Wiki Tympanoplasty with graft

[lmartien]

I have a scenario where a patient has a tympanoplasty (69631) with a skin substitute graft (Q4131) in the ASC. The doctor has asked about using 15732 (flap) with the procedure to help capture reimbursement or the graft product itself. In my opinion, this would be inappropriate as the graft is not autologous from the patient, but an allograft. Do anyone know if the graft product would be paid in either the ASC or HOPD setting? I'm thinking no for ASC and yes for HOPD but would like validation.

Thank you!

Linda

 

[capricew]

I have a scenario where a patient has a tympanoplasty (69631) with a skin substitute graft (Q4131) in the ASC. The doctor has asked about using 15732 (flap) with the procedure to help capture reimbursement or the graft product itself. In my opinion, this would be inappropriate as the graft is not autologous from the patient, but an allograft. Do anyone know if the graft product would be paid in either the ASC or HOPD setting? I'm thinking no for ASC and yes for HOPD but would like validation.

Thank you!

Linda

it really depends on the payer and the contract you have with them. Your contract must address how an implant/graft is paid. Technically since the graft is being implanted it is considered an implant. If your contract does not address this you probably will not be paid.

 

[lmartien]

Thank you, Caprice, your input is much appreciated. How would you answer if this patient was a traditional (no managed) Medicare patient?

Linda

 

[capricew]

Thank you, Caprice, your input is much appreciated. How would you answer if this patient was a traditional (no managed) Medicare patient?

Linda

LMARTIEN,
The only graft substance that Medicare will pay for is Cornea tissue. Medicare will not pay for screws, plates, tendons etc. The reason is because Medicare will either 1) make the procedure a device intensive procedure and the procedure code billed will have the implant cost factored in or 2) Medicare will simply state that additional reimbursement for implants are not payable because the implants used are inherent to the procedure being done. (the procedure could not be performed without the implants). That being said, if the doctor is not doing the flap procedure that you mentioned above, I would not bill it. Instead - look up the procedure you are doing and see if it is device intensive according to Medicare. My best example of a device intensive procedure that Medicare pays for is the Cochlear Implant procedure. Medicare does not pay for the implant itself, but, the reimbursement for the procedure is like 25k the last time i checked. This is a perfect example of how they factor the cost of the implant into the reimbursement for the procedure code being billed.

Best of luck!