2015 Hernia & Abdominal Wall Repair (AWR) Surgery Medicare Reimbursement Coding Guide Effective January 1, 2015

Transcription

1 2015 Reimbursement Coding Guide Effective January 1, 2015 MEDICARE NATIONAL AVERAGE RATES AND ALLOWABLES (NOT ADJUSTED FOR GEOGRAPHY) CPT * HCPCS Code COMPONENT SEPARATION Procedure Description Muscle, myocutaneous, or fasciocutaneous flap; trunk DIAPHRAGMATIC HERNIA Physician *MPFS (CF=$ ) Fac/Non-Fac $1, / $1, Classification 0329 HOSPITAL OUPATIENT Descriptor Level IV Skin ** Rate AMBULATORY SURGICAL CENTER ***ASC $2, $1, Repair, laceration of diaphragm, any approach $ Inpatient, not reimbursed in outpatient or ASC by Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or without creation of ventral hernia Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic ENTEROLYSIS Enterolysis (freeing of intestinal adhesion) (separate procedure), surgical, enterolysis (freeing of intestinal adhesion) (separate procedure) EPIGASTRIC HERNIA Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure) Repair epigastric hernia (eg, preperitoneal fat); incarcerated or FEMORAL HERNIA $6, Inpatient, not reimbursed in outpatient or ASC by $ Inpatient, not reimbursed in outpatient or ASC by $1, Inpatient, not reimbursed in outpatient or ASC by $ $ $ Repair initial femoral hernia, any age; reducible $ Repair initial femoral hernia, any age; incarcerated or $ Repair recurrent femoral hernia; reducible $ Repair recurrent femoral hernia; incarcerated or $ Level II $3, Page 1 of 9

2 Page 2 of 9 CPT * HCPCS Code INCISIONAL/VENTRAL HERNIA Procedure Description Physician *MPFS (CF=$ ) Fac/Non-Fac Classification Repair initial incisional or ventral hernia; reducible $ Repair initial incisional or ventral hernia; incarcerated or $ Repair recurrent incisional or ventral hernia; reducible $ Repair recurrent incisional or ventral hernia; incarcerated or Implantation of mesh or other prosthesis for open 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) , surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or INGUINAL HERNIA Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; incarcerated or Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or $ HOSPITAL OUPATIENT Descriptor $ NA NA $ $ $ $1, $ $1, $ $ $ $ $ Repair initial inguinal hernia, age 5 years or older; reducible $ Repair initial inguinal hernia, age 5 years or older; incarcerated or $ Repair recurrent inguinal hernia, any age; reducible $ Repair recurrent inguinal hernia, any age; incarcerated or $ Repair inguinal hernia, sliding, any age $ ** Rate AMBULATORY SURGICAL CENTER ***ASC Packaged into Payment for Other Services Packaged Service/Item $2,675.43

3 Page 3 of 9 CPT * HCPCS Code Procedure Description Physician *MPFS (CF=$ ) Fac/Non-Fac Classification 49650, surgical; repair initial inguinal hernia $ , surgical; repair recurrent inguinal hernia $ LUMBAR HERNIA Repair lumbar hernia $ MESH IMPLANT HERNIA Implantation of mesh or other prosthesis for open 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) PARACOLOSTOMY HERNIA Revision of colostomy; with repair of paracolostomy hernia (separate procedure) PARAESOPHAGEAL HERNIA, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures), surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure) HOSPITAL OUPATIENT Descriptor Level II Level II $ NA NA ** Rate AMBULATORY SURGICAL CENTER ***ASC $3, $2, $3, $2, Packaged into Payment for Other Services Packaged Service/Item $1, Inpatient, not reimbursed in outpatient or ASC by $1, $1, $5, $5, $1, Inpatient, not reimbursed in outpatient or ASC by $1, Inpatient, not reimbursed in outpatient or ASC by Esophagogastric fundoplasty partial or complete; laparotomy $ Inpatient, not reimbursed in outpatient or ASC by Esophagogastric fundoplasty partial or complete; thoracotomy $1, Inpatient, not reimbursed in outpatient or ASC by S2900 Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except neonatal; with implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, except neonatal; with implantation of mesh or other prosthesis ROBOTIC ASSISTANCE Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure) SPIGELIAN HERNIA Repair spigelian hernia $ $1, Inpatient, not reimbursed in outpatient or ASC by $1, Inpatient, not reimbursed in outpatient or ASC by $1, Inpatient, not reimbursed in outpatient or ASC by $1, Inpatient, not reimbursed in outpatient or ASC by $1, Inpatient, not reimbursed in outpatient or ASC by $1, Inpatient, not reimbursed in outpatient or ASC by Not Valid for

