2018 REIMBURSEMENT GUIDE

Transcription

1 TABLE OF CONTENTS: Component Separation Technique and Hiatal Hernia Repair...08 Hernia Repair...03 Laparoscopic Repair Hernia...06 Stoma Procedures...11 Level II Codes PCS Codes...14 Modifiers...13 $ Medicare Inpatient Payment (MS-DRG)...16

2 OviTex Reinforced BioScaffolds are implants purposefully designed for hernia and abdominal wall reconstruction that combine biologic and synthetic materials in a unique embroidered construction. OviTex products are intended for use as a surgical mesh to reinforce and/ or repair soft tissue where weakness exists. Indications for use include the repair of hernias and/or abdominal wall defects that require the use of reinforcing or bridging material to obtain the desired surgical outcome. OviTex products are available in various shapes, sizes, and configurations to suit surgeon preference and the complexity of the soft tissue repair. The device may be trimmed to a desired shape to further accommodate an individual patient s requirements. OviTex is compatible with all surgical techniques: open, laparoscopic, and robotic approaches. PHYSICIAN, HOSPITAL OUTPATIENT, AND ASC CODING AND MEDICARE REIMBURSEMENT The following table provides 2018 national average Medicare Fee Schedule, Payment Category (), and (ASC) payment rates for the CPT codes relating to hernia and abdominal repair procedures identified in this guide. Payments will vary by geographic locality. 2

3 Component Separation Technique Muscle, myocutaneous, or fasciocutaneous flap; trunk (Note: Report twice if procedure is bilateral) $1, $2, $1, Hernia Repair Removal of mesh in abdominal wall for infection $ Inpatient Only Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible $ $2, $1, Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or strangulated $ $2, $1, Repair initial inguinal hernia, age 5 years or older; reducible $ $2, $1, $ 3

4 Hernia Repair (Continued) Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated Repair recurrent inguinal hernia, any age; reducible Repair recurrent inguinal hernia, any age; incarcerated or strangulated Repair inguinal hernia, sliding, any age $ $2, $1, $ $2, $1, $ $2, $1, $ $2, $1, Repair lumbar hernia $ $4, $2, Repair initial incisional or ventral hernia; reducible Repair initial incisional or ventral hernia; incarcerated or strangulated Repair recurrent incisional or ventral hernia; reducible Repair recurrent incisional or ventral hernia; incarcerated or strangulated $ $2, $1, $ $2, $1, $ $4, $2, $ $4, $2, $ 4

5 Hernia Repair (Continued) Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) $ $2, Packaged Service/Item; No Separate Payment Made Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure) Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated Repair umbilical hernia, younger than age 5 years; reducible Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated Repair umbilical hernia, age 5 years or older; reducible Repair umbilical hernia, age 5 years or older; incarcerated or strangulated $ $2, $1, $ $2, $1, $ $2, $1, $ $2, $1, $ $2, $1, $ $2, $1, Repair spigelian hernia $ $2, $1, $ 5

6 Laparoscopic Repair - Hernia Laparoscopy, surgical; repair initial inguinal hernia $ $4, $2, Laparoscopy, surgical; repair recurrent inguinal hernia $ $4, $2, Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia (includes mesh insertion, when performed); reducible $ $4, $2, Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated $ $4, $2, Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible $ $7, $3, $ 6

7 Laparoscopic Repair - Hernia (Continued) Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated $1, $7, $3, $ $7, $3, $1, $7, $3, * Unlisted lap procedure, hernioplasty, herniorrhaphy, herniotomy parastomal hernia repair Contractor Priced 5361 $4, Revision of colostomy; with repair of paracolostomy hernia (separate procedure) $ Inpatient Only * CPT status code is C. C = Contractor priced. Medicare Administrative Contractors will establish payment amounts for these services, generally on an individual case basis, following review of documentation, such as an operative report. $ 7

8 Hiatal Hernia Repair Repair, diaphragmatic hernia (other than neonatal), traumatic; acute $ Inpatient Only Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic $ Inpatient Only Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) $1, $7, Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh $1, $7, Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh $1, $7, $ 8

9 Hiatal Hernia Repair (Continued) Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List separately in addition to code for primary procedure) $ Inpatient Only Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis $1, Inpatient Only Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis $1, Inpatient Only Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis $1, Inpatient Only $ 9

