OR Base Rate Charge

We currently have a base rate charge and per minute rate for our OR charges. We have started receiving denials for outlier claims for the base rate charge. They state this is for routine items and are not covered. Has anyone else who charges a base and per minute OR rate started seeing these? If so, have you succeeded in appealing these? Any suggestions would be appreciated. 

Comments

  • We have a timed class charge for our OR cases.... 1st hour and each additional 1/2 hour based on time in OR room and time out of OR room. We have not seen the denials you mention... at least not that I am aware of.

  • We bill the same way as you Nathan however when the charges flow to the claim the total dollars are equally split between billed CPT codes so each line has a CPT associated with it.

  • We also bill that way and have not received denials for the procedures. We are seeing denials from POC payers on IP claims for the supplies indicating they are routine and not separately billable. We are still working on how to win appeal on those denials.

  • edited October 6

    We bill with a base charge and per minute charge and recently got a denial on a claim where an itemized bill was requested from the payor (similar scenario) because of an outlier provision.

    We were able to explain the charge design to the payor and the denial was overturned. We also renamed our set up charge to "Operating Room Initial" to remove the word "set up". We aren't billing for the room set up, we are billing for the procedure, so I am hoping this prevents further denials.

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