4 Page 4 of 9 Physician HOSPITAL OUPATIENT AMBULATORY SURGICAL CENTER CPT * HCPCS Code TRAM FLAP Procedure Description Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging) Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double pedicle, including closure of donor site UMBILICAL HERNIA *MPFS (CF=$ ) Fac/Non-Fac Classification Descriptor ** Rate ***ASC $1, Inpatient, not reimbursed in outpatient or ASC by $2, Inpatient, not reimbursed in outpatient or ASC by $2, Inpatient, not reimbursed in outpatient or ASC by Repair umbilical hernia, younger than age 5 years; reducible $ Repair umbilical hernia, younger than age 5 years; incarcerated or $ Repair umbilical hernia, age 5 years or older; reducible $ Repair umbilical hernia, age 5 years or older; incarcerated or reducible UNLISTED HERNIA $ Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy Carrier Priced 0130 Level I $3, NOTES: 1 Use in conjunction with , S-Codes are not valid for payment Multiple Procedure Discounting Multiple surgical procedures furnished during the same operative session are discounted. 50% is paid for any other surgical procedure(s) performed at the same time. MPFS Facility allowables and ASC rates include patient cost-sharing (coinsurance and deductibles). HOPPS rates include patient cost-sharing (co-payments and deductibles). These amounts are national averages and are not adjusted for geography. The above 2015 MPFS payment rates reflect policies finalized in the CY 2015 Physician Fee Schedule Final Rule, CMS-1612-FC that was placed on display at the Federal Register on October 31st, These rates reflect a zero percent update effective January 1st, 2015 through March 31st, 2015, as provided for by the Protecting Access to Act of The CF published in the January update is $ Current law requires physician fee schedule rates to be reduced by an average of 21.2 percent from the CY 2014 rates because of the existing SGR factor used to calculate the conversion factor. In most prior years, Congress has taken action to avert a large reduction in MPFS rates before they went into effect. Without further congressional action, this updated CF is due to expire on March 31st, The above National Average and ASC Rates represent the reimbursement amounts paid directly to the facility for the technical portion of the procedure. The Physician (surgeon) would separately receive the professional fee (MPFS Allowable) for the procedure performed. Rates referenced in this guide do not reflect Sequestration, automatic reductions in federal spending that result in a 2% across-the-board reduction to all rates. REFERENCES: CMS 2015 Alpha-Numeric HCPCS File Updated 11/12/2014 * PFS Relative Value Files, RVU15B ( ), effective April 1, 2015 ** CMS-1613-CN ( ) HOPPS Addendum A and B, effective January 1, 2015 ***CMS-1613-CN ( ) ASC Addendum AA, BB, DD1, DD2, and EE, effective January 1, 2015 ICD-9-CM VOLUME 3 HOSPITAL PROCEDURE CODES Procedure Code* Description COMPONENT SEPARATION Cutting and preparation of pedicle grafts or flaps DIAPHRAGMATIC HERNIA Laparoscopic repair of diaphragmatic hernia, abdominal approach Other and open repair of diaphragmatic hernia, abdominal approach Repair of diaphragmatic hernia, abdominal approach, not otherwise specified Repair of diaphragmatic hernia with thoracic approach, not otherwise specified Plication of the diaphragm Repair of parasternal hernia Laparoscopic repair of diaphragmatic hernia, with thoracic approach Other and open repair of diaphragmatic hernia, with thoracic approach

