Editor’s note: In the June issue of NN&I, our Legal Angle editors looked at the regulatory and legal risks and rewards of turning an interventional access suite into an ambulatory surgical center where fistulas and grafts could be placed. This month we asked two developers to explain the reimbursement opportunities in building these centers. 

Based on the benefits associated with ambulatory surgical centers (ASCs), the growth of Office-Based Labs (OBLs) seems to be a logical transition and normal migration for outpatient endovascular care. Following approval by the Centers for Medicare & Medicaid Services for arterial endovascular interventions performed in outpatient centers, there has been explosive growth of OBLs throughout the United States. Based on industry estimates, more than 800 OBLs are operating in the U.S.

Several specialties practice in the OBL setting, but the most common are interventional nephrology, vascular surgery, radiology, and interventional cardiology. Procedure mix varies greatly, but most cases performed are interventions for peripheral artery disease (PAD), interventional radiology, and dialysis access.

Growth has been accelerated by significant advances in minimally invasive vascular procedures and devices, which in turn enhance efficiency and safety of various vascular procedures performed in the OBL. Almost all dialysis work, including fistulograms, thrombectomies, and angioplasties, are performed in this setting as well as peripheral diagnostic and interventional procedures, like atherectomies and stenting.

Changes in Medicare reimbursement

Dialysis vascular access services performed in vascular access centers (VACs) experienced a major overall reduction in Medicare reimbursement in 2017. This was due to a CMS policy requiring that services billed together more than 75% of the time be bundled for payment. As a result, new interventional CPT code bundles were developed (see Table 1). This table also shows the approximate difference in reimbursement for certain interventional dialysis services performed in a VAC as compared to the same services performed in an ASC setting.

These Medicare cuts may substantiate the idea of evaluating the financial, operational and legal viability of converting office-based vascular access centers (VAC) to hybrid ASCs.

The cardiovascular access center

The cardiovascular access center can be set up as a new surgery center in the same building as the OBL or contiguous with the office, depending on regulations and the configuration of the current facility. Medicare requires that these centers are certified and licensed, and private payers require them to be accredited as an ASC. Some states also do require a certificate of need (CON). It is also necessary to remain an accredited OBL to capture both OBL and ASC reimbursement structures. Cases can be scheduled to best maximize reimbursement by operating as an OBL on certain days of the week and an ASC on other days.

What to consider

ASCs should be developed around four basic management cornerstones: patient care, risk management, business office, and payer contracting.

Most ASCs are a success or failure before they’re built. Planning is absolutely critical to long-term success. 1 Several presentations at the 2017 Outpatient Endovascular and Interventional Society (www.oeisociety.com) revealed that approximately 25% of OBLs fail, and almost half are struggling. This is primarily due to inadequate planning on the front end with a lack of understanding about the business and market dynamics, case volume implications, and the proper reimbursement mix for the center to make the venture profitable.

Jason Gries, a partner who focuses on health care issues at Chicago-based McGuireWoods LLP, has a process map for evaluating whether to convert an OBL to a hybrid ASC. The first step is determining if your OBL is adversely impacted by recent CMS rate cuts. Second, evaluate the costs to convert to an ASC. Third, estimate the conversion timeline. FInally, evaluate the legal considerations.

Once the cardiovascular access center is operational, cases can be scheduled to best maximize reimbursement. For example, fistula maintenance reimburses better in the ASC, so those cases would be performed on days when the center operates as an ASC. PAD cases reimburse at a higher rate in OBLs, so those cases should be scheduled on days when the center operates as an OBL.

Early results from cardiovascular access centers show an increase in reimbursement from 25-30% versus standard OBL reimbursement. As CMS modifies reimbursement for procedures each year, the cardiovascular access center allows for flexibility in the scope of services, which can offset a dramatic reduction in reimbursement for certain procedures.


Converting to the cardiovascular access center widens the scope of practice for physicians while offering a better experience for patients and staff, lowers the cost of services to payers, and provides freedom for physician entrepreneurs to operate and provide quality patient care.


  1. Zasa JS, Zasa RJ eds. Developing and managing ambulatory surgery centers (2016). ASD Management, Inc.