Wiki Reimbursement for Surgical Tray (A4550)

Create Wiki
A

ABridgman

Guest
Messages
107
Best answers
0
Curious if anyone knows if and what Medicare and other payers will reimburse for this code, I can't find an answer anywhere.

I am cross-posting this question from another thread about Testopel Insertion....because A4550 has uses beyond just that procedure, so the answer might be useful to others.

I have begun to think about just billing a 99070 and include an invoice....for all the things on a surgical tray....since I can't seem to determine IF or WHAT Medicare will pay for surgical trays.
 
There are no RVU's for 99070 and Medicare bundles the surgical trays with the procedure code reported. The code A4550 is also bundled with the procedure codes reported, according to Medicare.
 
That is what I was afraid of.

I have a provider who is desperately trying to get reimbursed for this...he claims he is losing money on this procedure, because Medicare does not pay enough to cover the cost of the pellets.

I have NO IDEA how much he is paying for them.

I was looking for any way I could offset any expense possible.

So the Surgical Tray A4550 would be bundled with the 11080 insertion code, and not paid seperately...considered as part of the 11080, right?
 
If you are billing Testopel to Medicare, I believe you are not billing it correctly. The administration code for Testopel to medicare is 11980. You would then report the HCPCS code J3490 for the pellets. The NDC # must be indicated in the record, and Loope 2410 for EDI claims, or box 19 of the HCFA. You will want to report a total unit of only 1 for the J3490. Whatever the provider paid out of his pocket for the pellets, you will charge that fee on the J3490 code.
I coded and billed for a Urology clinic for many years and never had trouble getting reimbursement for the providers. Hope this helps.
 
Yes, Missy, THAT does help!!

I was trying to figure a way to get this provider paid for his services, such that he would not be losing money on the pellets...which he claimed he was.

I will use this information - I had thought we used 5 units when five pellets were inserted.

So we use just one unit....and bill actual cost?
And Medicare will pay that amount?

This same doctor also does estrogen pellets for women. But it was the Testopel, specifically, that he said he was losing money on.
 
When you bill the Testopel to Medicare, you are going to bill the amount the provider paid out of pocket for the pellets. Then, in box 19 you are going to report the NCD number, then the letters UNI and the total number of pellets the doctor used for that patient. Medicare will pay for the cost.

Example, in Box 19

NCD123456789UNI5

If you dont indicate in Box 19, the claim will not kick out for a acutal human to process it, and you will only be paid for 1 unit. So make sure you report it correctly, otherwise you will have to call and ask for a re-opening.
 
Thanks, Missy.
That explains the problem.

We did not have the UNI and number of pellets after the NDC Code in box 19, thus it did not kick to a human being to process.

I had thought that indicating the number of units along with the NDC in Loop 2410 was sufficient....and that only the NDC number itself needed to be in Box 19.
 
No, the processors need to know the number of units that were dispensed to the patient, to determine if the billed amount is appropriate.
As an aside, depending on where you are in the US, the provider will be reimbursed for the insertion of the pellets, which in my area is $106.52, and the actual amount of what the provider paid out of his pocket for the pellets.
 
Last edited:
You must log in or register to reply here.
Top