5 Page 5 of 9 Procedure Code* ENTEROLYSIS Laparoscopic lysis of peritoneal adhesions Other lysis of peritoneal adhesions EPIGASTRIC HERNIA Description Repair of other hernia of anterior abdominal wall Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis FEMORAL HERNIA Unilateral repair of femoral hernia with graft or prosthesis Other unilateral femoral herniorrhaphy Bilateral repair of femoral hernia with graft or prosthesis Other bilateral femoral herniorrhaphy INCISIONAL/VENTRAL HERNIA Incisional hernia repair Repair of other hernia of anterior abdominal wall Other open incisional hernia repair with graft or prosthesis Laparoscopic incisional hernia repair with graft or prosthesis Other laparoscopic repair of other hernia of anterior abdominal wall with graft or prosthesis Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis INGUINAL HERNIA Laparoscopic repair of direct inguinal hernia with graft or prosthesis Laparoscopic repair of indirect inguinal hernia with graft or prosthesis Laparoscopic repair of inguinal hernia with graft or prosthesis, not otherwise specified Laparoscopic bilateral repair of direct inguinal hernia with graft or prosthesis Laparoscopic bilateral repair of indirect inguinal hernia with graft or prosthesis Laparoscopic bilateral repair of inguinal hernia, one direct and one indirect, with graft or prosthesis Laparoscopic bilateral repair of inguinal hernia with graft or prosthesis, not otherwise specified Unilateral repair of inguinal hernia, not otherwise specified Other and open repair of direct inguinal hernia Other and open repair of indirect inguinal hernia Other and open repair of direct inguinal hernia with graft or prosthesis Other and open repair of indirect inguinal hernia with graft or prosthesis Repair of inguinal hernia with graft or prosthesis, not otherwise specified Bilateral repair of inguinal hernia, not otherwise specified Other and open bilateral repair of direct inguinal hernia Other and open bilateral repair of indirect inguinal hernia Other and open bilateral repair of inguinal hernia; one direct and one indirect Other and open bilateral repair of direct inguinal hernia with graft or prosthesis Other and open bilateral repair of indirect inguinal hernia with graft or prosthesis Other and open bilateral repair of inguinal hernia; one direct and one indirect with graft or prothesis Bilateral inguinal hernia repair with graft or prosthesis, not otherwise specified LUMBAR HERNIA 53.9 Other hernia repair PARACOLOSTOMY HERNIA Revision of intestinal stoma, not otherwise specified

6 Procedure Code* Description Repair of pericolostomy hernia Other revision of stoma of large intestine PARAESOPHAGEAL HERNIA 42.7 Esophagomyotomy Repair of esophageal stricture Esophagogastroplasty Other procedures for creation of esophagogastric sphincteric competence Laparoscopic procedures for creation of esophagogastric sphincteric competence Other repair of stomach Laparoscopic repair of diaphragmatic hernia, abdominal approach Other and open repair of diaphragmatic hernia, abdominal approach Repair of diaphragmatic hernia, abdominal approach, not otherwise specified Repair of diaphragmatic hernia with thoracic approach, not otherwise specified Laparoscopic repair of diaphragmatic hernia, with thoracic approach Other and open repair of diaphragmatic hernia, with thoracic approach ROBOTIC ASSISTANCE Open robotic assisted procedure Laparoscopic robotic assisted procedure Percutaneous robotic assisted procedure Endoscopic robotic assisted procedure Thoracoscopic robotic assisted procedure Other and unspecified robotic assisted procedure SPIGELIAN HERNIA Repair of other hernia of anterior abdominal wall Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis TRAM FLAP Transverse rectus abdominis myocutaneous [TRAM] flap, pedicled UMBILICAL HERNIA Other and open repair of umbilical hernia with graft or prosthesis Laparoscopic repair of umbilical hernia with graft or prosthesis Other laparoscopic umbilical herniorrhaphy Other open umbilical herniorrhaphy UNLISTED HERNIA 53.9 Other hernia repair NOTES: The ICD-9-CM Hospital Procedure Codes listed above may be used in the MS-DRG Classifications (See Inpatient DRG Payment Rates Table) The appropriate MS-DRG classification is also dependent on the diagnosis code, demographics, sex and possible co-conditions. REFERENCES: *2015 Hospital ICD-9-CM Volume 3, 9th Revision, Clinical Modification, Sixth Edition INPATIENT DRG PAYMENT RATES MS-DRG* MS-DRG Title Arithmetic Mean Length of Stay (Days) National Average Payment** COMPONENT SEPARATION 356 Other Digestive System O.R. w MCC 11.3 $22, Other Digestive System O.R. w CC 6.7 $12, Other Digestive System O.R. w/o CC/MCC 3.9 $8, Wnd Debrid & Skn Grft Exc Hand, for Musculo-Conn Tiss Dis w MCC 14.2 $31, Wnd Debrid & Skn Grft Exc Hand, for Musculo-Conn Tiss Dis w CC 7.8 $17, Wnd Debrid & Skn Grft Exc Hand, for Musculo-Conn Tiss Dis w/o CC/MCC 4.8 $11,430.27

