This presentation provides an introduction to the process of negotiating a carve-out, a special contract, for reimbursement with an insurance carrier for procedures that do not have a SOSD. Essentially you are negotiating for a portion of the facility payment the ASC, HOPD or hospital would bill--and you are not being reimbursed.

1. Negotiating Carve-Outs for Hand-
and-Wrist Surgical Procedures with
Zero SOSD
June 4 2021
Jeffrey Restuccio, CPC, COC, MBA
Certified medical coder, auditor, and reimbursement consultant
http://www.IOECTR.com
ritecode@gmail.com
(901) 517-1705

2. Hand-and-Wrist Orthopedic Procedures
The focus of this presentation are the 97 hand-and-wrist
orthopedic surgical procedures that have zero Site-of-Service
Differential (SOSD) when performed in an Office-Based Surgical
Suite (OBSS).
For these procedures the clinic must negotiate fair overhead
reimbursement for each procedure with each carrier when
performed in an OBSS.
Endoscopic Carpal Tunnel Release (ECTR) [CPT code 29848] will
be used an a representative procedure.
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2

3. NON-FAC PE
(Non-Facility) Practice Expenses include the following six
components (1-3 Direct; 4-6 Indirect):
1. Clinical staff time
2. The equipment
3. Supplies typically used during a procedure.
4. Administrative staff.
5. Building space
6. Office supplies.
These are your OBSS “overhead” costs. Direct expenses are
calculated; indirect costs are allocated per specialty and Medicare
PE experts.
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4. Step-By-Step Spreadsheet
I have created a spreadsheet with multiple tabs to provide
information on how to calculate your direct and indirect costs
and negotiate with insurance companies. TABS include:
• Instructions
• Step-by-Step (41 Steps)
• ECTR Totals by Place of Service (ASC, HOPD, hospital)
• 2021 facility reimbursement comparison
• Six Physician Expense Components
• Benefits
• Glossary
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5. Total Reimbursement (MCR): ECTR
• dddBelow are 2021 charges for
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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

6. Carrier Negotiation
• Focus on benefits to the insurance carrier (lower costs) and the
patient (quicker recuperation/no general anesthesia).
• One strategy is simply lay your cards out on the table and ask the
insurance company what their total reimbursement for the relevant
hand-and-wrist procedures are including all pre and post-op visits,
labs, anesthesia, and both professional fees and facility fees.
• Your offer is a percent of what they are currently paying.
• If the total facility costs for the ASC are $1,500 ask for $1,200.
Remember that whatever you propose they will likely counter.
• The key is finding someone at the insurance company who knows
the costs or will take the time to determine them. A lot depends on
the level of expertise of the carrier rep.
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7. Negotiation 101
Negotiations are based on leverage. You have leverage if:
• If you are a large clinic and they need you in network.
• You are the only hand and wrist surgeon in a small town.
• You perform procedures no other orthopedic surgeon can
perform.
• You already have a negotiated contract for other services.
• The only facility in your area is the hospital (very expensive to
the insurance company).
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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. Negotiating Carve-Outs for Hand
and Wrist surgical Procedures with
Zero SOSD
June 4 2021
Jeffrey Restuccio, CPC, COC, MBA
Certified medical coder, auditor, and reimbursement consultant
http://www.IOECTR.com
ritecode@gmail.com
(901) 517-1705