US Reimbursement Guide 2021 - Smith+Nephew
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US Reimbursement Guide 2021
VISIONAIRE◊ Adaptive Guides US
Reimbursement Guide
VISIONAIRE Patient Matched Adaptive Guides
VISIONAIRE Patient Matched Adaptive Guides use the patient’s MRI and X-Ray to determine accurate alignment cuts and
implant placement for each patient. However, the surgeon’s input on each patient is critical. The surgeon has the ability
to make adjustments as he/she sees fit to address the patient’s specific anatomy, making this process not only patient-
specific, but surgeon-specific as well. Patient-specific, single-use distal femoral and proximal tibia cutting guides are based
off the patient’s mechanical axis. VISIONAIRE Adaptive Guides can be used with LEGION◊, GENESIS◊ II and JOURNEY◊ II
Total Knee Systems.
Coding Payment System
Reimbursement coding refers to coding classification In the hospital [inpatient] environment, the selected
systems and medical nomenclature. Several coding systems ICD-10 diagnosis and procedure codes are converted into
exist with various levels of detail and for various purposes. a MS-DRG payment code.
The health care industry (including providers and insurers)
uses coding to indicate the patient’s condition (diagnosis) In the case of total joint replacement in the hospital
and the treatment of the patient for that diagnosis setting often defines assignment of a particular MS-DRG
(procedures). The patient’s diagnosis and procedures payment code. For example, MS-DRG codes 469 or 470
performed during the hospital stay are described using ICD- stipulate that a major joint procedure was performed.
10 codes, which must be supported by documentation in There usually is no additional payment for treatment in the
the patient record. The ICD-10 code is a significant factor hospital setting outside of the MS-DRG payment.
in determining the hospital’s reimbursement, as further
described under “Payment System.”
Provider Purpose Coding Payment system
Acute care short term Payment for services MS-DRG The Medicare Severity Diagnosis-Related Group (MS-DRG) code set
hospital provided to an inpatient classifies a patient into a DRG group based on the average resources used
to treat patients in that DRG.
Hospital Outpatient Payment for services APC Ambulatory Payment Classification (APC) is a code set to describe facility
provided to an outpatient outpatient services delivered to a Medicare outpatient. Payment rate
is established for each APC code. Depending on the services provided,
hospitals may bill for more than one APC per patient visit.
Ambulatory Surgery Payment for services ASC An ASC exclusively provides outpatient surgical services to patients who
Center provided in an ambulatory don’t need hospitalization and will typically discharge less than 24 hours
surgery center after admission. This system for payment is called the ASC Payment
System and is used when paying for covered surgical procedures, including
ASC facility services that are furnished in connection with the covered
surgical procedure.
Home care services Payment for patient stay in Home health Payment rate includes all nursing and therapy services, medical supplies,
a home care setting resource group aide and medical social services over a 60-day episode of care period.
Durable Medical Equipment is excluded. The payment rate is based on
case-mix adjustment, outlier payment, etc.
Skilled nursing facility Payment for patient stay in RUG Per diem rate covers all costs and is based on case-mix classification
a skilled nursing facility system (RUG III).
Physicians (inpatient, Payment for services CPT Current Procedural Terminology (CPT) is a numeric coding system of
outpatients) provided by a physician services and procedures furnished by physicians and other health care
professionals and published by American Medical Association.
Non-physician providers Payment for services HCPCS Level II HCPCS Level II is an alpha-numeric coding system for products, supplies,
(outpatient) provided by a non- and services used outside of physician offices. HCPCS II codes are often
physician to an outpatient product related. Payment for durable medical equipment (DME) is equal to
80% of the lesser of either actual charge for the item or the fee schedule
amount. DMEPOS fee schedule is based on HCPCS Level II codes.
Source: www.cms.gov
For coding, payment, coverage and sample letters, please visit the Reimbursement website at
www.smith-nephew.com/reimbursement. Or you can contact us directly at reimbursement@smith-nephew.com or 1-888-711-9903.
2Knee replacement
2021 Medicare Coding, Coverage and Payment Reference Sheet
Visit the site at www.smith-nephew.com/reimbursement to obtain specific geographic payment information.
