FST Reimbursement Flashcards
What is the Patient Eligibility inclusion and exclusion criteria?
Inclusion:
- No age restriction
- Medicare Beneficiary
- Diagnosis of LSS with neurogenic claudication (NC)
Exclusion:
Patients who have received a laminectomy, laminotomy, fusion, interspinous process decompression, or mild in the lumbar region during the 12 months prior to the index date
What is the CPT code for mild?
0275T
What are 2 good comparison codes to establish work RVUs for mild?
63030 and 62287
Mild is a Catagory III code and is Carrier Priced. What does this mean?
What does it mean for a CPT code to be Category III and Carrier Priced?
Category III codes are temporary codes for emerging technology, services, and procedures. Payments for Category III CPT codes are determined on a case-by-case basis. MACs do not routinely publish payment rates for these codes because many of them require a review of medical records for evaluation and pricing. Each individual MAC and their Medical Directors have discretion on setting reimbursement for mild.
**This why physicians sometimes face difficulty establishing wRVUs and why we provide 63030 and 62287 as benchmark procedures as the MACs crosswalk mild to these other codes when determining reimbursement.**
Is mild covered by Medicare Advantage?
Yes. Mild is covered by all Medicare plan types. Authorization may be required with Medicare Advantage plans.
What 2 diagnosis codes are required by Medicare?
- M48.062 - Spinal stenosis with neurogenic claudication, lumbar region
- Z00.6 - Encounter for examination for normal comparison and control in clinical research program
What is the 2022 national average Medicare Physician, ASC, and Hospital reimbursement?
What is the national average physician Medicare Advantage reimbursement?
$1456
What is the national clinical trial number for the mild Medicare Claims Study?
Clinical Trial Number - 03072927
What modifier does Medicare require on the mild CPT code?
Modifier Q0 (Q-zero) - Investigational clinical service provided in a clinical research study that is in an approved clinical research study
What condition code does Medicare require on mild facility claims?
Condition Code 30 - Qualifying Clinical Trial
Medicare requires hospitals paid under the OPPS to report applicable codes and charges for all devices. Accurate reporting of HCPCS codes and charges for these internal and external device components is necessary so that the OPPS payment for the associated procedures will be correct in future years in which the claims are used to set the APC payment rates.
What is the most appropriate C code for the mild device?
C1889 - (Implantable/insertable device, not otherwise classified)
What is the global period for mild?
90 days
Services that are INCLUDED in the global surgery payment
In addition to the procedure:
- Pre-operative visits after the decision is made to operate.
- Intra-operative services that are normally a usual and necessary part of a procedure.
- All additional medical or surgical services required of the physician during the post-operative period of the procedure due to complications, which do not require additional trips to the operating room.
• Follow-up visits related to recovery from the procedure.
- Post-surgical pain management
- Supplies, except for those identified as exclusions
- Miscellaneous services (e.g., local incision care, removal of sutures)
What type of study is the mild medicare claims study?
Mild is a CMS-approved passive claims analysis study under the coverage with evidence development (CED) program that does not require IRB oversight, patient consent, or prior enrollment.
What place of service (POS) has Medicare approved mild to be performed?
- Outpatient Hospital (POS 22)
- ASC (POS 24)
- Outpatient Hospital -Off Campus (POS 19)
***Physicians office (POS 11) is NOT approved by Medicare***
Who is Pinnacle and what do they do?