7 Page 7 of 9 MS-DRG* MS-DRG Title Arithmetic Mean Length of Stay (Days) National Average Payment** 957 Other O.R. for Multiple Significant Trauma w MCC 14.0 $40, Other O.R. for Multiple Significant Trauma w CC 8.8 $22, Other O.R. for Multiple Significant Trauma w/o CC/MCC 5.7 $14, DIAPHRAGMATIC HERNIA 163 Major Chest w MCC 13.2 $29, Major Chest w CC 6.6 $15, Major Chest w/o CC/MCC 3.9 $10, Stomach, Esophageal and Duodenal w MCC 14.5 $31, Stomach, Esophageal and Duodenal w CC 7.8 $15, Stomach, Esophageal and Duodenal w/o CC/MCC 3.4 $8, ENTEROLYSIS 335 Peritoneal Adhesiolysis w MCC 13.2 $25, Peritoneal Adhesiolysis w CC 8.3 $13, Peritoneal Adhesiolysis w/o CC/MCC 5.0 $9, EPIGASTRIC HERNIA 353 Hernia Except Inguinal & Femoral w MCC 8.3 $17, Hernia Except Inguinal & Femoral w CC 5.0 $9, Hernia Except Inguinal & Femoral w/o CC/MCC 3.2 $7, FEMORAL HERNIA 350 Inguinal & Femoral Hernia w MCC 7.6 $14, Inguinal & Femoral Hernia w CC 4.4 $8, Inguinal & Femoral Hernia w/o CC/MCC 2.5 $5, INCISIONAL/VENTRAL HERNIA 353 Hernia Except Inguinal & Femoral w MCC 8.3 $17, Hernia Except Inguinal & Femoral w CC 5.0 $9, Hernia Except Inguinal & Femoral w/o CC/MCC 3.2 $7, INGUINAL HERNIA 350 Inguinal & Femoral Hernia w MCC 7.6 $14, Inguinal & Femoral Hernia w CC 4.4 $8, Inguinal & Femoral Hernia w/o CC/MCC 2.5 $5, LUMBAR HERNIA 353 Hernia Except Inguinal & Femoral w MCC 8.3 $17, Hernia Except Inguinal & Femoral w CC 5.0 $9, Hernia Except Inguinal & Femoral w/o CC/MCC 3.2 $7, PARACOLOSTOMY HERNIA 347 Anal and Stomal w MCC 8.7 $15, Anal and Stomal w CC 5.1 $8, Anal and Stomal w/o CC/MCC 3.0 $5, PARAESOPHAGEAL HERNIA 133 Other ear, nose, mouth and throat O.R procedure w CC/MCC 5.4 $10, Other ear, nose, mouth and throat O.R procedure w/o CC/MCC 2.4 $5, Major Chest w MCC 13.2 $29, Major Chest w CC 6.6 $15, Major Chest w/o CC/MCC 3.9 $10, Stomach, Esophageal and Duodenal w MCC 14.5 $31, Stomach, Esophageal and Duodenal w CC 7.8 $15, Stomach, Esophageal and Duodenal w/o CC/MCC 3.4 $8,779.28