Current Procedural Terminology (CPT) is copyright 2021 American Medical Association. All Rights Reserved. No fee
schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data
contained herein.
Common physician coding
CPT codes are used by hospital outpatient departments, ambulatory surgery centers, and physicians to describe
professional services and procedures. Based on CY2021 Medicare Physician Fee Schedule national payment rates
are as follows:
CPT Code Description Payment
27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing $1,321
(total knee arthroplasty)
Source: American Medical Association. CPT 2021 Professional Edition. CMS 2021 Final Rule Physician Fee Schedule, CMS-1734-F
Rates calculated do not include the CMS Sequestration Reduction discount
Common inpatient coding
The International Classification of Disease tenth revision Procedure Coding System (ICD10-PCS) is a system of medical
classification used for procedural codes that track various health interventions taken by medical professionals effective October
1, 2015. Below you will find the ICD10-PCS that may apply to patients undergoing the Knee Replacement procedure:
DRG Cross
ICD10-PCS Description
Reference
0SRC069 Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Cemented, Open Approach 469, 470
0SRC06A Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Uncemented, Open Approach 469, 470
0SRC06Z Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Open Approach 469, 470
0SRD069 Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Cemented, Open Approach 469, 470
0SRD06A Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Uncemented, Open Approach 469, 470
0SRD06Z Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Open Approach 469, 470
0SRC0L9 Replacement of Right Knee Joint with Unicondylar Synthetic Substitute, Cemented, Open Approach 469, 470
0SRC0LA Replacement of Right Knee Joint with Unicondylar Synthetic Substitute, Uncemented, Open Approach 469, 470
0SRD0L9 Replacement of Left Knee Joint with Unicondylar Synthetic Substitute, Cemented, Open Approach 469, 470
0SRD0LA Replacement of Left Knee Joint with Unicondylar Synthetic Substitute, Uncemented, Open Approach 469, 470
0SRD0LZ Replacement of Left Knee Joint with Unicondylar Synthetic Substitute, Open Approach 469, 470
0SRC069 Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Cemented, Open Approach 469, 470
0SRC06A Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Uncemented, Open Approach 469, 470
0SRC06Z Replacement of Right Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Open Approach 469, 470
0SRD069 Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Cemented, Open Approach 469, 470
0SRD06A Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Uncemented, Open Approach 469, 470
0SRD06Z Replacement of Left Knee Joint with Oxidized Zirconium on Polyethylene Synthetic Substitute, Open Approach 469, 470
0SRC0J9 Replacement of Right Knee Joint with Synthetic Substitute, Cemented, Open Approach 469, 470
0SRC0JA Replacement of Right Knee Joint with Synthetic Substitute, Uncemented, Open Approach 469, 470
0SRC0JZ Replacement of Right Knee Joint with Synthetic Substitute, Open Approach 469, 470
0QRC0JZ Replacement of Left Lower Femur with Synthetic Substitute, Open Approach 469, 470
0QRG0JZ Replacement of Right Tibia with Synthetic Substitute, Open Approach 469, 470
0QRH0JZ Replacement of Left Tibia with Synthetic Substitute, Open Approach 469, 470
0QRC0JZ Replacement of Left Lower Femur with Synthetic Substitute, Open Approach 469, 470
Source: https://edit.cms.gov/medicare/icd-10/2021-icd-10-pcs (last accessed May 2021)
3Knee replacement (continued) Diagnosis-related groups (DRG) are used to reimburse hospitals for inpatient stays. Each inpatient stay is assigned a DRG that is determined according to the principal diagnosis, major procedures, discharge status, and complicating secondary diagnoses. Each DRG is assigned a flat payment rate, which is adjusted according to the individual hospital’s teaching status, disproportionate share services for treating low-income patients, and location in urban versus rural regions, etc. Note that DRGs do not include payment for physician services, which are coded and reimbursed separately. Capital and Operating rates are not included in the national DRG payment rates. There are three levels of severity in most DRG categories: 1. MCC—Major Complication/Comorbidity, which reflect the highest level of severity; 