10 Hiatal Hernia Repair (Continued) Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis $1, Inpatient Only Repair, paraesophageal hiatal hernia (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis $1, Inpatient Only Repair, paraesophageal hiatal hernia (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis $1, Inpatient Only 0437T Implantation of nonbiologic or synthetic implant (eg, polypropylene) for fascial reinforcement of the abdominal wall (List separately in addition to code for primary procedure)** Contractor Priced -- Packaged Service/Item; No Separate Payment Made Packaged Service/Item; No Separate Payment Made ** As with most add-on codes, this code is approved to be used with only certain primary procedures. Please refer to your CPT manual for approved primary procedures. $ 10

11 Stoma Procedures Colectomy, partial; with skin level cecostomy or colostomy $1, Inpatient Only Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure) $1, Inpatient Only Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula $1, Inpatient Only Revision of ileostomy; simple (release of superficial scar) (Separate procedure) $ $2, $1, Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure) $1, Inpatient Only $ 11

12 Stoma Procedures (Continued) Revision of ileostomy; complicated (reconstruction in-depth) (Separate procedure) $1, Inpatient Only Colostomy or skin level cecostomy $1, Inpatient Only Revision of colostomy; simple (release of superficial scar) (Separate procedure) $ $2, $1, Revision of colostomy; complicated [reconstruction in-depth] (Separate procedure) $1, Inpatient Only Revision of colostomy; with repair of paracolostomy hernia (Separate procedure) $1, Inpatient Only Suture of large intestine; (colorrhaphy) for perforated ulcer, diverticulum, wound, injury, or rupture (single or multiple perforations); with colostomy $1, Inpatient Only $ 12

13 Level II Codes v The following is the Level II code that relates to hernia repair procedures using OviTex: Codes C1781 Description Mesh (Implantable) (ie, Davol Synthetic Mesh, AlloMax Surgical Graft, Phasix Mesh, Phasix ST Mesh, XenMatrix Surgical Graft and XenMatrix AB Surgical Graft) Modifiers Modifiers explain that a procedure or service was changed without changing the definition of the CPT code set. Here are some common modifiers related to hernia repair procedures. Modifier Description 50 Bilateral Procedure 51 Multiple Procedures 59 Distinct Procedural Service $ 13

14 -PCS Codes vi -CM (diagnosis) and -PCS (procedure) codes were implemented October 1, It is the physician s responsibility to select the codes that appropriately represent the service performed, as well as to report the -CM code based on the findings or the pre-service signs, symptoms, or conditions of the individual patient. The following are examples of series descriptors of -PCS procedure codes that relate to hernia repair procedures (not an all inclusive list). -PCS Codes 0BQ 0BU 0D8 0DB 0DJ 0DN 0DQ 0DT 0DU 0DV 0F5 Series Descriptors Repair/Respiratory System Supplement/Respiratory System Division/Gastrointestinal System Excision/Gastrointestinal System Inspection/Gastrointestinal System Release/Gastrointestinal System Repair/Gastrointestinal System Resection/Gastrointestinal System Supplement/Gastrointestinal System Restriction/Gastrointestinal System Destruction/Hepatobiliary System and Pancreas $ 14

15 -PCS Codes 0FB 0FJ 0FN 0FT 0W2 0WJ 0WQ 0WU 0YQ 0YU Series Descriptors Excision/Hepatobiliary System and Pancreas Inspection/Hepatobiliary System and Pancreas Release/Hepatobiliary System and Pancreas Resection/Hepatobiliary System and Pancreas Change/Anatomical Regions, General Inspection/Anatomical Regions, General Repair/Anatomical Regions, General Supplement/Anatomical Regions, General Repair/Anatomical Regions, Lower Extremities Supplement/Anatomical Regions, Lower Extremities $ 15

