Zimmer Patient Specific Instruments Reimbursement Guide Market Access

Transcription

1 Zimmer Patient Specific Instruments Reimbursement Guide Market Access Effective September 1, 2012

2 Zimmer Patient Specific Instrumentation Zimmer Patient Specific Instruments (PSI) streamline total knee replacement surgery by ensuring accurate and reproducible guide fixation. Our proprietary stabilizing feature enhances guide fixation while ensuring the end surgical result matches your preoperative plan. Based on the patient s MRI, mechanical axis-based pin guides conform precisely to the patient s anatomy. Zimmer Patient Specific Instruments simplify the total knee process from start to finish without compromising your surgical decision making, surgical technique, or intraoperative flexibility. In addition, the Zimmer Patient Specific Instruments Planner software is available for the Zimmer Unicompartmental High Flex Knee System. This next generation in surgical planning allows for pre-operative views of the patient s knee anatomy to develop a custom and personalized surgical plan for each unique patient. PAYER COVERAGE Coverage defines what services and procedures payers will reimburse. Coverage is usually described in medical policies, and is payer-specific. Payers may have different coverage policies for the same procedure. Each payer makes its own coverage policies. Total knee arthroplasty (TKA) and unicompartmental knee replacement (UKR), for advanced medial, lateral, or patellofemoral compartment joint disease are widely accepted procedures that most payers cover. When Zimmer Patient Specific Instruments are utilized during a TKA or UKR, they becomes an integral part of the surgical procedure that should not require special payer coverage consideration beyond that normally required for the TKA or UKR procedure itself. However, coverage will likely need to be evaluated for the pre-operative MRI required to use Zimmer Patient Specific Instruments. Coverage policies can vary by payer, and providers should contact payers directly to clarify coverage policies and medical guidelines. Similarly, prior authorization requirements for TKA, UKR, or imaging services can vary by payer, so providers should also contact their payers directly for information specific to their prior authorization requirements. Should a payer establish a non-coverage policy for TKA, UKR, or the pre-operative MRIs, it may still be possible to obtain coverage on a case-by-case basis. A clinical determination of medical necessity will be required of the healthcare professional (HCP), and might necessitate peer-to-peer discussions between the treating physician and the payer s medical director. Pre-Operative Scans The first scan may be acquired for a gross overview of the patient s anatomy; essentially a diagnostic scan that is ordinarily billable assuming formal interpretation is made with generation of a form imaging report. If the patient has diagnostic findings on the first scan and is a surgical candidate a scan with much greater detail may be needed. If a second scan is taken for diagnostic purposes and a formal interpretation is made with generation of a formal imaging report, that substantiates separate coding and billing. However, if the second scan is taken only for the purpose of the PSI, that would be considered integral and should not be separately coded or billed. Current Procedural Terminology (CPT ) copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 2

3 Zimmer Patient Specific Instrumentation CODING REFERENCE GUIDE PHYSICIAN CODING CPT Code CPT Description Arthroplasty, patella; with prosthesis Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) Revision of total knee arthroplasty, with or without allograft; 1 component Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component OUTPATIENT HOSPITAL AND FREE-STANDING ASC CPT Code CPT Description OPPS Status Indicator APC Group Arthroplasty, patella; with prosthesis T 0048 A Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) Revision of total knee arthroplasty, with or without allograft; 1 component Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component T 0425 J8 C NA C5 C NA C5 C NA C5 Ambulatory Surgery Center Payment Indicator Status indicators (T) Multiple procedure reductions apply; (C) Inpatient procedure Payment indicators (A2) Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight; (C5) Inpatient Procedures; (J8) Device-intensive procedure; paid at adjusted rate. NA Medicare has not developed a rate for the In-Office setting as the procedure is typically performed in the hospital setting. HOSPITAL PROCEDURE CODING ICD-9 Code ICD-9 Description Revision of knee replacement, total (all components) Revision of knee replacement, tibial component Revision of knee replacement, femoral component Revision of knee replacement, patellar component Revision of total knee replacement, tibial insert (liner) Other repair of knee Total knee replacement Current Procedural Terminology (CPT ) copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 3

4 HOSPITAL INPATIENT CODING MS-DRG MS-DRG Description 461 Bilateral or Multiple Major Joint Procedures of Lower Extremity with MCC 462 Bilateral or Multiple Major Joint Procedures of Lower Extremity without MCC 466 Revision of Hip or Knee Replacement with MCC 467 Revision of Hip or Knee Replacement with CC 468 Revision of Hip or Knee Replacement without CC/MCC 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC 485 Knee Procedures with Principal Diagnosis of Infection with MCC 486 Knee Procedures with Principal Diagnosis of Infection with CC 487 Knee Procedures with Principal Diagnosis of Infection without CC/MCC 488 Knee Procedures without Principal Diagnosis of Infection with CC/MCC 489 Knee Procedures without Principal Diagnosis of Infection without CC/MCC CC Complications and/or comorbidities, MCC Major Complications and/or comorbidities PHYSICIAN QUALITY REPORTING SYSTEM (PQRS): #20 - Perioperative Care: Timing of Antibiotic Prophylaxis - Ordering Physician #21 - Perioperative Care: Selection of Prophylactic Antibiotic - First OR Second Generation Cephalosporin #22 - Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac Procedures) #23 - Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients) IMAGING PROCEDURE CODES CPT Code CPT Description Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation 4

