Wiki ASC reimbursement for multiple procedures

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Maria Valladares

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If ASC facility bills code 26418 x 2 (2 different tendons on same finger), does Medicare reimburse at 100% for first and 50% for second? or does Medicare only reimburse one 26418 as the OPPS status indicator for this code is "J1" which means only 1 gets paid under OPPS?
Thank you for your help and happy holidays!, Maria
 
Maria Valladares said:
If ASC facility bills code 26418 x 2 (2 different tendons on same finger), does Medicare reimburse at 100% for first and 50% for second? or does Medicare only reimburse one 26418 as the OPPS status indicator for this code is "J1" which means only 1 gets paid under OPPS?
Thank you for your help and happy holidays!, Maria
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With J1 status indicator, the reimbursement is a comprehensive rate, which means the payment will be the same amount whether there is one unit billed or multiple. It's not quite accurate to say that 'only 1 gets paid' because OPPS rates are not a fee schedule - they are prospective payments intended to cover facility costs. The rate assigned to that classification is based on a weighted average for all of the codes in that group using cost data reported by all facilities. So if you bill two units, you're still being reimbursed for two units, it's just that the rate is an estimated average that over time is expected to pay an amount that will cover the facility's cost in aggregate. So for some surgeries, you'll receive less and some more, but over time it would be correct. Hope that makes some sense.
 
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