement information is provided for
educational purposes only.
• It is not intended to represent the only, or necessarily the best,
coding advice for the situations discussed, but rather represents an
approach, view, statement, or opinion that may be helpful to
persons responsible for coding and billing in a medical clinic.
• The statements made in this presentation should not be construed
as policy or procedure, nor as standards of care. State requirements
and policies change all the time; while every effort was made to
ensure accuracy, the author makes no representations and/or
warranties, express or implied, regarding the accuracy of the
information contained in this presentation and disclaims any liability
or responsibility for any consequences resulting from or otherwise
related to any use of, or reliance on this information.
www.IOECTR.com 8

9. Facility Total Fee Comparison
Endoscopic Carpal Tunnel Release
June 5 2021
Jeffrey Restuccio, CPC, COC, MBA
Certified medical coder, auditor, and reimbursement consultant
http://www.IOECTR.com
ritecode@gmail.com
(901) 517-1705