Performing a Caudle Epidural (62311) in a Non-Facility for Neurosurgery Billing, Pain Management Billing, and Orthopedic Billing

 

Many spine surgeons and non-surgical providers are very familiar with performing the epidural steroid injection for the lumbar or sacral region of the spine which is CPT code 62311 — also known as the caudal ESI.  What providers performing these procedures might not be familiar with is the neuosurgery billing aspect of submitting the 62311 with place of service code 22 or 24 (facility) compared to billing place of service code 11 (non-facility).

 

RVU Breakdown

 

In the article “Place of Service Affects your Reimbursement”, Mary Legrand, a consultant with Karen Zupko & Associates, states: “Every CPT has a Relative Value Unit (RVU) that determines billing reimbursement based on three components: malpractice, work, and practice expense (American Academy of Orthopedic Surgeons, 2008).”  When dealing with the RVU’s based on facility, it would fall into the practice expense category.  When a provider performs a service in a facility such as a hospital or surgical center, the RVU is lower because the provider is not incurring the full expense and liability associated with providing the services. However when a provider performs a service at his or her own practice, the practice incurs the full expense for the service and for that reason is reimbursed at a higher overall RVU.

 

62311 Medicare Fee Schedule

 

When comparing Facility versus Non-Facility payment for 62311 illustrated in Table 1, you will note that billing Medicare for the 62311 in the facility reimburses $87.82, and in the non-facility at $208.99. When evaluating the billing, providers will find that there is a 239.97% increase in reimbursement when procedure 62311 is done in a place-of-service 11—Non Facility location.

 

Table 1. Comparing the Place-of-Service Increase of Revenue for 62311

Facility Physician Payment in Hospital $87.82
Non Facility Physician Payment in Office $208.99
Increase from Facility to Non-Facility 239.97% increase

 

Doing the Math

 

Last year we billed out 149 caudle epidural steroid injections (62311) for multiple clients nationwide; all 149 procedures were performed in a facility place-of-service (22, or 24).  If you look at Table 2, you will notice that if these procedures were performed at a non-facility (place-of-service 11) the revenue would more than double.

 

Table 2. ASC Billing and Non-Facility

149 Caudle ESI’s billed in a Facility location $87.82 $13,085.18 
149 Caudle ESI’s  at Non- Facility location $208.99 x 149 $31,139.51
  Revenue Increase $18,054.33

 

Having a Procedure Room in a Non-Facility

 

When performing the 62311 or other procedures at a non-facility location, having a procedure room in your office is medically necessary.  You will need an x-ray table, fluoroscopy (billed out with CPT 77003), and any other equipment that is medically necessary for this procedure or other procedures you may be performing.

 

Other Orthopedic Billing that Benefit from a Non-Facility Location

 

If you look at Table 3, you will notice just a couple of examples of when it would profit providers to perform certain procedures in a non-facility compared to a facility.  Switching these procedures to non-facility in the short term may have obvious costs, but in the long term could benefit and assure more revenue for the providers practice.

 

Table 3.

Procedure CPT Facility Fee Non-Facility Fee
26055 Trigger Finger Release $307.02 $563.32
64721 Carpal Tunnel Release $425.13 $427.85
64479 Transforaminal Epidural with imaging guidance; Cervical or thoracic single level $134.11 $260.73
64480 Add on code for 64479—each additional level $66.71 $124.92 
64483 Transforaminal epidural with imaging guidance: lumbar or sacral $111.98 $242.01 
64484 Add on code for 64483—each additional level $52. 76 $100.07

 

Works Cited

LeGrand, Mary. American Academy of Orthopedic Surgeons. April 2008. <http://www.aaos.org/news/aaosnow/apr08/managing1.asp>.

 

About Apache Health

Apache Health is a revenue cycle management (RCM) analytics, benchmarking, and auditing company. The founders of Apache formerly ran a large RCM company that was acquired by a private equity group in a rollup. Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients.  Using many factors and a blend of artificial intelligence and specialty specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers. Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track in-house billing performance improvement over time.