Medicare Outpatient Transitional Pass-Through Payment for the aScopeTM Duodeno: Coding and Payment Guide

For more information, please contact the Ambu Reimbursement Support Team: us-reimbursement@ambu.com | (800)262-8462, select option 7

UPDATE ON INPATIENT REIMBURSEMENT

Ambu submitted an application to CMS in October 2020 for inpatient New Technology Add-on Payment (NTAP), which would provide similar additional reimbursement for Medicare inpatient procedures. If approved by CMS, NTAP would take effect October 1, 2021.

The information below is on the TPT payment policy issued in July 2020, which remains in effect until June 30, 2023.

Medicare Outpatient Transitional Pass-Through Payment

Effective January 1, 2020 | Download PDF

Effective July 1, 2020, the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers the Medicare program, created a new transitional pass-through (TPT) category and new HCPCS C code for single-use endoscopes, such as the aScopeTM Duodeno, used in performing endoscopic retrograde cholangiopancreatography (ERCP) procedures in the hospital outpatient department (HOPD). TPT status remains in effect until June 30, 2023.

HOPDs may obtain additional, separate payment for devices with TPT status, in addition to payment for the procedure(s) furnished during the patient encounter. When applicable, hospitals should bill the newly established HCPCS code C1748 – “Endoscope, single-use (i.e. disposable), upper GI, imaging/illumination device (insertable).”1

Application of TPT Payment in Non-Medicare Claims

TPT payment applies to patients with traditional Medicare; however, Medicaid, Medicare Advantage and commercial health plans may also recognize the C code and provide separate additional payment. Applicability of separate additional payment for HCPCS code C1748 is based on the hospital’s contract with the patient’s health plan. To determine if HCPCS code C1748 and separate payment applies to claims for non-Medicare patients, we suggest reviewing the hospital’s contract, or contacting the patient health plan for more information.

How TPT Payment Works

The payment for devices with TPT varies based on the hospital’s charge for the device, and the TPT payment is only available for certain procedures. Eligible procedures and their CPT codes are listed below.

To calculate the TPT payment amount, the hospital’s charge amount for the device is adjusted by applying the hospital’s cost-to-charge-ratio (CCR) for the revenue center associated with the device. CMS determines each hospital’s CCR based on an analysis of their historic charges and costs. The total payment for the patient encounter will include the TPT payment as well as the APC payment associated with the reported CPT code(s).

Please note that from July 1, 2020 to December 31, 2020, CMS also applied a device offset to the TPT payment calculation. As of January 1, 2021, the offset is no longer applied.

TPT Payment Example

The following is an example of how the TPT payment and the total procedure payment are determined:

1. Hospital establishes charge for the device. The hospital will establish an appropriate charge for single-use duodenoscopes, taking into consideration the revenue center’s CCR and device cost.

2. Medicare applies the CCR to the established charge. The hospital bills the charge to Medicare. Medicare thenapplies the revenue center CCR it has calculated for the hospital.

3. The TPT payment is calculated. The charged amount is multiplied by the CCR to calculate the TPT payment.

4. APC payment added. The APC payment for the related CPT code is added (e.g., the APC payment for CPT43262 is $3,081, rounded). See the table below for the APC payment amounts for each TPT-eligible CPT code.

5. Total case payment is calculated. Add the TPT payment to the APC payment for the related CPT code tocalculate the total payment for the patient case.

Coding for the aScope Duodeno

HCPCS Code for Reporting the aScope Duodeno

HCPCS Code

Descriptor

C1748 Endoscope, single-use (i.e. disposable), upper GI, imaging/illumination device (insertable)

 

Revenue Codes

Revenue Code

Descriptor

272 Sterile supplies                                                                                                                 
2782 Medical/surgical supplies and implants; other implants

 

Coding and 2021 National Medicare Payment Rates for ERCP

CPT3 Code

Descriptor

Physician Payment4

HOPD Payment5

APC

43260 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) $327 $3,081 5303
43261 Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple $343 $3,081 5303
43262 Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy $363 $3,081 5303
43263 Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi $363 $3,081 5303
43264 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from biliary/pancreatic duct(s) $370 $3,081 5303
43265 Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any method (eg, mechanical, electrohydraulic, lithotripsy) $440 $5,029 5331
43274 Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent $470 $5,029 5331
43275 Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) $382 $3,081 5303
43276 Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged $489 $5,029 5331
43277 Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct $384 $3,081 5303
43278 Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed $439 $3,081 5303

 

References

1. Additional information regarding this new device category and TPT payment status for single-use endoscopes is available at: https://www.cms.gov/files/document/r10166cp.pdf (See Section 7 and Tables 8 and 9) and https://www.cms.gov/files/document/r10540cp.pdf pg 87 (Dec.31, 2020).

2. Items that are insertable may be billed with revenue code 0278 per the National Uniform Billing Committee (NUBC)’s UpdatedGuidance on Other Implant Revenue Code (0278) effective July 1, 2020 available at https://www.nubc.org/system/files/media/file/2020/04/Guidance%20on%20Other%20Implant%20RC0278.pdf

3. Current Procedural Terminology (CPT®) is a registered trademark of the American Medical Association (AMA). Copyright 2020AMA. All rights reserved. No fee schedules, basic units, relative value units, or related listings are included in CPT. The AMAassumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

4. 2021 CMS PFS Final Rule, Addendum B (available on CMS website), 85 Fed. Reg. 248 (Dec. 28, 2020).

5. 2021 CMS OPPS/ASC Final Rule, Addendum AA and B (available on CMS website), 85 Fed. Reg. 249 (Dec. 29, 2020).

About the aScope Duodeno

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The aScope Duodeno is a single-use sterile duodenoscope that seamlessly integrates into existing hospital systems and offers an intuitive, lightweight design with similar functionality to reusable duodenoscopes. The aScope Duodeno is part of a system that includes a reusable process unit, the Ambu® aBox™ Duodeno. Duodenoscopes are used for visual examination of the duodenum and play a key role in diagnosis and treatment of conditions like gallstones, pancreatitis, and tumors or cancer in the bile duct and pancreas.

Indications for Use

The aScope Duodeno is designed to be used with the aBox Duodeno, endoscopic accessories (e.g. biopsy forceps) and other ancillary equipment (e.g. video monitor) for endoscopy and endoscopic surgery within the duodenum.

The aBox Duodeno is designed to be used with the aScope Duodeno, endoscopic accessories (e.g. biopsy forceps) and other ancillary equipment (e.g. medical grade video monitor) for endoscopy and endoscopic surgery within the duodenum.

Disclaimer

The reimbursement information provided in this Guide was obtained from third-party sources and information that is publicly available on the internet. The reported Medicare national average payments are subject to change and may vary based on geographic location and other individual factors. Information in this Guide is not legal advice, nor is it advice about how to code or complete claims for payment. It is the provider’s responsibility to report the appropriate codes based on the procedures furnished to a specific patient and the patient’s medical condition. Providers are also responsible for submitting claims for these services consistent with the specific payer billing requirements.

Payer billing, coding, and coverage requirements vary from payer to payer and are updated and change over time. Ambu encourages providers to verify current billing, coding and coverage policies and requirements with the specific payer if the provider has questions. Providers may also contact the American Gastroenterology Association (AGA), the American Society for Gastrointestinal Endoscopy (ASGE) and/or the American Medical Association (AMA).

Ambu does not promote the use of its products outside of the approved FDA approved indications for use and labeling.

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