5 SPECIALTY SOCIETY GUIDANCE American College of Radiology (May/June 2009 ACR Radiology Coding Resource Q & A): Question: An orthopedic surgeon ordered an MRI of the knee for use in prosthetic design and for the design of custom cutting jigs. An interpretation is not necessary. However, the hospital requires that the radiologist render an interpretation. Is it appropriate for the radiologist to report the professional component of the MRI study when an interpretation is rendered? When magnetic resonance imaging (MRI) scans of the knee are performed and exported for prosthesis design and/or for the design of custom cutting jigs without a request for an interpretation, it would be appropriate for the entity that owns the equipment to report only the technical component of CPT code 73721, 73722, or (Magnetic Resonance Imaging, any joint of the lower extremity) based on whether or not contrast was administered. In this scenario, no professional component (PC) should be charged. If, however, an interpretation of the study is requested, and the medical necessity of the procedure is substantiated with an order from the referring physician, then the professional component of the appropriate CPT code ( ) should be reported by the radiologist that renders the interpretation. Current Procedural Terminology (CPT ) copyright 2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 5

6 Zimmer Reimbursement Hotline Phone: Fax: Available Monday Friday, 8 a.m. 5 p.m. EST The Zimmer Reimbursement Hotline is a support hotline staffed by reimbursement specialists including a certified coder to answer questions regarding coding and reimbursement. The Zimmer Reimbursement Hotline is designed to assist health care providers and their staff by providing reimbursement assistance for Zimmer technologies. The Zimmer Reimbursement Hotline can assist in the following areas: Share insurance guidelines for commercial and government health programs Assist providers on payer specific claims submission requirements Evaluate claim denial reasons and provide assistance with appeals. Provide published CMS fee schedules and payment process methodologies Provide coding information specific to payer requirements and coding guidelines The Zimmer Reimbursement Hotline cannot: Submit a claim Guarantee coverage or specific payment level Complete Medical Necessity documentation on behalf of the prescribing physician Submit an appeal Represent a provider during appeals process with payers Recommend what providers charge for Zimmer products Tell the provider what codes should be used to maximize reimbursement Disclaimer THE INFORMATION PRESENTED IN THIS REIMBURSEMENT GUIDE IS INTENDED FOR INFORMATIONAL PURPOSES ONLY, AND NOTHING HEREIN IS ADVICE, LEGAL ADVICE OR A RECOMMENDATION OF ANY KIND, AND IT SHOULD NOT BE CONSIDERED AS SUCH. THE CODING AND COVERAGE INFORMATION IN THIS REIMBURSEMENT GUIDE WAS OBTAINED FROM THIRD PARTY SOURCES AND IS SUBJECT TO CHANGE WITHOUT NOTICE, INCLUDING AS A RESULT IN CHANGES IN REIMBURSEMENT LAWS, REGULATIONS, RULES, AND POLICIES. REIMBURSEMENT GUIDE CONTENT IS INFORMATIONAL ONLY, GENERAL IN NATURE, AND DOES NOT COVER ALL SITUATIONS OR ALL PAYERS RULES OR POLICIES, AND IS NOT INTENDED TO APPLY TO ANY PARTICULAR SITUATION. 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 PATIENT S MEDICAL CONDITION, PROCEDURES PERFORMED, AND THE PRODUCTS USED. THE INFORMATION PRESENTED IN THIS REIMBURSEMENT GUIDE REPRESENTS NO PROMISE OR GUARANTEE FROM ZIMMER 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, THE APPLICABLE MEDICARE ADMINISTRATIVE CONTRACTOR, OR TO APPROPRIATE PAYERS. ZIMMER SPECIFICALLY DISCLAIMS LIABILITY OR RESPONSIBILITY FOR THE RESULTS OR CONSEQUENCES OF ANY ACTIONS TAKEN IN RELIANCE ON INFORMATION PRESENTED IN THIS REIMBURSEMENT GUIDE. ADDITIONALLY, THE INFORMATION PROVIDED IN THIS REIMBURSEMENT GUIDE SHOULD NOT BE MISCONSTRUED AS ADVERTISING OR PROMOTION. ZIMMER NEITHER PROMOTES NOR ADVOCATES OFF-LABEL USE OF ANY ZIMMER PRODUCT. PLEASE CONSULT THE PRODUCT LITERATURE SUPPLIED WITH ZIMMER PRODUCTS TO DETERMINE INTENDED USE. This Reimbursement Guide is effective September 1, Zimmer, Inc. 11/30/2012 LL 6