expect, declined by 70% once facilities could no longer bill for the
post-surgical anesthetic with an average wholesale price of $285 for a
20-mL vial. Now, however, as an incentive for using non-opioid pain
medications, Medicare will provide separate reimbursement for
Exparel when it is administered in ASCs (yes, surgery centers only).
For the 20-mL (266 mg) dose, the allowed amount for reimbursement
is $319.20. For the 10-mL (133 mg) dose, the allowed amount for reim-
bursement is $159.60. Imagine the losses you'd incur if your coder did-
n't know to use C9290 to bill for Exparel.
You'll also want to look at your Category III codes, a set of tempo-
rary codes used for data-collection purposes with emerging technolo-
gy, services and procedures. One example is 0474T, the code for
inserting an anterior segment aqueous drainage device. Without expla-
nation, Medicare will no longer reimburse for this code. If your sur-
geon inserts an anterior segment aqueous drainage device, CMS will
assign an E5 payment status indicator to that 0474T code. The indica-
tor states that the procedure is a "surgical procedure/item not valid
for Medicare purposes because of coverage, regulation and/or statute;
no payment."
If you didn't know about this Medicare policy change, it's possible
you'd go months before you realized you're not getting paid for this
procedure. In this example, not only would you lose out on the rev-
enue from the procedures, but you'd also be on the hook for the
$2,040 drainage device.
Upcoding new technologies. Be skeptical when vendor reps of
new minimally invasive technology say you can apply more
extensive CPT codes. Let's say a physician inserts an implant for nasal
vestibular lateral wall stenosis. A rep might tell you it's OK to code
with the higher-paying CPT code of 30465, which is for a full repair of
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