Procedures traditionally performed in hospital ORs have migrated to ambulatory settings over the past 10 years, but outpatient spine surgery remains a burgeoning concept. Here at the Medical District Surgery Center in Las Vegas, we perform between 10 and 20 procedures each month and are reimbursed from $3,000 to $35,000 per case. The specialty can be lucrative if you balance your search for profits against proper patient selection, talented and confident surgeons and a clear understanding of the costs involved.

Comfortable and confident
Our surgeons perform three types of spine procedures, focusing resources and OR time on cases with high rates of success and on patients who can ambulate quickly. The simplest, micro disc or decompression surgery, removes disc material from under the nerve root, solving nerve compression while creating additional room for the nerve to heal. The procedure is performed through a 1.5-inch incision in the lower back and is often performed on patients complaining of leg pain resulting from pressure on the spine.

Based on surgical complexity, anterior cervical disc fusions present moderate challenges. Surgeons enter through the front of the neck, remove disc material via a decompression technique, fuse across the decompression and promote growth in the fused area with a bone graft. The procedure may also involve the complete removal of a disc and insertion of a cervical implant before fusion.

The most challenging technique is the lumbar fusion, in which surgeons employ an anterior approach, posterior approach or both to fuse one or two levels of vertebrae in the back. A posterior approach is technically difficult, due to a small visual field and navigation around spinal nerves. Combining a posterior approach with an anterior procedure fuses both the front and back of the targeted vertebrae, providing a more stable fusion.

To ease the burden on the staff and shorten the learning curve, our facility hired a former hospital surgical tech with extensive spine experience. She provided an expert voice as we trained OR teams in room turnover and setup, especially in the pulling of instruments for each case.

Instrumentation for spine is extensive, sometimes requiring up to 20 trays. Starting from scratch, the bill to equip your center could reach $350,000. For cutting through vertebrae and cartilage you'll need power drills, costing about $35,000. Retractors, distractors, rongeurs and curettes can run $200 to $400 each. You'll need several of these instruments and several instrument trays per procedure. Total expenditures for the trays may be $80,000.

Additional equipment essentials include a bi-polar irrigation system to flush the surgical site and stop intra-operative bleeding. The system costs about $10,000. Precise navigation around the spine's delicate blood vessels and nerves requires C-arm imaging, a capital purchase that can run close to $150,000.

Proper patient positioning calls for a table with customizing capabilities, providing the surgeon with posterior and anterior access to the spine as well as unobstructed C-arm integration. Our table cost $60,000. We augment the table with a $5,000 frame used to maintain patients in a flexed position for posterior procedures.

Like the surgical microscopes designed for ENT and eye cases, spine scopes incorporate unique features; namely, high-powered light sources and an ergonomic design that allows for access to the surgical site with large instrumentation and C-arm integration. The cost of a new scope ranges from $100,000 to $200,000. Our surgeons trialed many models and settled on a refurbished scope for $50,000.

Covering your costs
Coding for spine surgery involves up to four CPT codes per procedure. The additional codes generally cover the additional costs of instruments, supplies and staff.

Separate codes exist for disc removal, vertebrae resection, insertion of an implant and vertebrae fusion. Close to 20 codes are used for spine surgery, all of which work off the following: 63082 for vertebral corpectomy, 22554 for anterior vertebrae arthrodesis, 22630 for posterior vertebrae arthrodesis, 99070 for insertion of an implant and 76005 for fluoroscopic guidance.

Proper coding covers the base costs of each procedure, but the additional expense of spine implants is steep, ranging from $3,000 to $20,000 per piece. Ensuring adequate reimbursement for implants begins with the contracts you negotiate with insurance carriers.

Medicare doesn't recognize spine surgery performed in a surgery center as a reimbursable procedure. Many managed care providers follow Medicare's lead, so check with each carrier before inking a contract. Target patients with payers that reimburse for both the procedure and implants inserted into the spine. We have 15 contracts with third-party payers, and each recognizes implants as a cost separate from the procedure cost. Consider this carveout, like those you negotiate for orthopedic cases, an absolute requirement. In addition to the carveout, negotiate a cost-plus markup into your contracts. We negotiate a 20 percent markup, based on the implant's list price, with all our carriers; this cushion covers the handling and shipping fees we incur when ordering the implants. We order our implants as needed, so the cost-plus markup also serves as financial protection in the event that a cancelled case renders a customized implant useless.

When scheduling out-of-network patients, know the plan's reimbursement policy. Some simply don't reimburse for spine, some pay 50 percent of charges and others may reimburse for only 75 percent of the bill. As a facility in Las Vegas, we treat patients from all over the world, many of whom present with insurance plans we've never seen. Our business office sometimes takes an unavoidable hit, but we try to keep partial reimbursements to a minimum.