REIMBURSEMENT GUIDE EFFECTIVE JANUARY 2018 Medtronic provides this information for your convenience only. It does not constitute legal advice or a recommendation regarding clinical practice. Information provided is gathered from third-party sources and is subject to change without notice due to frequently changing laws, rules and regulations. Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other payers as to the correct form of billing or the amount that will be paid to providers of service. Please contact your Medicare contractor, other payers, reimbursement specialists and/or legal counsel for interpretation of coding, coverage and payment policies. This document provides assistance for FDA approved or cleared indications. Where reimbursement is sought for use of a product that may be inconsistent with, or not expressly specified in, the FDA cleared or approved labeling (eg, instructions for use, operator s manual or package insert), consult with your billing advisors or payers on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related service. ICD-10-CM 1 DIAGNOSIS S Diagnosis codes are used by both physicians and hospitals to document the indication for the procedure. The Medtronic RF ablation system is used for palliation of metastatic malignant lesions in a vertebral body as well as for palliation of pain associated with metastatic lesions involving bone. The codes shown below are commonly assigned for these indications. When ablation is performed, code C79.51 is ordinarily sequenced first. 2 ICD-10-CM C79.51 Secondary malignant neoplasm of bone G89.3 Neoplasm related pain (acute) (chronic) 1. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). http://www.cdc.gov/nchs/icd/ icd10cm.htm. Updated October 1, 2017. Accessed November 21, 2017. 2. ICD-10-CM Official Guidelines for Coding and Reporting FY 2017, I.C.6.b.5. PHYSICIAN CODING AND PAYMENT JANUARY 1, 2018 - DECEMBER 31, 2018 Physicians use CPT 1 codes for all services. Under Medicare s Resource-Based Relative Value Scale (RBRVS) methodology for physician payment, each CPT code is assigned a point value, the relative value unit (RVU), which is then converted to a flat payment amount. The listed CPT codes are appropriate for radiofrequency bone tumor ablation procedures: MEDICARE RVU 2 MEDICARE NATIONAL AVERAGE 3 CPT 20982 Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis), including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency 4 PHYSICIAN OFFICE FACILITY PHYSICIAN OFFICE FACILITY 111.35 10.56 $4,278 $381 CHECK 1. CPT copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings 2. Centers for Medicare & Medicaid Services. Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018 Final Rule; 82 Fed. Reg. 52976-53371. https:// www.gpo.gov/fdsys/pkg/fr-2017-11-15/pdf/2017-23953.pdf Published November 15, 2017. Accessed November 21, 2017. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU. The total RVU as shown here is the sum of three components: physician work RVU, practice expense RVU, and malpractice RVU. RVUs and payment are different in the non-facility (office) setting versus the facility setting. For non-facility settings, payment is higher to the physician to account for the additional direct and indirect costs incurred by the practice when rendering the service in that setting. Non-facility expenses may include the cost of the physician s practice overhead, including rent, staff salaries and benefits, medical equipment, and supplies. In the facility, these direct and indirect costs are absorbed by the facility and thus are reflected in the payment to the facility (e.g., hospital, ASC). 3. Medicare national average payment is determined by multiplying the sum of the three RVUs by the conversion factor. The conversion factor for CY 2018 is $35.9996 per 82 Fed. Reg. 53344. https://www. gpo.gov/fdsys/pkg/fr-2017-11-15/pdf/2017-23953.. Published November 15, 2017. Accessed November 21, 2017. See also the January 2018 release of the PFS Relative Value File RVU18A at http:/ www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/pfs-relative-value-files.html. Released November 15, 2017. Accessed November 21, 2017. Final payment to the physician is adjusted by the Geographic Practice Cost Indices (GPCI). Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the payment amount shown. 4. Code 20982 is reported once per operative episode, regardless of whether multiple lesions are treated in different bones. The MUE value=1 with no appeal permitted. See also CPT Assistant, September
