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Policy No:  125

Originally Created: 03/01/2015

Section: Administrative

Last Reviewed: 03/01/2019

Last Revised: 03/01/2019

Approved: 03/07/2019

Effective:  07/01/2019

The policy applies to inpatient hospitals, outpatient hospitals, ambulatory surgical centers, physicians and other qualified health care professionals.

Definitions

Implant

An object, device or material that is inserted surgically, or embedded via surgical or nonsurgical means, or grafted into the body and remains in the body either indefinitely for prosthetic and/or therapeutic purposes or remains in the body for a temporary or provisional period of time for diagnostic and/or therapeutic purposes. An external fixation device is considered an implant only when a component of the fixation device is implanted and remains in the body.

Implant Components

Implant integral parts (i.e. screws, plates, rods) remaining in the body used in conjunction with the primary implant.

Implant Supplies

Elements (i.e., supplies and/or tools) of implant kits or implant systems used to place or remove implants, but do not remain in the body.

Medical and Surgical Supplies

Medical and/or Surgical supplies that are used as a part of a surgical procedure.

Provisional Implants

An implant which is intended to be placed temporarily or on a short-term basis; that is expected to be removed and replaced with a permanent implant.

Policy Statement

For claims with case reimbursement payment methodology at the time of service, implants and implant components implanted and remaining in the patient will not be considered 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, implants and implant components are not eligible for separate reimbursement when:

  • Implants, 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 (i.e., 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 are removed during the operative session.

Implant supplies are not eligible for separate reimbursement.

Examples of non-reimbursable implant supplies include, but are not limited to:

  • Specialized implant placement instruments (i.e. forceps, scissors, needle holder or other instruments)
  • Specialized drill bits, saw blades and others

Medical and Surgical Supplies for all Surgical Procedures

Notwithstanding the above, medical/surgical supplies that are used as part of the surgical procedure regardless if the procedure is an implant or non-implant procedure are not separately reimbursable.

Unless otherwise specified in the provider agreement, the maximum allowable is intended to include, but is not limited to the following non-reimbursable medical/surgical supplies. This list is not considered all-inclusive:

  • Anesthesia supplies
  • Monitoring supplies (i.e. temperature, EKG leads, BP cuffs, O2 saturation monitors), catheters and stethoscopes
  • Casting and splinting supplies
  • Gowns (surgical and patient), surgical gloves
  • Heparin, saline flushes and any type of IV flush or diluent to administer substances or drugs
  • Intravenous supplies
  • Leg compression system
  • Needles (sterile), syringes, dressings, gauze, tape
  • OR packs, procedural trays
  • Skin prep, towels, drapes
  • Staplers (surgical), sutures and skin glue
  • Suction/irrigation supplies and additives
  • Surgical instruments, including forcepts, scissors, needle holder or other instruments whether or not reusable
  • Vascular clips, hemostatis agents (i.e., Flowseal)
  • Guide wires

References

HCPro, Bill and Charge for Supplies Correctly to Reduce Risk and Minimize Lost Revenue; Just Coding News: Outpatient, January 13, 2010

Medicare Claims Processing Manual, Chapter 14 - Ambulatory Surgical Centers (PDF)

Administrative Manual, Facility Guidelines, ASC Facility Fee Services

Cross References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.