2. CC—Complication/Comorbidity, which is the next level of severity; and 3. Non-CC—Non-Complication/Comorbidity, which do not significantly affect severity of illness and resource use. Based on CY2021 Medicare DRG national payment rates are as follows: DRG Description Medicare DRG Payment 469 Major joint replacement or reattachment of lower extremity w mcc $18,172 470 Major joint replacement or reattachment of lower extremity w/o mcc $11,193 Source: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps (last accessed May 2021) Private Insurers Private insurers cover hospital inpatient services that are considered medically necessary and within the benefit structure of the patient’s health insurance coverage. Payment for the Knee Replacement procedure may be based on a percentage of the billed or allowed charges, per diem, or on a negotiated payment rate. Check with your payer organizations to determine the payment methodology for the Knee Replacement procedure. Common Outpatient and Ambulatory Surgery Center coding Procedures performed in the hospital outpatient or ASC setting of care are reported to third party payers utilizing a system of CPT code, ambulatory payment classification (APC) codes and comprehensive ambulatory payment classification (C-APC) codes. Payment methodologies differ with payer guidelines including Medicare, government payers and private commercial insurers. Specific payer guidelines should be followed for each case: CPT Code Description APC Status Indicator OPPS Payment Indicator ASC 27447 Level IV Musculoskeletal Procedures 5115 J1 $12,314.76 J8 $8,774.20 Payment Status Indicator J1 in the hospital outpatient setting of care indicate that the assigned APC is a comprehensive APC (C-APC) and includes all services and procedures performed and supplies utilized during the patient encounter for the primary procedure. Payment Indicator J8 means Device-intensive procedure Sources: https://edit.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms- 1736-fc (last accessed May 2021) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment (last accessed May 2021) Disclaimer: Coverage varies from Payer to Payer. Please contact your payer for coverage information. 4
Common imaging coding
CPT codes are used by hospital outpatient departments, ambulatory surgery centers, Independent Diagnostic Testing
Facility (IDTF), and physicians to describe professional services and procedures. Based on CY2021 Medicare Imaging Fee
Schedule national payment rates are as follows:
CPT Code Description IDTF & Physician Payment OPPS
73721 Magnetic resonance (e.g. Proton) imaging, any joint of lower extremity; w/o contrast material $228 $297
73721-26 Professional component $67 $67
73721-TC Technical component $162 $230
73562 Radiologic examination, knee; 3 views $41 $90
73562-26 Professional component $9 $9
73562-TC Technical component $32 $81
73564 Radiologic examination, knee; complete, 4 or more views $47 $120
73564-26 Professional component $11 $11
73564-TC Technical component $36 $109
73565 Radiologic examination, knee; both knees, standing, anteroposterior $42 $89
73565-26 Professional component $9 $9
73565-TC Technical component $33 $81
76498 Unlisted magnetic resonance procedure (eg, diagnostic, interventional) *Carrier Priced *Carrier Priced
76498-26 Professional component *Carrier Priced *Carrier Priced
76498-TC Technical component *Carrier Priced *Carrier Priced
77073 Bone length studies (orthoroentgenogram, scanogram) $46 $122
77073-26 Professional Component $14 $14
77073-TC Technical Component $32 $109
*Carrier-priced code. Carriers will establish RVUs and payment amounts for these services, generally on a case-by-case basis following review of
documentation, such as an operative reports.
Modifier Descriptor
-26 Professional Component: Certain procedures are a combination of professional and technical components.
-TC Technical Component: Certain procedures are a combination of professional and technical components.
When billing without a modifier, this means the services performed included both components.
Medicare reimbursement for diagnostic imaging procedures is comprised of a professional component, the amount paid
for the physician’s interpretation and report, and a technical component, the amount paid for all other services (including
staffing and equipment costs).
When combined and paid to the same individual or entity, this amount is often referred to as the total or global
reimbursement.
