Coding Accuracy Critical to Ensure Reimbursement for New Medical Technology

by | Last updated Dec 13, 2023 | Published on Sep 12, 2017 | Medical Coding

Critical Reimbursement
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In recent years, several new technologies have made difficult medical conditions easier to treat and manage. However, experts caution that physicians adopting/advocating advanced tools should be mindful about reimbursement. A recent article in Becker’s ASC Review recommends that surgery centers seek help from a medical coding company to thoroughly review CPT descriptions of new tools or procedures before use to determine their compliance and financial impact.

Innovative wearable devices help maximize the independence and participation of people with disabilities. Wearable sensors have diagnostic and monitoring applications. According to a recent report in The Next Web, smart motion sensing devices are helping PTs improve patient outcomes with benefits such as remote access and more data. Robotic surgical platforms, new implants, and innovative instruments are revolutionizing surgery. Since 1970, CPT codes are updated on annually based on changes in medical and surgical procedures and technological advances. In order to receive a code, a new procedure or technology must first satisfy certain criteria. It should:

  • Be done by a reasonable number of the specialty that presents the code
  • Be performed at reasonable frequency
  • Be adopted throughout the country
  • Have peer-reviewed literature supporting its value

FDA approval may also be important.

As the North American Scientists Associates (NAMSA) points out reimbursement is one of the main elements driving the development of a new product. Coverage, coding and payment are three independent pillars of reimbursement. Typically, medical manufacturers would notify the American Medical Association (AMA) about their intention to release a new product or procedure so as to develop a Category III code that can be put in place for up to five years. Subsequently, the product/procedure can be moved into Category I codes if it is established that there is sufficient use. However, as technology moves very faster, old codes are often reassigned to address the issue. Vendors may provide reimbursement information when marketing a new technology. Physicians can lose revenue if the CPT codes are not approved for the product or procedure. Experts say that physicians can avoid such concerns by paying attention to the following points before they use new technology:

  • Be wary of unlisted codes used in marketing material: Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. Unlisted and miscellaneous codes are used when submitting claims for these procedures. Unlisted and miscellaneous codes do not provide comprehensive information about the service or item being billed. For instance, unlisted codes used in orthopedics include:
    • 27599 Unlisted procedure, femur or knee
    • 29999 Unlisted procedure, arthroscopy
    • 27899 Unlisted procedure, leg or ankle

    Vendors of new medical products/procedures often use unlisted codes in their marketing material. An unlisted procedure code or Not Otherwise Classified (NOC) code should have a concise description of the services rendered, or else they will br rejected. Therefore, the codes that vendors provide should be examined to ensure that it properly matches the new technology or procedure, and that all new tools and procedures are linked to documented codes. Physicians need to ask their medical coding service provider to verify if the vendor is providing accurate coding and reimbursement information.

  • Assess CPT descriptions: The starting point of a good reimbursement plan is an assessment of whether or not the product or service is currently described in any existing Current Procedural Terminology (CPT) code. Before approving a new procedure, the surgeon should determine what the payer will be charged and how much will be reimbursed.
  • Review the contract: A thorough understanding of payer contract language and vendor information is crucial for accurate medical billing. In most cases, marketing materials of device manufacturers will have a disclaimer that they are not liable for coding errors. To ensure adequate coverage and reimbursement, physicians need to review the contract with the insurance company, and modify it if the proper language, terminology, or matching CPT codes are not included. They should also ask vendors for supporting information from the AMA or specialty associations. Payers should be asked if they consider the new product or procedure “investigational” or “experimental,” as this can affect payment.

Physicians are always looking to take advantage of medical advances in information technology and related fields. While new technologies that hold great promise to improve diagnostics and monitoring are flooding the market every day, FDA approval, clinical trial outcomes data, the presence of appropriate coding and payment levels are vital for reimbursement of new products and procedures.

Knowledge of physician reimbursement and coding as well as payer coverage decisions is critical to maximizing practice income. The support of an experienced medical billing and coding company can prove invaluable to ensure compliance and navigate the challenges of implementing new technologies.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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