In this month's cover story, contributing editor Dianne Taylor presents a fascinating look at how such inpatient cases as abdominal hysterectomy, spinal surgery and mastectomy are turning into outpatient ones. Dianne's report of how increasingly complex procedures are migrating to ASCs begins on page 34.

What you won't find there is how to add minimally invasive breast biopsies to your surgical profile - not because stereotactic breast biopsy doesn't belong in the outpatient setting, but because we thought it wise to temper our enthusiasm with a story of how things can go terribly wrong when you add a new procedure.

Back in 1995, a physician-owner who had the considerable clout that belongs to a surgeon who performs 25 percent of his cosmetic surgery center's cases insisted that his facility invest $300,000 in a permanently affixed stereotactic table and a machine called the ABBI (Advanced Breast Biopsy Instrumentation), and another $100,000 to convert the business office into a treatment room, complete with an alcove where the X-ray tech could stand.

The physician-owner made a strong case. Patients are going to insist on this minimally invasive way to check for breast cancer rather than traditional open surgical biopsies, he said. If we don't do it, the hospital will. And one more thing: If you don't buy this, I'm going to take my breast augmentations somewhere else.

Soon after the center caved into the surgeon's demands, the whole thing cratered. On the one hand, the center found out after the fact that there wasn't yet a CPT code for the procedure and that it couldn't charge the radiology codes that hospitals do.

On the other hand, the payback analysis was useless because it used figures and costs for open breast biopsy that did not take into account the cost of disposables ($395.19 for a spring-loaded gun and vacuum that sucks out specimen) and a radiology tech. At the time, Blue Cross was paying $396 for the procedure.

"We lost close to $400 on every case," says the administrator who inherited the ABBI - and the surgeon who insisted on it - and learned some tough lessons, including:

• Be sure there's a CPT code to go along with the case you want to add (or negotiate a carveout with your high-volume payers).
• Bank on fewer cases than the surgeon predicts.
• Explore costs beyond the capital investment, including supplies, staffing, maintenance, and OR and recovery times.

"I think you should be adding new procedures," she says. "You just have to be cautious what you add."