Medical Cost Reimbursement of Medical Devices

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Outline of process and codes for medical cost reimbursement

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Medical Cost Reimbursement of Medical Devices

  1. 1. Medical Cost Reimbursement of Medical Devices Dickson Consulting 351 Old Babcock Trail Gibsonia, PA 15044 724-272-1527 [email_address] www.dicksonconsulting.biz
  2. 2. Overview of Reimbursements <ul><li>Administered by Centers for Medicaid & Medicare (CMS) </li></ul><ul><ul><li>Inpatient Prospective Payment System (IPPS) </li></ul></ul><ul><ul><li>Codes for hospital reimbursement, not doctors </li></ul></ul><ul><li>American Medical Association (AMA) administers codes for reimbursement of physicians </li></ul><ul><li>Other systems for reimbursement-private insurance companies </li></ul>
  3. 3. Types of Codes <ul><li>ICD-international classification of diseases </li></ul><ul><li>DRG’s-diagnosis related groups </li></ul><ul><li>CPT-current procedural terminology </li></ul>
  4. 4. ICD Codes <ul><li>Administered by CMS </li></ul><ul><li>ICD-9-CM diagnostic codes </li></ul><ul><ul><li>A system for the international classification of diseases </li></ul></ul><ul><ul><li>Identify why a patient was provided health care services </li></ul></ul><ul><li>ICD-9-CM procedure codes </li></ul><ul><ul><li>Actual procedures performed by health care providers </li></ul></ul>
  5. 5. Examples of ICD-9-CM Codes <ul><li>ICD-9-CM Diagnostic Codes </li></ul><ul><ul><li>410 Acute myocardial infarction </li></ul></ul><ul><ul><ul><ul><li>410.0 Acute myocardial infarction of anterolateral wall </li></ul></ul></ul></ul><ul><ul><li>411 Other acute and subacute forms of ischemic heart disease </li></ul></ul><ul><ul><ul><ul><li>411.0 Postmyocardial infarction syndrome </li></ul></ul></ul></ul><ul><li>ICD-9-CM Procedure Codes </li></ul><ul><ul><li>37.68 Insertion of percutaneous external heart assist device </li></ul></ul><ul><ul><li>37.22 Left heart cardiac catheterization </li></ul></ul><ul><ul><li>37.65 Implant of external heart assist system </li></ul></ul><ul><ul><li>37.64 Removal of heart assist system </li></ul></ul>
  6. 6. DRG Codes <ul><li>Diagnosis Related Groups=DRG </li></ul><ul><li>New codes effective October 1, 2007 </li></ul><ul><li>New codes based on indication of severity </li></ul><ul><ul><li>MCC=major co-morbidity and complication </li></ul></ul><ul><ul><li>CC=Co-morbidity and complication </li></ul></ul><ul><li>Payments vary based on geographic region, training hospital, etc. </li></ul><ul><li>When more than one procedure is performed reimbursement is based on highest value DRG </li></ul>
  7. 7. Examples of DRG Codes <ul><li>216= Cardiac valve and other major cardiothoracic procedure with cardiac catheterization with MCC </li></ul><ul><li>217= Cardiac valve and other major cardiothoracic procedure with cardiac catheterization with CC </li></ul><ul><li>218= Cardiac valve and other major cardiothoracic procedure with cardiac catheterization without MCC/CC </li></ul><ul><li>1= Heart transplant or implant of heart assist system with MCC </li></ul><ul><li>2= Heart transplant or implant of heart assist system with CC </li></ul><ul><li>215= Other heart assist system implant </li></ul>
  8. 8. CPT Codes <ul><li>Used for payment of physician services </li></ul><ul><li>Determined by the AMA Based on Resource Based Relative Value Scale (RBRVS) </li></ul><ul><li>Cost is divided into three components </li></ul><ul><ul><li>Physician work </li></ul></ul><ul><ul><li>Practice expense </li></ul></ul><ul><ul><li>Professional liability insurance </li></ul></ul><ul><ul><li>Translated into relative value units </li></ul></ul>
  9. 9. Examples of CPT Codes <ul><li>33975= Implantation of single extracorporeal ventricular assist device (VAD) </li></ul><ul><li>33977= Removal of single extracorporeal VAD </li></ul><ul><li>33960= Prolonged extracorporeal circulation for cardiopulmonary insufficiency </li></ul><ul><li>33961= Prolonged extracorporeal circulation for cardiopulmonary insufficiency for each additional 24 hours </li></ul>
  10. 10. Example of Code Application <ul><li>Circulatory assist system is utilized to stabilize a patient in a PCI procedure in a cardiac catheterization laboratory. The reimbursement would be determined as follows: </li></ul><ul><li>Insertion of percutaneous heart assist device: </li></ul><ul><ul><li>ICD-9-CM code = 37.68 </li></ul></ul><ul><ul><li>CPT code = 0048T </li></ul></ul><ul><li>Potential DRG codes: </li></ul><ul><ul><li>DRG 216 (with MCC and CC) </li></ul></ul><ul><ul><li>DRG 217 (with CC) </li></ul></ul><ul><ul><li>DRG 218 (without MCC or CC) </li></ul></ul>
  11. 11. Example of Code Application <ul><li>Multiple facilities are involved or procedures are performed in connection with open heart surgery. </li></ul><ul><li>Patient is transferred from an open heart center to a destination therapy or a transplant center, the transferring facility should receive a per diem derived from the expected DRG payment. </li></ul><ul><li>If a longer term ventricular assist device is implanted or a heart transplant occurs the receiving facility should receive DRG 1 or 2. </li></ul><ul><li>If at the receiving facility, a circulatory assist device is used for the patient in a heart surgery procedure, the circulatory assist device is removed, the patient recovers native heart function and is discharged home, then the receiving facility should receive DRG 1 or 2. </li></ul>
  12. 12. Additional Information From CMS <ul><li>Home page: www.cms.hhs.gov </li></ul><ul><li>Regulations for new codes issued August 1, 2007: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf </li></ul><ul><li>Intermediary-Carrier Directory effective January 1, 2007: </li></ul><ul><li>www.cms.hhs.gov/contractinggeneralinformation/downloads/02_ICdirectory.pdf </li></ul><ul><li>ICD-9 Provider and Diagnostic Codes: www.cms.hhs.gov/ICD9providerdiagnosticcodes/06_codes.asp#topofpage </li></ul>
  13. 13. Additional Information From AMA <ul><li>Home page: www.ama-assn.org </li></ul><ul><li>CPT code information: </li></ul><ul><li>www.ama-assn.org/ama/pub/category/3113.html </li></ul><ul><li>CPT Codebook, Professional Edition </li></ul><ul><li>Physician ICD-9-CM Codebook </li></ul>
  14. 14. Disclaimers <ul><li>This document is for informational purposes only, and is not intended to provide specific instructions on billing for medical procedures. </li></ul><ul><li>Specific insurers should be consulted for their requirements for coding, billing and payments. </li></ul><ul><li>Reliance on this document, does not guarantee that reimbursements will be made in accordance with this document. </li></ul><ul><li>This document is not intended to encourage any healthcare provider to provide services to patients, or utilize any medical device. </li></ul><ul><li>This presentation is not intended to address reimbursement for off-label procedures. </li></ul>

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