klamond
Networker
I received the following information from an attorney we deal with. Has anyone heard of a physician being reimbursed for implants (ie; hcpcs C1713; C1762) at ASC if physician purchases and not the ASC?? Sounds too good to be true...
Good afternoon Everyone,
I have news regarding implants used for MVA cases.
Implants are reimbursed if the physician requesting the surgery order the implants. The MVA carrier will then reimburse the physician and not the surgery center.
As per my email _________ Law Firm PIP Dept:
N.J.A.C. 11:3-29.5 is the Administrative Code that deals specially with ASCs. Subsection (a) reads:
(a) ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including:
1. Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;
2. All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient's care;
3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment;
4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare (see: https://www.cms.gov/HospitalOutpatientPPS/Downloads/CMS1506FC_Addendum_D 1.pdf) are considered ancillary services to surgical procedures and are not permitted to be reimbursed separately in a HOSF;
5. Administrative, recordkeeping, and housekeeping items and services;
6. Blood, blood plasma, platelets, etc.;
7. Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and
8. Implantable DME and prosthetics.
N.J.A.C. 11:3-29.4 deals with PHYSICIAN reimbursement. Subsection (f), paragraph 8 reads:
(f) Except as specifically stated to the contrary, the following shall apply to physician charges for multiple and bilateral surgeries (CPT 10000 through 69999), co-surgeries and assistant surgeons:
8. Prosthetic and other devices, including neuro-stimulators, internal/external fixators, single use spine wands and spine probes, tissue grafts, plates, screws, anchors and wires, whether implanted, inserted, or otherwise applied by covered surgical procedures shall be reimbursed at no more than the invoice for the device plus 20 percent. This provision applies regardless of where the procedure is performed, including trauma centers, hospital emergency rooms, inpatient surgeries and outpatient surgical facilities.
Good afternoon Everyone,
I have news regarding implants used for MVA cases.
Implants are reimbursed if the physician requesting the surgery order the implants. The MVA carrier will then reimburse the physician and not the surgery center.
As per my email _________ Law Firm PIP Dept:
N.J.A.C. 11:3-29.5 is the Administrative Code that deals specially with ASCs. Subsection (a) reads:
(a) ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that do not have an amount in the ASC facility fee column are not reimbursable if performed in an ASC. The ASC facility fees include services that would be covered if the services were furnished in a hospital on an inpatient or outpatient basis, including:
1. Use of operating and recovery rooms, patient preparation areas, waiting rooms, and other areas used by the patient or offered for use to persons accompanying the patient;
2. All services and procedures in connection with covered procedures furnished by nurses, technical personnel and others involved in the patient's care;
3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment;
4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicates those CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary services that are integral to surgical procedures and are not permitted to be reimbursed separately in an ASC. Appendix, Exhibit 7 indicates those services that, according to Medicare (see: https://www.cms.gov/HospitalOutpatientPPS/Downloads/CMS1506FC_Addendum_D 1.pdf) are considered ancillary services to surgical procedures and are not permitted to be reimbursed separately in a HOSF;
5. Administrative, recordkeeping, and housekeeping items and services;
6. Blood, blood plasma, platelets, etc.;
7. Anesthesia materials, including the anesthetic itself, and any materials, whether disposable or re-usable, necessary for its administration; and
8. Implantable DME and prosthetics.
N.J.A.C. 11:3-29.4 deals with PHYSICIAN reimbursement. Subsection (f), paragraph 8 reads:
(f) Except as specifically stated to the contrary, the following shall apply to physician charges for multiple and bilateral surgeries (CPT 10000 through 69999), co-surgeries and assistant surgeons:
8. Prosthetic and other devices, including neuro-stimulators, internal/external fixators, single use spine wands and spine probes, tissue grafts, plates, screws, anchors and wires, whether implanted, inserted, or otherwise applied by covered surgical procedures shall be reimbursed at no more than the invoice for the device plus 20 percent. This provision applies regardless of where the procedure is performed, including trauma centers, hospital emergency rooms, inpatient surgeries and outpatient surgical facilities.