HOSPITAL OUTPATIENT CODING AND PAYMENT JANUARY 1, 2018 - DECEMBER 31, 2018 Hospitals use CPT codes for outpatient services. Under Medicare s APC methodology for hospital outpatient payment, each CPT code is assigned to one of approximately 710 ambulatory payment classes. Each APC has a relative weight that is then converted to a flat payment amount. Multiple APCs can sometimes be assigned for each encounter, depending on the number of procedures coded and whether any of the procedure codes map to a Comprehensive APC. For 2018, there are 62 APCs which are designated as Comprehensive APCs (C-APCs). Each CPT procedure code assigned to one of these C-APCs is considered a primary service, and all other procedures and services coded on the bill are considered adjunctive to delivery of the primary service. This results in a single APC payment and a single beneficiary copayment for the entire outpatient encounter, based solely on the primary service. Separate payment is not made for any of the other adjunctive services. Instead, the payment level for the C-APC is calculated to include the costs of the other adjunctive services, which are packaged into the payment for the primary service. When more than one primary service is coded for the same outpatient encounter, the codes are ranked according to a fixed hierarchy. The C-APC is then assigned according to the highest ranked code. In some special circumstances, the combination of two primary services leads to a complexity adjustment in which the entire encounter is re-mapped to another higher-level APC. C-APCs are identified by status indicator J1. CPT 1 APC 2 STATUS INDICATOR 3 2018 MEDICARE PAYMENT 4 20982 Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis), including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency 5 5114, Level 4 Musculoskeletal Procedures J1 $5,606 CHECK 1. CPT copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings 2. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems..82 Fed. Reg. 52356-52637. https:// www.gpo.gov/fdsys/pkg/fr-2017-11-13/pdf/2017-23932.pdf. Published November 13, 2017. Accessed November 21, 2017. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 82 FR 61184..https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf. Published December 27, 2017. Accessed January 5, 2018. 3. Status Indicator (SI) shows how a code is handled for payment purposes: J1 = paid under comprehensive APC, single payment based on primary service without separate payment for other adjunctive services 4. Medicare national average payment is determined by multiplying the APC weight by the conversion factor. The conversion factor for 2018 is $78.636. The conversion factor of $78.636 assumes that hospitals meet reporting requirements of the Hospital Outpatient Quality Reporting Program. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...82 Fed. Reg. 52398. https://www.gpo.gov/fdsys/pkg/fr-2017-11-13/pdf/2017-23932.pdf Published November 13, 2017. Accessed November 21, 2017. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems...Final Rule. 82 FR 61184..https://www.gpo.gov/fdsys/pkg/FR-2017-12-27/pdf/2017-27949.pdf. Published December 27, 2017. Accessed January 5, 2018. Payment is adjusted by the wage index for each hospital s specific geographic locality, so payment will vary from the national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 5. Code 20982 is reported once per operative episode, regardless of whether multiple lesions are treated in different bones. The MUE value=1 with no appeal permitted. See also CPT Assistant, September Device C-Codes 1 C1886 Catheter, extravascular tissue ablation, any modality (insertable) 1. Code C1886 may be used to report the ablation catheter device, in addition to CPT code 20982 for the ablation procedure. While Medicare does not require billing of this particular C-code and it does not allow additional payment for it, some