Outpatient spine surgery is a growing specialty, but it's not without its challenges. Coding is complex, payors are fickle and the cost of implants can easily gobble up your facility's profit. Here's how to keep your spine program healthy.

1 Schedule logically. Schedule all like spine cases back-to-back in the same room, says Deb Wilde, RN, BSN, CNOR, clinical director at the Surgery Center of Fort Collins (Colo). That way the turnover team doesn't have to change the room's footprint between cases. This will also save time and improve efficiency during the procedure because the OR team is familiar with where the microscope, C-arm, tables and carts are located.

2 Get a good coder. Getting paid for spine procedures is tricky because of the wide variety of codes and modifiers used to describe complex conditions and treatments that can be billed separately or bundled together. Coding must be based on precise documentation that describes at which nerve and level a procedure was performed, and which implants were used. When the documentation is vague, the coder needs to be comfortable speaking with surgeons to get more information. "You're kind of like a detective. You need to go and see what they've done," says Shelia Gainey, CPC, the medical coder at the Carolina Center for Specialty Surgery in Charlotte, N.C.

If your facility has contracted to be reimbursed for implants — and it should have such a contract — you'll need to include the invoice for the specific implant for which you're billing. "It's to prove that you really used it," says Ms. Gainey. The coder should also be well-versed in your contracts with the different payors so the facility is reimbursed for everything it's entitled.

Many spine codes have changed in recent years. For example, anterior cervical discectomy and fusion (ACDF) used to be 2 codes. Now it's a single code. "Some insurance companies don't have updated information," says Ms. Gainey. You'll need the latest code books for supporting documentation when a payor with an outdated book rejects a claim.

3 Manage par levels. If implants and supplies sit too long and the expiration date for sterility passes, you may not be able to return them. This can really sting if it's pedicle screws and rods that cost more than $3,500 per case. Verify your stock weekly and order just a bit more than what you'll need for the coming week based on your scheduled caseload. "Look at your usual workload and add 10%," says Ron Jones, CST, manager of purchasing and logistics for the Laser Spine Institute's 3 surgery centers in Florida, Arizona and Pennsylvania. Adding a bit extra will keep you covered if your vendor has a problem.

4 Get a good GPO. Joining a group purchasing organization will give you access to favorable pricing way beyond your size. "You can get hospital pricing although you're a small surgery center," says Mr. Jones. Go with a large national organization with a wide selection of supplies and capital equipment that you use regularly. When you're a member of a GPO you can even get better pricing for products that are not sold through the GPO. Most large manufacturers extend lower prices to GPO members, even on products sold directly by the manufacturer. "If you're a small company, you're going to pay full price if you're not part of a GPO," says Mr. Jones.

For example, nearly every case in which a bit of bone needs to be removed requires a small diamond tip burr, which costs about $135. The Laser Spine Institute gets the "GPO price" from the manufacturer and pays about $95 for the burrs. The spine centers get a similar reduction on side-firing lasers that the surgeons use, says Mr. Jones.

5 Beware of implant creep. Surgeons are often ready to try new implants based on new efficacy research, a tight relationship with a rep or the desire to use the latest technology. One thing that's often not on the surgeon's mind is how much the device costs. Strictly forbid using non-standardized implants. At the Laser Spine Institute, a products and formulary committee must approve any new devices, medications or supplies. The committee includes representation from surgeons, anesthesia providers, nursing staff and materials managers. The physicians on the committee are in charge of vetting implants and other surgical devices. "If a surgeon wants to use it, it goes through the chief of surgery," says Valerie Maxam-Moore, RN, MN, senior director of medical operations at the Laser Spine Institute. Other supplies and equipment are analyzed by users, such as the nurses and surgical techs, as well as the materials management department. The committee debates each item's benefit, cost and any storage or other logistical considerations. Most decisions are based heavily on the product's efficacy and safety profile in the medical literature. "We would never sacrifice quality for price," says Ms. Maxam-Moore.

6 Look at prices and package sizes. Perform a pricing audit of everything you buy with a fresh eye. Look at the price of supplies and medications in different size packages. You'll be surprised what you find, says Ms. Maxam-Moore. Take irrigation fluid, which is used for nearly every spine case. A 500ml bottle costs about $3, while a 1,000ml bottle costs just $1.80. So get the bigger one, says Ms. Maxam-Moore. This may mean that you'll have to dispose of the unused portion, but it may be worth it, especially for products you use frequently. "Over months and months, the savings become huge," she says.

7 Cultivate your relationship with device reps. The device rep's job is more than just getting you to buy new products. It's to keep you and your surgeons as repeat customers. Let the reps make your life easier. "We have a solid relationship with our reps," says Ross Alexander, MBA, administrator of the Surgery Center of Fort Collins. When you become a good customer, the reps can help you out. For example, if a surgeon is not exactly sure what size implant a patient will need, ask the rep to bring in different sizes before the case. The surgeon chooses the appropriate implant and the unused ones go back in the rep's trunk. "We're billed for what we use," says Mr. Alexander. That way, the surgery center doesn't have to order implants in multiple sizes that would have to be invoiced by the vendor. This will save you time and money up front because you don't have to tie up cash in inventory or pay for the unused implants that you may ultimately return.

8 Be aggressive with vendors. Let your vendors know that you mean business. "We let them know that we're volume-based and that we can get this number [of cases] to you," says spine surgeon Michael Frey, MD, co-founder of the Park Center for Procedures in Fort Myers, Fla. Showing the vendor that you can meet volume benchmarks will give you more leverage when it comes time to negotiate a price.

Later, when prices inevitably rise, negotiate rather than cave in, says Dr. Frey. Tell the vendor, "This is the price we're comfortable paying." You might get your price. At the same time, get a price from the vendor's competitor. If the other vendor can give you a similar quality product and service at a better price, consider switching.

9 Market to people with high-paying insurance. Private insurance reimbursement rates vary greatly for spine procedures. So get to know which insurers pay well for your most common spine cases and find out where the patients with this insurance are coming from, says Karen Reiter, RN, CNOR, RNFA, chief executive of D.I.S.C. Sports and Spine Center in Marina Del Rey, Calif. "We looked at every single insurance company that paid us."

Once you identify the high and low payors, you might find that many of the patients with high-paying insurance work at large companies in your area. "Market to those companies," says Ms. Reiter. Contact the human resources departments of these companies and propose on-site wellness events where your surgeons can discuss topics such as body mechanics or safe lifting. Arrange company tours of your facility. Once the employees know your surgeons and facility, says Ms. Reiter, there's a better chance that when they or their family members have spine pain they'll contact you.