Policy Statement
Our health plan may review documentation, including, but not limited to, itemized bills, invoices, and medical records, to determine whether items reported with implant revenue codes meet our health plan’s definition of an implantable device. Our health plan requires providers to make such documentation available to our health plan upon request. Contracted providers will be expected to comply with documentation requests per provider contract. Our health plan does not reimburse an implant revenue code if the item does not satisfy our health plan’s definition of an implantable device.
When supplying an invoice, units must be clearly indicated on the manufacturer’s invoice to be considered for reimbursement.
Fees such as shipping and handling will not be reimbursed unless specified in the provider's contract.
For claims with case rate reimbursement methodology at the time of service, implants and implant components implanted and remaining in the patient are not eligible for separate reimbursement.
For claims paid to any other reimbursement methodology, implants and implant components implanted and remaining in the patient will be paid according to the stipulations of the contract our health plan has with the provider at the time of service.
Notwithstanding the above, implant and implant components are not eligible for reimbursement when:
- Implants or implant components are opened and then found to be incorrect and not used.
- Implants, implant components that are inadvertently dropped from the sterile field and cannot be used again.
- Implants or implant components that are implanted then removed (e.g., implant screw removed and replaced when the wrong length of screw is used on a plate).
- Implants or implant components that malfunction and are replaced during implantation.
- Provisional or temporary implants removed during the operative session.
- Implant procedure code when billed without an implant device procedure code.
Medical, surgical, diagnostic, and implant supplies are an integral part of the procedure and included in the surgical room or operating room charge and anesthesia charges; except as otherwise provided in this policy, are not eligible for other reimbursement.
Examples of such supplies that are not eligible for reimbursement (outside of the reimbursement for the surgical room/OR charge) include, but are not limited to, the following:
- Specialized implant placement instruments (e.g., Forceps, scissors, needle holders or other instruments)
- Specialized drill bits, saw blades and others.
- Anesthesia supplies
- Monitoring supplies (e.g., temperature, EKG leads, BP cuffs, O2 saturation monitors, catheters)
- OR packs, procedural trays
- Gowns (surgical and patient), surgical gloves
- Skin prep, towels, drapes
- Surgical instruments, including forceps, scissors, needle holder or other instruments whether or not reusable.
- Needles (sterile), syringes, dressings, gauze, tape
- Intravenous supplies
- Heparin, saline flushes and any type of IV flush or diluent to administer substances or drugs
- Suction/irrigation supplies and additives
- Vascular clips, hemostasis agents (e.g., Flowseal®)
- Staplers (surgical), staples, sutures and skin glue
- Casting and splinting supplies
- Leg compression system
- Guide wires, introducers, catheters
For a medical, surgical, diagnostic, and implant supply to be eligible for separate reimbursement outside of the reimbursement for the surgical room/OR charge, our health plan must determine that the following criteria are met:
- Customized for the individual patient
- Specific documentation and rationale to support the need for customization.
- Not reusable or representative of the cost for each preparation.
References
Cross References
- Adm 101 - Global Days
- Fac 103 - Reimbursement of Facility Room and Board
- Fac 105 - Reimbursement of Chest X-Rays and Radiologic Guidance for Facilities