commercial payers recognize it and allow additional payment. Please refer to the facility s specific commercial payer contracts. Under Medicare s MS-DRG methodology for hospital inpatient payment, each inpatient stay is assigned to one of about 755 diagnosis-related groups, based on the ICD-10-CM codes assigned to the diagnoses and ICD-10-PCS codes assigned to the procedures. Each MS-DRG has a relative weight that is then converted to a flat payment amount. Only one MS-DRG is assigned for each inpatient stay, regardless of the number of procedures performed. The MS-DRGs shown are those typically assigned to the following scenarios. For spinal cord stimulation therapy for chronic pain, DRG assignment varies depending on the diagnosis and the specific procedures performed. ICD-10-PCS 2 Procedure Codes The following ICD-10-PCS codes are appropriate for bone tumor ablation procedures:. The root operation ablation is shown by the third character in each code, 5-Destruction. The Medtronic RF ablation system uses the percutaneous approach, shown by the fifth character in each code, 3-Percutaneous. Other code characters differentiate the anatomic site. The codes shown below are used for the common sites of bone tumor ablation. Other codes are available for less common sites. ICD-10-PCS Thorax 0P503ZZ 0P513ZZ 0P523ZZ 0P593ZZ 0P5B3ZZ Destruction of Sternum, Percutaneous Approach Destruction of Right Rib, Percutaneous Approach Destruction of Left Rib, Percutaneous Approach Destruction of Right Clavicle, Percutaneous Approach Destruction of Left Clavicle, Percutaneous Approach continued on next page
ICD-10-PCS 2 Procedure Codes continued ICD-10-PCS Vertebrae and Spine 0P543ZZ Destruction of Thoracic Vertebra, Percutaneous Approach 0Q503ZZ Destruction of Lumbar Vertebra, Percutaneous Approach Shoulder and Upper Arm 0P553ZZ Destruction of Right Scapula, Percutaneous Approach 0P563ZZ Destruction of Left Scapula, Percutaneous Approach 0P5C3ZZ Destruction of Right Humeral Head, Percutaneous Approach 0P5D3ZZ Destruction of Left Humeral Head, Percutaneous Approach 0P5F3ZZ Destruction of Right Humeral Shaft, Percutaneous Approach 0P5G3ZZ Destruction of Left Humeral Shaft, Percutaneous Approach Pelvis, Hip and Leg 0Q513ZZ Destruction of Sacrum, Percutaneous Approach 0Q5S3ZZ Destruction of Coccyx, Percutaneous Approach 0Q523ZZ Destruction of Right Pelvic Bone, Percutaneous Approach 0Q533ZZ Destruction of Left Pelvic Bone, Percutaneous Approach 0Q543ZZ Destruction of Right Acetabulum, Percutaneous Approach 0Q553ZZ Destruction of Left Acetabulum, Percutaneous Approach 0Q563ZZ Destruction of Right Upper Femur, Percutaneous Approach 0Q573ZZ Destruction of Left Upper Femur, Percutaneous Approach 0Q583ZZ Destruction of Right Femoral Shaft, Percutaneous Approach 0Q593ZZ Destruction of Left Femoral Shaft, Percutaneous Approach 0Q5B3ZZ Destruction of Right Lower Femur, Percutaneous Approach 0Q5C3ZZ Destruction of Left Lower Femur, Percutaneous Approach 0Q5G3ZZ Destruction of Right Tibia, Percutaneous Approach 0Q5H3ZZ Destruction of Left Tibia, Percutaneous Approach 0Q5J3ZZ Destruction of Right Fibula, Percutaneous Approach 0Q5K3ZZ Destruction of Left Fibula, Percutaneous Approach Diagnosis-Related Groups (DRGs) When bone tumor ablation procedures are performed, without any additional procedures during the same inpatient admission, the following DRGs are typically assigned. Ablation of Thorax, Vertebrae and Spine, Shoulder and Upper Arm, Pelvis and Leg MS-DRG 1 RELATIVE WEIGHT 495 Local Excision and Removal of Internal Fixation Devices Except Hip and Femur W 496 Local Excision and Removal of Internal Fixation Devices Except Hip and Femur W CC 497 Local Excision and Removal of Internal Fixation Devices Except Hip and Femur WO CC/ 3.0121 $18,152 CHECK 1.9746 $11,900 CHECK 1.3874 $8,361 CHECK