5Knee replacement (continued) ICD10-PCS Description CPT Crosswalk BQ37Y0Z Magentic Resonance Imaging (MRI) of Right Knee using Other Contrast, Unenhanced and Enhanced 73721 BQ37YZZ Magentic Resonance Imaging (MRI) of Right Knee using Other Contrast 73721 BQ37ZZZ Magentic Resonance Imaging (MRI) of Right Knee 73721 BQ38ZZZ Magentic Resonance Imaging (MRI) of Left Knee 73721 BQ38Y0Z Magentic Resonance Imaging (MRI) of Left Knee using Other Contrast, Unenhanced and Enhanced 73721 BQ38YZZ Magentic Resonance Imaging (MRI) of Left Knee using Other Contrast 73721 BQ07ZZZ Plain Radiography of Right Knee 73562, 73564, 73565, 77073 BQ08ZZZ Plain Radiography of Left Knee 73562, 73564, 73565, 77073 BQ0DZZZ Plain Radiography of Right Lower Leg 77073 BQ0FZZZ Plain Radiography of Left Lower Leg 77073 Cautionary Note: Many third-party payers require prior authorization before paying for a new procedure and will generally deny reimbursement if such approval is not received in advance. Source: www.cms.gov For any additional questions or concerns, please call 1-888-711-9903 or email reimbursement@smith-nephew.com. All VISIONAIRE◊ Patient Matched Instrumentation inquiries should be directed to VISIONAIRE Support at 1-800-262-3536 Option 1 or mail to: visionairesupport@smith-nephew.com For coding, payment, coverage and sample letters, please visit the Reimbursement website at www.smith-nephew.com/reimbursement. Or you can contact us directly at reimbursement@smith-nephew.com or 1-888-711-9903. 6
Checklist for total joint procedures
to assist with medical necessity
documentation requirements for
CMS-Medicare Part A
Indications – choose one and see below
— Osteoarthritis (OA)
— Avascular necrosis (osteonecrosis) tibial plateau/femoral condyle
— Nonunion/malunion articular fracture
— Rheumatoid arthritis
— Bone tumor involving knee
Indication not listed (provide clinical justification below)
Osteoarthritis All other Indications Description of Services
(OA) Required Required
All At least 2 Obtain X-Ray or MRI to demonstrate at least 2 of the following:
— Subchondral cysts
— Subchondral sclerosis
— Periarticular osteophytes
— Joint subluxation
— Joint space narrowing
All All Joint pain – Document in patient record and history and physical and include the following –
Duration of pain, months, weeks, etc.:
— Level of pain and worsening of pain
— Increased pain with activity
— Pain interferes with activities of daily living
— Pain increases with weight-bearing
— Pain with passive range of motion
— Limited ROM
All All Findings at knee:
— Pain with passive range of motion
— Limited ROM
— Crepitus
— Joint effusion/swelling
All At least 1 Trial of medication – usually at least 3 months:
— Indicate whether NSAIDs (or other meds) were used for pain
— Duration of medical therapy
— Or, if patient cannot tolerate pain medications, document contraindication to meds
All At least 1 Physical therapy/support – at least 3 months:
— Physical therapy – 12 weeks
— External joint support (canes or braces) 12 weeks
— Document course and response to external joint/PT
All All Risks and benefits of surgery:
— Risks and benefits of surgery discussed
— Note if patient has co-morbidities that may impact outcomes or increase risk and
address these issues
All All Documentation requirements:
— Confirm patient records include all necessary reports and documentation in progress notes
— Duplicate records to provide to hospital on or before patients admission to the hospital
*Confirm with hospital regarding documentation needs. Local Medicare coverage/documentations vary. Contact Medicare Administrative Contractor if you have any questions
regarding coverage or payment.
