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2020 REIMBURSEMENT GUIDE for Hernia Repair Procedures Using Ovitex® Reinforced Tissue Matrix

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2020 REIMBURSEMENT GUIDE for Hernia Repair Procedures Using Ovitex® Reinforced Tissue Matrix 2020 REIMBURSEMENT GUIDE for Hernia Repair Procedures Using OviTex® Reinforced Tissue Matrix TABLE OF CONTENTS Component Separation Technique and Hiatal Hernia Repair ..............08 Hernia Repair .........................03 Laparoscopic Stoma Procedures .................11 Repair – Hernia ......................06 ICD-10 HCPCS MOD ICD-10 HCPCS MOD CODES CODES CODES $ CODES CODES CODES $ ICD-10ICD-10 HCPCSHCPCS MODMOD CODESCODES CODESCODES CODESCODES $$ ICD-10 HCPCS MOD ICD-10 HCPCS MOD CODES CODES HCPCSCODES Level II Codes$ ............13 CODES ICD-10-PCSCODES CodesCODES ..................14$ Medicare Hospital ICD-10 HCPCS MOD ICD-10 HCPCS MOD Inpatient Payment CODES CODES CODES CODESModifiers ................................CODES CODES13 $ $ (MS-DRG) ................................16 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix OviTex Reinforced Tissue Matrices are implants purposefully designed for hernia and abdominal wall reconstruction that combine biologic and synthetic materials in a unique embroidered construction. OviTex products are intended for use as a surgical mesh to reinforce and/or repair soft tissue where weakness exists. Indications for use include the repair of hernias and/or abdominal wall defects that require the use of reinforcing or bridging material to obtain the desired surgical outcome. OviTex products are available in various shapes, sizes, and configurations to suit surgeon preference and the complexity of the soft tissue repair. The device may be trimmed to a desired shape to further accommodate an individual patient’s requirements. OviTex is compatible with all surgical techniques: open, laparoscopic, and robotic approaches. PHYSICIAN, HOSPITAL OUTPATIENT, AND ASC CODING AND MEDICARE REIMBURSEMENT The following table provides 2020 national average Medicare Physician Fee Schedule (MPFS), Hospital Outpatient Ambulatory Payment Classifications (APC), and Ambulatory Surgery Center (ASC) payment rates for the CPT codes relating to hernia and abdominal repair procedures identified in this guide. Payments will vary by geographic locality. CPT® 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 2 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv Component Separation Technique 15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk (Note: Physicians report bilateral $1,573.87 5055 $2,977.29 $1,504.38 procedures with modifier -50 or with RT & LT) Hernia Repair +11008** Removal of mesh in abdominal wall for infection Excluded From Payment $288.36 — Inpatient Only (List separately in addition to in ASCs for CY 2020 code for primary procedure) 49500 Repair initial inguinal hernia, age 6 months to younger $432.71 5341 $3,109.34 $1,377.21 than 5 years, with or without hydrocelectomy; reducible 49501 Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without $636.26 5341 $3,109.34 $1,377.21 hydrocelectomy; incarcerated or strangulated 49505 Repair initial inguinal hernia, age 5 years or older; $547.48 5341 $3,109.34 $1,377.21 reducible **As with most add-on codes, this code is approved to be used with only certain primary procedures. Please refer to your CPT manual for approved primary procedures. ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 3 ICD-10 HCPCS ICD-10MOD HCPCS ICD-10ICD-10MOD HCPCSHCPCS MODMOD CODES CODES CODESCODES CODES$ CODESCODES CODES$CODES CODESCODES $$ 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv Hernia Repair (continued) 49507 Repair initial inguinal hernia, age 5 years or older; $616.05 5341 $3,109.34 $1,377.21 incarcerated or strangulated 49520 Repair recurrent inguinal $664.05 5341 $3,109.34 $1,377.21 hernia, any age; reducible 49521 Repair recurrent inguinal hernia, any age; incarcerated or $753.91 5341 $3,109.34 $1,377.21 strangulated 49525 Repair inguinal hernia, $603.06 5341 $3,109.34 $1,377.21 sliding, any age 49540 Repair lumbar hernia $708.80 5361 $4,833.71 $2,194.07 49560 Repair initial incisional or $775.93 5341 $3,109.34 $1,377.21 ventral hernia; reducible 49561 Repair initial incisional or ventral hernia; incarcerated or $977.67 5341 $3,109.34 $1,377.21 strangulated 49565 Repair recurrent incisional $807.69 5361 $4,833.71 $2,194.07 or ventral hernia; reducible 49566 Repair recurrent incisional or ventral hernia; incarcerated or $986.69 5361 $4,833.71 $2,194.07 strangulated ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 4 ICD-10 HCPCS ICD-10MOD HCPCS ICD-10ICD-10MOD HCPCSHCPCS MODMOD CODES CODES CODESCODES CODES$ CODESCODES CODES$CODES CODESCODES $$ 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv Hernia Repair (continued) +49568** Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh Packaged Service/Item; Packaged Service/Item; for closure of debridement for $281.50 — No Separate No Separate necrotizing soft tissue infection Payment Made Payment Made (List separately in addition to code for the incisional or ventral hernia repair) 49570 Repair epigastric hernia (eg, preperitoneal fat); reducible $437.41 5341 $3,109.34 $1,377.21 (separate procedure) 49572 Repair epigastric hernia (eg, preperitoneal fat); $543.51 5341 $3,109.34 $1,377.21 incarcerated or strangulated 49580 Repair umbilical hernia, $349.71 5341 $3,109.34 $1,377.21 younger than age 5 years; reducible 49582 Repair umbilical hernia, younger than age 5 years; $507.06 5341 $3,109.34 $1,377.21 incarcerated or strangulated 49585 Repair umbilical hernia, $467.72 5341 $3,109.34 $1,377.21 age 5 years or older; reducible 49587 Repair umbilical hernia, age 5 years or older; incarcerated $500.20 5341 $3,109.34 $1,377.21 or strangulated 49590 Repair spigelian hernia $601.97 5341 $3,109.34 $1,377.21 **As with most add-on codes, this code is approved to be used with only certain primary procedures. Please refer to your CPT manual for approved primary procedures. ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 5 ICD-10 HCPCS ICD-10MOD HCPCS ICD-10ICD-10MOD HCPCSHCPCS MODMOD CODES CODES CODESCODES CODES$ CODESCODES CODES$CODES CODESCODES $$ 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv Laparoscopic Repair – Hernia 49650 Laparoscopy, surgical; $451.12 5361 $4,833.71 $2,194.07 repair initial inguinal hernia 49651 Laparoscopy, surgical; $587.54 5361 $4,833.71 $2,194.07 repair recurrent inguinal hernia 49652 Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia $782.78 5361 $4,833.71 $2,194.07 (includes mesh insertion, when performed); reducible 49653 Laparoscopy, surgical, repair, ventral, umbilical, spigelian, or epigastric hernia $977.31 5361 $4,833.71 $2,194.07 (includes mesh insertion, when performed); incarcerated or strangulated 49654 Laparoscopy, surgical, repair, incisional hernia (includes $888.89 5362 $8,413.11 $3,588.58 mesh insertion, when performed); reducible ICD-10ICD-10 ICD-10HCPCSHCPCS HCPCSMODMOD ICD-10MOD HCPCS MOD CODESCODES CODESCODESCODES CODESCODES CODES$$ CODES$ CODES $ 6 ICD-10 HCPCS ICD-10MOD HCPCS ICD-10ICD-10MOD HCPCSHCPCS MODMOD CODES CODES CODESCODES CODES$ CODESCODES CODES$CODES CODESCODES $$ 2020 REIMBURSEMENT GUIDE For Hernia Repair Procedures using OviTex® Reinforced Tissue Matrix CPTi Codes and 2020 National Average Medicare Reimbursement for Common Hernia Repair and Abdominal Wall Procedures Physician Hospital Ambulatory APC CPT Code Description Fee Scheduleii Outpatient Surgery Center Assignment (MPFS) Paymentiii Paymentiv Laparoscopic Repair – Hernia (continued) 49655 Laparoscopy, surgical, repair, incisional hernia (includes $1,087.02 5362 $8,413.11 $3,588.58 mesh insertion, when performed); incarcerated or strangulated 49656 Laparoscopy, surgical, repair, recurrent incisional hernia $964.31 5362 $8,413.11
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