Diagnosis-Related Groups (DRGs) continued Ablation of Femur MS-DRG 1 RELATIVE WEIGHT 498 Local Excision and Removal of Internal Fixation Devices of Hip and Femur W CC/ 499 Local Excision and Removal of Internal Fixation Devices of Hip and Femur WO CC/ 2.429 $14,638 CHECK 1.2418 $7,484 CHECK 1. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and FY2018 Rates Final Rule, 82 Fed. Reg. 37990-38589. https://www.gpo.gov/fdsys/pkg/fr-2017-08-14/pdf/2017-16434.pdf. Published August 14, 2017. Accessed September 21, 2017 and Correction 82 Fed. Reg. 46138-46163 https://www.gpo.gov/fdsys/pkg/fr-2017-10-04/pdf/2017-21325.pdf. Published October 4, 2017. Accessed October 5, 2017.U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). http://www.cms.gov/medicare/coding/icd10/2018-icd-10- PCS-and-GEMs.html. Updated October 1, 2017. Accessed November 21, 2017. 2. Payment is based on the average standardized operating amount ($5,572.53) plus the capital standard amount ($453.95). Centers for Medicare & Medicaid Services. Medicare Program: Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System Changes and FY2018 Rates; 82 Fed. Reg. 38548. Tables 1A-1D. https://www.gpo. gov/fdsys/pkg/fr-2017-08-14/pdf/2017-16434.pdf. Published August 14, 2017. Accessed September 21, 2017 and Correction 82 Fed. Reg. 46146 https://www.gpo.gov/fdsys/pkg/fr-2017-10-04/ pdf/2017-21325.pdf. Published October 4, 2017. Accessed October 5, 2017. The payment rate shown is the standardized amount for facilities with a wage index greater than one. The average standard amounts shown also assume facilities receive the full quality update. The payment will also be adjusted by the Wage Index for specific geographic locality. Therefore, payment for a specific hospital will vary from the stated Medicare national average payment levels shown. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. AMBULATORY SURGERY CENTERS CODING AND PAYMENT JANUARY 1, 2018 - DECEMBER 31, 2018 ASCs use CPT codes for their services. Medicare payment for procedures performed in an ambulatory surgery center is based on Medicare s ambulatory patient classification (APC) methodology for hospital outpatient payment. However, Comprehensive APCs are used only for hospital outpatient services and are not applied to procedures performed in ASCs. Each CPT code designated as a covered procedure in an ASC is assigned a comparable relative weight as under the hospital outpatient APC system. This is then converted to a flat payment amount using a conversion factor unique to ASCs. Multiple procedures can be paid for each claim. Certain ancillary services, such as imaging, are also covered when they are integral to covered surgical procedures, although they may not be separately payable. In general, there is no separate payment for devices; their payment is packaged into the payment for the procedure. Many payers use a similar type of fee schedule to reimburse ASCs, while other payers use alternate mechanisms depending on their contracts with the ASC. CPT 1 PAYMENT INDICATOR 2 CHECK 20982 Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., percutaneous, including imaging guidance when performed; radiofrequency 4 metastasis) including adjacent soft tissue when involved by tumor extension, G2 $2,721 1. CPT Copyright 2017 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. No fee schedules, basic units, relative values, or related listings 2. The Payment Indicator shows how a code is handled for payment purposes. G2 = surgical procedure, non-office-based, payment based on hospital outpatient rate adjusted for ASC 3. Medicare national average payment is determined by multiplying the relative weight by the ASC conversion factor. The 2018 ASC conversion factor is $45.575. The conversion factor of $45.575 assumes the ASC meets quality reporting requirements. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment Systems... Final Rule. 82 Fed. Reg. 52561. https://www.gpo.gov/fdsys/pkg/fr-2017-11-13/pdf/2017-23932.pdf Published November 13, 2017. Accessed November 21, 2017. Payment is adjusted by the wage index for each ASC s specific geographic locality, so payment will vary from the stated national average Medicare payment levels displayed. Also note that any applicable coinsurance, deductible, and other amounts that are patient obligations are included in the national average payment amount shown. 4. Code 20982 is reported once per operative episode, regardless of whether multiple lesions are treated in different bones. The MUE value=1 with no appeal permitted. See also CPT Assistant, September
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