16 Medicare Inpatient Payment (MS-DRG) Payment for inpatient hospital services is based on a classification system determined by patient diagnosis known as Medicare Severity - Diagnosis Related Groups (MS-DRGs). The MS-DRG assignment is based on the combination of -CM and -PCS codes reported. Only one MS-DRG is assigned to a patient for a particular hospital admission. Therefore, one payment is made per patient and that payment is based upon the MS-DRG assignment. The following are examples of series descriptors of -PCS procedure codes that relate to hernia repair procedures (not an all inclusive list). MS-DRGs and 2018 National Average Medicare Rates for Hernia and Abdominal Wall Repair Procedures MS-DRG Hernia Repair Description National Average MS-DRG Rate vii 350 Inguinal and Femoral Hernia Procedures With MCC* $14, Inguinal and Femoral Hernia Procedures With CC** $8, Inguinal and Femoral Hernia Procedures Without CC/MCC $6, Hernia Procedures Except Inguinal and Femoral With MCC $18, Hernia Procedures Except Inguinal and Femoral With CC $10, Hernia Procedures Except Inguinal and Femoral Without CC/MCC $7, $ 16

17 MS-DRG Parastomal Description National Average MS-DRG Rate vii 347 Anal and Stomal Procedures With MCC $15, Anal and Stomal Procedures With CC $8, Anal and Stomal Procedures Without CC/MCC $6, Hiatal 326 Stomach, Esophageal, and Duodenal Procedures With MCC $27, Stomach, Esophageal, and Duodenal Procedures With CC $12, Stomach, Esophageal, and Duodenal Procedures Without CC/MCC $9, Abdominal Wall 335 Peritoneal Adhesiolysis With MCC $24, Peritoneal Adhesiolysis With CC $14, Peritoneal Adhesiolysis Without CC/MCC $9,755 $ 17

18 MS-DRG Small Bowel and Large Bowel/Intestinal Procedures Description National Average MS-DRG Rate vii 329 Major Small & Large Bowel Procedures With MCC $29, Major Small & Large Bowel Procedures With CC $14, Major Small & Large Bowel Procedures Without CC/MCC $10, Rectal Resection With MCC $23, Rectal Resection With CC $12, Rectal Resection Without CC/MCC $7, Anal & Stomal Procedures With MCC $15, Anal & Stomal Procedures With CC $8, Anal & Stomal Procedures Without CC/MCC $6,117 Major complications and/or comorbidity Complications and/or comorbidity $ 18

19 Disclaimer Information presented in this document is current as of December 6, Any subsequent changes which may occur in coding, coverage and payment are not reflected herein. TELA Bio does not guarantee that use of the codes noted above will ensure coverage and/or payment. It is always the provider s responsibility to determine and submit appropriate codes, charges, modifiers and bills for the services that were rendered. This information is provided as of the date listed above, and all coding and reimbursement information is subject to change without notice. Payers or their local branches may have their own coding and reimbursement requirements and policies. Before filing any claims, providers should verify current requirements and policies with the payer. Do not use OviTex in patients known to be sensitive to materials of ovine (sheep) origin. For additional important safety information, please see the OviTex Reinforced BioScaffold Instructions for Use. For Prescription Use Only. TELA Bio, Inc. owns or has applied for the following trademarks or service marks: TELA Bio, OviTex. All other trademarks are trademarks of their respective owners or holders. MK-EM-0031 rev00 (January 2018) References i CPT codes and descriptions only are copyright 2016 American Medical Association. All rights reserved. No fee schedules are included in CPT. The American Medical Association assumes no liability for data contained or not contained herein. ii Federal Register / Vol. 82, No. 219 / Wednesday, November 15, iii Federal Register / Vol. 82, No. 217 / Monday, November 13, iv ibid. v PMIC Digital Book Series Copyright 2017 by Practice Management Information Corporation, Los Angeles, CA All rights reserved. vi -PCS 2018, Practice Management Information Corporation (PMIC). Copyright 2017 Uniform Copyright Convention. vii Federal Register / Vol. 82, No. 155 / Monday, August 14, Note: The payment amounts indicated are estimates only based upon information published in CMS-1677-F, released 8/2/17 and related data tables. Calculations assume that all hospitals are receiving the full quality reporting and meaningful EHR update of 1.35%. Actual payment may vary based on hospital-specific factors not reflected in the source data. Actual payment may also vary based on adjustments that CMS may make from time to time. Payment amounts include uncompensated care payment (UCP). They do not include the 1% hospital acquired condition (HAC) adjustment, nor the 2% sequestration adjustment TELABIO ( ) reimbursement@telabio.com 19