Sample Reimbursement Cases
Sample Reimbursement Cases Final coding determinations are always the decision of the health service provider; it is the responsibility of the health service provider to confirm the appropriate coding required by their local Medicare Carriers, Fiscal Intermediaries and commercial payors. Case 1: Open Initial Ventral Hernia Repair (without CC/MCC) using Permacol™ Biologic Implant HCPCS/ CPT Codes ICD-9 Procedure Code Physician Professional ASC APC Description Rate MS-DRG Rate Repair initial incisional or ventral hernia: incarcerated or strangulated 49561 53.61 $838 $1,292 154 Hernia/ Hydrocele Procedures $2,092 355* $5,357 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair +49658 $250 $562 (50%) 154 Hernia/ Hydrocele Procedures $1,046 (50%) 9364 Porcine Implant, Permacol, per sqcm $18.57/ sqcm Porcine Implant, Permacol, per sqcm Hospital Outpatient $18.57/ sqcm C9364^ Hospital Inpatient Case 2: Open Initial Ventral Hernia Repair (with MCC) Using Parietex™ Mesh HCPCS/ CPT Codes ICD-9 Procedure Code Physician Professional ASC APC Description Rate MS-DRG Rate Repair initial incisional or ventral hernia: incarcerated or strangulated 49561 53.61 $838 $1,292 154 Hernia/ Hydrocele Procedures $2,092 353* $13,804 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair +49658 $250 $562 (50%) 154 Hernia/ Hydrocele Procedures $1,046 (50%) Mesh Implantable C1781 Mesh Implantable N Hospital Outpatient N1 *Actual MS-DRG Classification subject to ICD Diagnosis. ^Effective 7/1/09 Permacol is assigned to C9364; Porcine Implant, Permacol, per square centimeter. 1 Hospital Inpatient Sample Reimbursement Cases Case 3: Repair incarcerated or strangulated recurrent inguinal hernia, any age (with CC) indirect, using Parietex™ Mesh HCPCS/ CPT Codes ICD-9 Procedure Code Physician Professional ASC APC Description Rate MS-DRG Rate Repair incarcerated or strangulated recurrent inguinal hernia, any age 49521 53.04 $690 $1,292 154 Hernia/ Hydrocele Procedures $2,092 351* $6,995 Mesh Implantable C1781 Mesh Implantable N Hospital Outpatient N1 Hospital Inpatient Case 4: Laparoscopic surgical repair of incisional hernia, incarcerated or strangulated (without CC/MCC) using Permacol™ Biologic Implant Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion when performed) incarcerated of strangulated Porcine Implant, Permacol, per sqcm HCPCS/ CPT Codes ICD-9 Procedure Code Physician Professional ASC APC Description Rate MS-DRG Rate 49561 53.61 $838 $1,292 154 Hernia/ Hydrocele Procedures $2,092 355* $5,357 C9364^ Hospital Outpatient $18.57/ sqcm 9364 Porcine Implant, $18.57 / Permacol, per sqcm sqcm *Actual MS-DRG Classification subject to ICD Diagnosis. ^Effective 7/1/09 Permacol is assigned to C9364; Porcine Implant, Permacol, per square centimeter. 2 Hospital Inpatient Sample Reimbursement Cases Case 5: Laparoscopic surgical repair of inguinal hernia (without CC/MCC) indirect, using Parietex™ Mesh HCPCS/ CPT Codes ICD-9 Procedure Code Physician Professional ASC APC Description Rate MS-DRG Rate Laparoscopy, surgical, repair, recurrent inguinal hernia 49651 17.12 $493 $1,420 131 Level II Laparoscopy $2,900 352* $4,507 Mesh Implantable C1781 Mesh Implantable N Hospital Outpatient N1 Hospital Inpatient Case 6: Laparoscopic surgical repair of incisional hernia, incarcerated of strangulated (with CC) using Permacol™ Biologic Implant Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion when performed) incarcerated of strangulated Porcine Implant, Permacol, per sqcm HCPCS/ CPT Codes ICD-9 Procedure Code Physician Professional ASC APC Description Rate MS-DRG Rate 49655 53.62 $990 $1,592 130 Level I Laparoscopy $2,503 354* $7,785 9364 Porcine Implant, Permacol, per sq cm $18.57/ sqcm C9364^ Hospital Outpatient $18.57/ sqcm *Actual MS-DRG Classification subject to ICD Diagnosis. ***Check with local Medicare Carrier or commercial payor regarding appropriate coding for multiple procedures. ^Effective 7/1/09 Permacol is assigned to C9364; Porcine Implant, Permacol, per square centimeter. 3 Hospital Inpatient Sample Reimbursement Cases Case 7: Component Separation Technique (Other Digestive System O.R. Procedures with MCC) using Permacol™ Biologic Mesh – Inpatient Procedure HCPCS/ CPT Codes ICD-9 Procedure Code Physician Professional ASC APC Description Rate MS-DRG Cutting and preparation of pedicle grafts or flaps 15734** 86.71 $1,241 NA NA NA NA 356* Acellular xenograft implant, graft first 100 sqcm or less (add-on code to 15431) 15430 $454 NA NA NA NA Acellular xenograft implant, graft each additional 100 sqcm or less 15431 NA for Medicare, possible commercial payment NA NA NA NA Porcine Implant, Permacol, per sq cm C9364^ NA NA NA NA Hospital Outpatient *Actual MS-DRG Classification subject to ICD Diagnosis. **Check with local Medicare Carrier or commercial payor regarding appropriate coding for multiple procedures. ^Effective 7/1/09 Permacol is assigned to C9364; Porcine Implant, Permacol, per square centimeter. 4 Hospital Inpatient Rate $21,417 NA for Medicare, possible commercial payment Sample Reimbursement Cases Case 8: Transverse rectus abdominis myocutaneous (TRAM) flap, pedicled (w/ CC/MCC) using Permacol™ Biologic Mesh – Inpatient Procedure HCPCS/ CPT Codes ICD-9 Procedure Code Physician Professional ASC APC Description Rate MS-DRG Rate Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single pedicle, including closure of donor site; with microvascular anastomosis (supercharging) 19368 85.72 $2,089 NA NA NA NA 584* $7,956 Acellular xenograft implant, graft first 100 sq CM or less 15430 $454 NA NA NA NA 15431 NA for Medicare, possible commercial payment NA NA NA NA NA NA NA NA Acellular xenograft implant, graft first 100 sq CM or less (add-on code to 15431) Porcine Implant, Permacol, per sq cm C9364^ Hospital Outpatient Hospital Inpatient NA for Medicare, possible commercial payment *Actual MS-DRG Classification subject to ICD Diagnosis. ^Effective 7/1/09 Permacol is assigned to C9364; Porcine Implant, Permacol, per square centimeter. >Note the appropriate Inpatient MS-DRG classification is dependent on the diagnosis code, demographics, sex, and possible co-conditions. >Reimbursement rates shown are National Average (wage index=1), and for hospitals submitting qualifying quality data. >National average weights for hospitals not submitting qualifying quality data are approximately 1.8% less. >Rates shown do not consider hospital specific status as DSH, SCH, IME adjustment, etc. COVIDIEN and COVIDIEN with Logo are trademarks of Covidien AG. © 2009 Covidien. 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