Arthrex provides product-specific information about codes and billing scenarios that may used for procedures that employ our products. Payment methods for these technologies will vary by payer and site of service. Payer policies, and the laws and regulations that guide them are complex and change frequently. Ultimately, the provider of a service is responsible for decisions regarding coding, coverage, and reimbursement matters. Precertification or preauthorization will confirm coverage, and likely payment. Medicaid coverage, coding and payment will vary by place of service and state. The information provided is gathered from government and private payers CMS, (Centers for Medicare and Medicaid) AMA, (American Medical Association) and other sources for coding policies. It is not intended to maximize reimbursement but represents commonly used methods to account for the use of Arthrex products. It does not constitute legal advice and no warranty regarding completeness or accuracy is implied. The essential components which determine appropriate payment for a procedure or a product are site of service/coding/coverage/payment system/geographical location/national and local medical review policies and/or payer edits. Coding Systems
- CPT Current Procedural Terminology (CMS)
- HCPCS Healthcare Common Procedure Coding System (CMS)
- ICD-9 International Classification of Diseases -9th Rev.
- PFS Physician Fee Schedule (CMS)
- RBRVS RBRVS Revenue Based Relative Value Scale (AMA)
Site of Service
Medicare reimburses based on Diagnosis Related Groups (DRGs). Hospitals use three digit revenue codes to track costs with proper revenue centers. All procedure and product codes used in an inpatient environment must be linked to the appropriate revenue code and mapped to the appropriate DRG. Medicaid and private payers are reimbursed by per diem rates which themselves require ICD-9 (International Classification of Diseases-9th Revision) procedure codes. Private Insurers generally follow Medicare coding and coverage but in some cases providers negotiate separate "carve-out" payments for certain high cost items.
Medicare reimbursement is based in the Ambulatory Payment Classification System (APC) groups. APCs are associated with CPT procedure codes. Pass-through device codes are applicable.. Medicaid and private payer reimbursement maybe driven by modifications to APCs, per diem rates, or by predetermined fee schedules. Separate reimbursement for devices is dependant on the individual payer, region,and contractual arrangements. The medical device pass-through system accounts for the use of anchors or screws for opposing bone-to-bone and tissue-to-bone fixation.
Ambulatory Surgical Center
Freestanding facilities provide services usually by contract with private or commercial payers and agreements with Medicare/Medicaid. Medicare reimbursement is based on the APC (Ambulatory Payment Classification System) The payment for each procedure includes supplies and implants. Medicare has no mechanism for separate payment for implants. Some private payer contracts have allowances for implants or special supplies. These contracts are negotiated between the facility and the payer.
Procedures requiring arthroscopy are generally not performed in a physician office. For those procedures that may be performed in that setting, Private payer coverage will vary by state/region and usually follow Medicare policy. Precertification or prior authorization is recommended to confirm coverage. Physicians may use the HCPCS (Healthcare Common Procedure Coding System) as well as the required CPT and ICD-9 descriptors to bill for their services. Physicians are reimbursed under the Physician Fee Schedule. The Physician Fee Schedule data base link will show the allowed Medicare payments. CPT is a trademark of the AMA. No fee schedules, units or values are included or inferred. DRG Guidebook, 2006 Nineteenth Ed., St. Anthony Publishing, 2005 CPT codes, descriptions and material ©2006 American Medical Association