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Zimmer Biomet Signature ONE

K

KristinM522

Networker
Messages
53
Good morning, are anyone's providers using the Zimmer Biomet Signature ONE preoperative planning guides for TSA? One of my docs was under the impression that utilizing this product would allow him to bill 0055T (self pay). I think I finally got him to understand that that product does not fit the code description for 0055T but he is still adamant that we can charge patients for it under a different code. Anyone have experience with this? I am going to speak with the rep today but thought I'd get insight from other coders before my call.

Thanks!
 
The problem is generally, if the provider has a contract/in-network it most likely will not allow the patient to be billed for it. ABN probably would not be allowed for Medicare. Possibly a CT code for the scan?

https://www.zimmerbiomet.com/conten...e-Scans-Associated-Coding-Reference-Guide.pdf
Providers should contact payers directly to clarify coverage policies and prior authorization requirements as these can vary by payer.

Some policy examples, these are for CAN but sometimes lumps in the pre-op scan w/ that like the Aetna below:
From the above link: "In instances where the provider is participating, there shall be no member liability."
"In instances where the provider is non-participating, the member’s liability may be up to the provider’s charge."

https://www.aetna.com/cpb/medical/data/800_899/0837.html See II:
  1. Pre-operative advanced imaging that is required for any experimental, investigational, or unproven procedure (e.g., where required for computer-assisted surgical navigation, robotic-assisted surgical navigation, or for customized patient implants and/or instrumentation)
All I could find from CGS with reference to it, but it mostly is talking about TKA & THA, see link above: "There has been a growing trend to utilize computer aided navigation and robotics in effort to improve alignment and reduce bone loss associated with joint replacement surgery. Some literature suggests a positive trend towards improvement based on very low- and low-quality evidence. However, most of the studies, including the systematic reviews, do not demonstrate a difference between conventional and aided outcomes with long term follow-up. There are concerns about increased operative time and cost, especially when evidence to support long term outcome improvement is lacking. While societies largely do not oppose use of these devices there is no direct societal support. In the AAOS evidence based practice guidelines state surgical navigation does not improve outcomes, function or pain over conventional techniques with moderate strength of recommendation based on high quality evidence.54 Future investigations using high quality methodology are needed to address long-term safety, patient-oriented outcomes (e.g., functional outcomes, implant longevity, revision rates, quality of life), implant longevity, and comparison of the different devices to each other. While this does not prohibit utilizing these modalities intraoperatively, they are not considered medically necessary and therefore not eligible for separate payment."
 
I really appreciate your response, Amy! We do not do the CT's in house so those are billed separately by an outside facility. I did speak to the rep yesterday and he has convinced our provider that we can use an internal tech code to charge patients a self pay price for this as long as the patient signs an ABN releasing us from billing the insurance ("because other providers are doing it" I hate that line!!). I have explained to my higher ups that we should not be (at the very least) charging Medicare patients for this or any other tech (S2900, 0054T) per Medicare rules. And have asked them to look over all the other commercial contracts to see if they explicitly bundle these services with total joint arthroplasties. I have been a surgical ortho coder for 15+ years but I do not deal with any of the billing side, just help with surgical denials. So when I talk to them I am not 100% confident in my billing knowledge but I can read lol Not to mention starting 1/1/2027 those T codes are being deleted and those services will fall under 20985 (we have a couple physicians who use 0054T) but since 20985 is a valid CPT code with a Medicare fee schedule I don't think they understand that high self pay price we have will have to go away and we will have to accept what Medicare/other payors allow. The whole situation makes me very anxious!
 
"Could" it be done? Possibly. The group or provider contracts and health plan policies are going to drive the answer. Since you are talking about TSA and most of the patient population have Medicare or other plans impacted by government regs, those have to be checked.
The issue again, is if it is deemed integral/bundled or investigative or experimental, etc. And, if the contract and/or policy states wording like the Aetna one above where the patient may not be billed. The reason codes will dictate this too if they attempt to bill it and you get a CO: Contractual Obligation (provider write-off/adjustment).

Advance Beneficiary Notice of Non-coverage Tutorial - MLN909183

Advance Beneficiary Notice of Noncoverage Tutorial
www.cms.gov

Related forum discussions, some might be older so double check the info.
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Thread '20985 and use of glenoid pin in sholder arthroplasty'

Hello,
If anyone has any information about this, I'd really appreciate it.
Surgeon is doing a total shoulder and coding 20985 for the following dictation:
Based on preoperative imaging and/or planning, a glenoid pin was placed (20985). The glenoid was reamed to the appropriate depth, version, and inclination. The glenoid was prepared to receive the baseplate and central post. The glenoid baseplate was then impacted in place and screws placed for fixation. The glenosphere was then impacted into place.
Is this documentation enough to code the 20985?
Even though I can't find any LCD's...
M

Thread 'Charging Medicare patients for 20985 and 0054T'

I have orthopedic surgeons collecting 300-500 dollars from Medicare and commercial payer patients for 20985 and 0054T because they are non-covered services per Medicare. In reading the descriptions of the codes they are not reimbursed as separate procedures but as add on codes to surgical codes so are not payable. Therefore I would say no, we can not make the patient pay for this is the payer designates the codes as such. I am new with the practice and want to make sure we are doing this by the book. Anyone have any experience with this? Thanks

Of course the device representative is going to say that. 🙃
 
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