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__ 16 <strong>PRESTIGE</strong>® Cervical Disc | REIMBURSEMENT GUIDE Section 4: Inpatient Reimbursement continued Sample UB-04 Claim Form __ __ __ 1 2 3a PAT. CNTL # 4 TYPE OF BILL b. MED. REC. # 5 FED. TAX NO. 6 STATEMENT COVERS PERIOD 7 FROM THROUGH 011X 8 PATIENT NAME a 9 PATIENT ADDRESS a b b c d 10 BIRTHDATE 11 SEX ADMISSION CONDITION CODES 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 29 ACDT 30 17 STAT 18 19 20 21 22 23 24 25 26 27 28 STATE e 31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37 CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH Locator 42: Enter 38 appropriate 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES revenue codes for all services provided b c CODE AMOUNT CODE AMOUNT CODE AMOUNT a d 1 2 42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 278 SUPPLY/IMPLANTS XX XXXX XX 1 2 3 4 5 6 7 Locator 43: Enter revenue center code descriptions Locator 47: Enter your charges 3 4 5 6 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 23 50 PAYER NAME PAGE OF 51 HEALTH PLAN ID CREATION DATE TOTALS 52 REL. 53 ASG. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI INFO BEN. 23 A 57 A B OTHER B C PRV ID C 58 INSURED’S NAME 59 P.REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO. A Locator 67: B Enter appropriate primary and C 63 TREATMENT AUTHORIZATION CODES secondary A B diagnosis codes 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME A B C A B C 722.71 A B C D E F G H I J K L M N O P Q a b c 66 DX 67 69 ADMIT 70 PATIENT 71 PPS 72 73 DX REASON DX CODE ECI 74 PRINCIPAL PROCEDURE a. OTHER PROCEDURE b. OTHER PROCEDURE 75 CODE DATE CODE DATE CODE DATE 76 ATTENDING NPI QUAL 8462 XXXXX LAST FIRST c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE CODE DATE CODE DATE CODE DATE 77 OPERATING NPI QUAL LAST FIRST 81CC 80 REMARKS a 78 OTHER NPI QUAL Locator 74: b LAST FIRST Enter appropriate principal and other c 79 OTHER NPI QUAL procedure codes UB-04 CMS-1450 APPROVED OMB NO. THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. d LAST FIRST National Uniform NUBC Billing Committee LIC9213257 68 C
<strong>PRESTIGE</strong>® Cervical Disc | REIMBURSEMENT GUIDE 17 Section 5: Outpatient Reimbursement Outpatient Coding and Payment HCPCS Codes and Ambulatory Payment Classification (APC) Assignment Facilities use HCPCS codes to report outpatient services. Under Medicare’s methodology for facility outpatient payment, each HCPCS code is assigned to one Ambulatory Payment Classification (APC). Each APC has a relative weight that is multiplied by a conversion factor to determine the facility payment. An APC and payment amount are assigned to each significant service. Although some services are bundled and not separately payable, total payment to the facility is the sum of the APC amounts for the services provided during the outpatient encounter. Many payers use Medicare’s APC methodology or a similar type of fee schedule to reimburse facilities for outpatient services. Other payers use a percent of charges mechanism, depending on their contract with the hospital. CPT Description APC 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical Status Indicator Relative Weight CY'14 Medicare Payment 0208 T 55.0874 $4,003.31 Source: CY 2014 Medicare Outpatient Prospective Payment and Ambulatory Surgery Center Payment Systems, Final Rule. Federal Register, December 10, 2013. Status Indicators Each HCPCS code in the Outpatient Prospective Payment System (OPPS) is assigned a status indicator to signify whether a discount (payment reduction) applies to the respective APC payment. The following status indicator is assigned to this procedure: T Significant Procedure, Multiple Reduction Applies Bill Type Codes 013X Hospital Outpatient 083X Hospital Outpatient (ASC) Revenue Center Codes 0360 Operating Room Services 0278 Medical/Surgical Supplies: Other Implants Coverage of Cervical Disc Arthroplasty in the Hospital Outpatient Setting As of January 1, 2013, Medicare will now cover cervical disc arthroplasty (22856) in the outpatient setting. Prior to 2013, this procedure was limited to inpatient services. Commercial payers may allow for the procedure to be performed in this setting. Hospitals should contact the payer and review their payer contracts to ensure coverage and payment for this procedure in the outpatient setting. Coverage of Cervical Disc Arthroplasty in the Ambulatory Surgery Center (ASC) Setting Cervical disc arthroplasty (22856) is not listed on Medicare’s Ambulatory Surgery Center List of Covered Procedures, meaning it is not covered in this setting. Commercial payer coverage policies may differ; therefore, the provider should contact the appropriate payer to verify coverage and payment. Outpatient Reimbursement
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