8 Page 8 of 9 MS-DRG* SPIGELIAN HERNIA MS-DRG Title Arithmetic Mean Length of Stay (Days) National Average Payment** 353 Hernia Except Inguinal & Femoral w MCC 8.3 $17, Hernia Except Inguinal & Femoral w CC 5.0 $9, Hernia Except Inguinal & Femoral w/o CC/MCC 3.2 $7, TRAM FLAP 582 Mastectomy for Malignancy w CC/MCC 2.9 $7, Mastectomy for Malignancy w/o CC/MCC 1.9 $6, Breast Biopsy, Local Excision and Other Breast w CC/MCC 5.2 $10, Breast Biopsy, Local Excision and Other Breast w/o CC/MCC 2.5 $8, Other O.R. for Injuries w MCC 10.2 $22, Other O.R. for Injuries w CC 5.7 $11, Other O.R. for Injuries w/o CC/MCC 3.3 $7, Other O.R. for Multiple Significant Trauma w MCC 14.0 $40, Other O.R. for Multiple Significant Trauma w CC 8.8 $22, Other O.R. for Multiple Significant Trauma w/o CC/MCC 5.7 $14, UMBILICAL HERNIA 353 Hernia Except Inguinal & Femoral w MCC 8.3 $17, Hernia Except Inguinal & Femoral w CC 5.0 $9, Hernia Except Inguinal & Femoral w/o CC/MCC 3.2 $7, UNLISTED HERNIA 353 Hernia Except Inguinal & Femoral w MCC 8.3 $17, Hernia Except Inguinal & Femoral w CC 5.0 $9, Hernia Except Inguinal & Femoral w/o CC/MCC 3.2 $7, NOTES: *One DRG per patient is assigned to each inpatient stay. REFERENCES: ** FY 2015 Final Rule, Federal Register, Vol. 79, No. 163, Friday, August 22, 2014 and Correction Notice, Federal Register, Vol. 79, No. 192, Friday, October 3, 2014, Table 1A-1E and Table 5. National Average Payment Rate is based upon the National Average Operating Standardized Amount ($5,437.85) plus the Capital Standard Federal Payment Rate ($434.97). SUPPLY CODES HCPCS Code C1726 C1781 C9364 Description Catheter, balloon dilatation, non-vascular Mesh (implantable) Porcine implant, permacol, per square centimeter REFERENCE: CMS 2015 Alpha-Numeric HCPCS File Updated 11/12/2014 *Packaged into Payment for Other Services

9 Page 9 of 9 Disclaimer: The information contained in this guide is provided to help you understand the reimbursement process. It is not intended to increase or maximize reimbursement by any payer. We strongly recommend that providers consult their payer organization with regard to local reimbursement policies. The information contained in this guide is provided for information purposes only and represents no statement, promise or guarantee by Covidien concerning levels of reimbursement, payment or charge. Similarly, all CPT HCPCS and ICD-9-CM codes are supplied for information purposes only and represent no statement, promise or guarantee by Covidien that these codes will be appropriate or that reimbursement will be made. ICD-9-CM is based on the official version of the World Health Organization s Ninth Revision, International Classification of Diseases. CPT codes and descriptions only are copyright 2013 American Medical Association. All rights reserved. CPT does not include fee schedules, relative values or related listings. The source for this information is the Centers for and Medicaid Services (CMS). Reimbursement rates reflected in this guide are National Average rates as published by CMS at the time of printing, and do not reflect provider payment adjustment factors such geographic adjustment, participation as a Disproportionate Share or Teaching Hospital, participation in the CMS Shared Service (ACO) program, or Value Base Purchasing adjustments. The content provided by CMS is updated frequently. It is the responsibility of the health services provider to confirm the appropriate coding required by their local Administrative Contractors (MACs), carriers, fiscal intermediaries and commercial payers. All Current Procedural Terminology (CPT) five-digit numeric codes, descriptions, numeric modifiers, instructions, guidelines and other material are copyright 2014 American Medical Association. All rights reserved. Code associations and values have been reviewed and validated by NMD Healthcare, Inc. COVIDIEN, COVIDIEN with logo, Covidien logo and positive results for life are U.S. and internationally registered trademarks of Covidien AG. * Trademark of its respective owner Covidien US ref# Longbow Drive Boulder, CO [t] [us]