Sources:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1236.pdf (last accessed May 2021)
7Pre-determination Prior authorization A pre-determination of benefits is a written request Prior Authorization means you must request pre-certification for verification of benefits. Insurance Carriers review of, or pre-certify, certain care in order to receive maximum these requests based on policy provisions, and send an available benefits under the patients’ medical plan. For explanation of your patient’s potential benefits. You may some types of care, you must precertify the care to receive request a predetermination before your patient’s medical any benefits at all. Pre-certification is the process by procedure. This term is used for both pre-authorization which healthcare companies review the proposed and pre-certification. Internally, it is also used to denote treatment and advises you as to how your patient’s prior approval of medical services to determine medical benefits may be paid. necessity or if a procedure is considered Experimental and Pre-certification is a process still used by health insurance Investigational (E & I). companies to control healthcare costs. Similar processes: pre-authorization, pre-certification, prior authorization. Appeals process The process you use if you disagree with any decision about healthcare services. If Medicare or Group Health Plan does not pay for an item or service you have provided, or if you are not given an item or service you think the patient should get, you can have the initial Medicare/Group Health Plan decision reviewed again. If the patient is in a Medicare managed care plan or has a Group Health Plan, you can file an appeal if the plan will not pay for, or does not allow or stops a service that you think should be covered or provided. The Medicare managed care plan or Group Health Plan must tell you in writing how to appeal. See patient membership plan materials or contact the plan for details about your appeal rights. Step 1: Request a pre-determination or prior authorization for the services – The pre-determination/prior authorization of benefits process allows the medical provider, at the patient’s request, to send a letter to the Medicare/Group Health Plan with the proposed procedure and all the proper documentation to support the procedure. Within a few weeks, the Medicare/Group Health Plan will generally respond with a statement of coverage they will provide for that procedure. Check with your Medicare/Group Health Plan to determine if they have a predetermination form to submit with your request. Step 2: If the predetermination or prior authorization is denied, your next step is to appeal the denial. The letter you receive from Medicare/Group Health Plan will let you know the reason for the denial, the appeal time frame and where to submit your appeal. Be sure to submit your appeal within the timeframe allowed. Additional tips when appealing: Check on the state guidelines, employer contracts and payer policies for the amount of time the payer has to complete the predetermination of benefits and appeals. If the payer did not follow those guidelines, you may have the right to appeal to the state or an external review entity. Please contact VISIONAIRE◊ support at 1-800-262-3536 Option 1 or mail to: visionairesupport@smith-nephew.com for appeals packets/ denials for VISIONAIRE/MRI’s. For coding, payment, coverage and sample letters, please visit the Reimbursement Website at www.smith-nephew.com/reimbursement. Or you can contact us directly at reimbursement@smith-nephew.com or 1-888-711-9903. The information in this document was obtained from third party sources and is subject to change without notice, including as a result of changes in reimbursement laws, regulations, rules and policies. All content in this document is informational only, general in nature and does not cover all situations or all payers’ rules or policies. The service and the product must be reasonable and necessary for the care of the patient to support reimbursement. Providers should report the procedure and related codes that most accurately describe the patients’ medical condition, procedures performed and the products used. This document represents no promise or guarantee by Smith & Nephew regarding coverage or payment for products or procedures by Medicare or other payers. Providers should check Medicare bulletins, manuals, program memoranda, and Medicare guidelines to ensure compliance with Medicare requirements. Inquiries can be directed to the hospital’s Medicare Part A fiscal intermediary, the physician’s Medicare Part B carrier, or to appropriate payers. Smith & Nephew specifically disclaims liability or responsibility for the results or consequences of any actions taken in reliance on information in this document. Information on reimbursement in the U.S. is provided as a courtesy. Due to the rapidly changing nature of the law and the Medicare payment policy, and reliance on information provided by outside sources, the information provided herein does not constitute a guarantee or warranty that reimbursement will be received or that the codes identified herein are or will remain applicable. This information is provided “AS IS” and without any other warranty or guarantee, expressed or implied, as to completeness or accuracy, or otherwise. 8
Notes
9Notes 10
Notes
11The information with this notice is general reimbursement information only. It is not information is subject to change without notice. Payers or their local branches may
legal advice, nor is it about how to code, complete or submit any particular claim for have their own coding and reimbursement requirements and policies. Before filing any
payment. Although we supply this information to the best of our current knowledge, claims, provider should verify current requirements and policies with their payer. CPT
it is always the provider’s responsibility to determine and submit appropriate codes, is a trademark of the American Medical Association. Current Procedural Terminology
charges, modifiers, and bills for services rendered. The coding and reimbursement (CPT) is copyright 2021 American Medical Association.
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