CODING AND BILLING GUIDE - VIA Disc NP

CODING AND BILLING GUIDE

JANUARY 2021 REIMBURSEMENT INFORMATION

VIA? Disc is intended to supplement degenerated intervertebral discs. VIA Disc is shipped in a single use package containing the following two components that are mixed together with sterile saline prior to use to form a single, injectable allograft:

1. Dried disc tissue (DT) particulate 2. Heterogeneous, spine-derived cells

CODING OPTIONS

This guide provides physician, hospital outpatient and ambulatory surgery center coding with key considerations for addressing the status of the code options provided. 2021 Medicare national average reimbursement rates are included.

COMMON PROCEDURAL TERMINOLOGY (CPT) CODES1 FOR VIA DISC

CODE

LONG DESCRIPTION

0627T

Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level

+0628T

each additional level (List separately in addition to code for primary procedure)

0629T

Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level

+0630T

each additional level (List separately in addition to code for primary procedure)

POSSIBLE ICD-10 CM DIAGNOSIS CODES? FOR DEGENERATIVE DISC DISEASE (DDD)

CODE

DESCRIPTION

M51.36

Other intervertebral disc degeneration, lumbar region

M51.86

Other intervertebral disc disorders, lumbar region

M54.4

Lumbago with sciatica

M54.5

Low Back Pain

M54.9

Dorsaliga, unspecified

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2021 REIMBURSEMENT REFERENCE GUIDE

Medicare national unadjusted payment rates.

CPT CODE1

LONG DESCRIPTION

0627T

Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level

OUTPATIENT HOSPITAL3

AMBULATORY SURGICAL CENTER4

APC: 5115 Status Indicator: JI Payment: $12314.76

Payment Indicator: G2 Payment Weight: 120.4434 Payment: $5895.95

+0628T 0629T

+0630T

each additional level (List separately in addition to code for primary procedure)

Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level

each additional level (List separately in addition to code for primary procedure)

APC: NA Status Indicator: N

APC: 5115 Status Indicator: JI Payment: $12314.76

APC: NA Status Indicator: N

KEY OPPS/ASC INDICATORS

J1: Hospital Part B Services paid through comprehensive APC N/N1: Non-covered service G2: Payment based on OPPS relative payment rates

Payment Indicator: N1

Payment Indicator: G2 Payment Weight: 120.4434 Payment: $5895.95

Payment Indicator: N1

FREQUENTLY ASKED QUESTIONS

WHAT CPT CODES CAN BE USED TO BILL FOR THE PROCEDURE IN WHICH VIA DISC IS FURNISHED?

The following CPT Category III codes can be used for this procedure:

? 0627T Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level

? +0628T each additional level (List separately in addition to code for primary procedure)

? 0629T Percutaneous injection of allogeneic cellular and/or tissue-

based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level

? +0630T each additional level (List separately in addition to code for

primary procedure)

DO CPT CODES 0627T, 0628T, 0629T AND 0630T HAVE A GLOBAL PERIOD?

? 0627T and 0629T have a global period of YYY. These are contractor-priced codes, for which MACs determine the global period.

? 0628T and 0630T ? these are add-on codes and are billed with the primary codes. The global period for the primary code applies to the primary codes.

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FREQUENTLY ASKED QUESTIONS (CONTINUED)

WHAT DIAGNOSIS CODE MAY BE REPORTED WHEN SUBMITTING A CLAIM FOR VIA DISC?

The possible codes are: ? M51.36 (Other intervertebral disc degeneration, lumbar region) ? M51.86 (Other intervertebral disc disorders, lumbar region) ? M54.4 (Lumbago with sciatica) ? M54.5 (Low back pain) ? M54.9 (Dorsaliga, unspecified)

IS THE PROCEDURE COVERED BY PAYERS?

DOES THIS PROCEDURE NEED A PRIOR AUTHORIZATION FROM THE PAYER?

The procedure may be covered on a case by case basis based on medical necessity. Please contact your patient's plan for coverage.

A prior authorization may be needed. The prior authorization process does not change when using CPT Category III codes. Prior authorization will require documentation to support the CPT Category III codes being used in order to help the payer understand what is being requested. Please contact your patient's payer for their prior authorization process.

CAN MY PATIENT USE THEIR HEALTH SAVINGS ACCOUNT (HSA) OR FLEXIBLE SPENDING ACCOUNT (FSA) TO PAY FOR THE PROCEDURE?

Yes, your patient can use their HSA or FSA as this procedure falls under the section 213(d) definition of the Internal Revenue Code of medical care.

COVERAGE PRIOR AUTHORIZATION INFORMATION

KEYS TO SUCCESS IN GAINING PRIOR AUTHORIZATION FOR CPT CATEGORY III CODES

The keys to successful prior authorization and appropriate reimbursement from a patient's payer include: ? Identify a staff member to coordinate all prior authorization and pre-certification processes. ? Follow the payer's requirements for coverage. ? Prepare a clear and concise letter of medical necessity. ? Educate the payer regarding the therapy, as needed.

STEPS IN THE PRIOR AUTHORIZATION PROCESS

STEP 1: COLLECT INFORMATION

Collect all patient, physician, and payer information: ? Patient's name ? Payer ? Patient's identification number (often social security number) ? Treating physician's name ? Facility where procedure will take place ? Obtain patient consent to release patient information to the payer ? Identify diagnosis and corresponding hospital and physician billing codes

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STEPS IN THE PRIOR AUTHORIZATION PROCESS (CONTINUED)

STEP 2: CONTACT THE PAYER

? Confirm eligibility and benefits. ? Inquire about coverage for the intended procedure.

? Determine payer requirements for prior authorization. If no prior authorization requirements are necessary, inquire if pre-determination can be filed.

? Verbal authorization may be given based on the above information; however, written authorization is preferred. Whether authorization is verbal or written, the provider should obtain an authorization number.

? For written authorization, you will need to provide: ? A letter of medical necessity/prior authorization letter. ? Request for prior authorization.

STEP 3: SEND THE REQUESTED INFORMATION

Gather all requested materials and mail or fax them to the individual or department responsible for the payer's prior authorization decisions.

STEP 4: FOLLOW-UP

Call the insurance payer to verify receipt of the prior authorization request and continue to follow up routinely with the payer until a coverage decision has been made.

STEP 5: RE-VERIFY ELIGIBILITY

When prior authorization has been granted, obtain the prior authorization number for your files and ask if an approval letter will be mailed out. Re-verify the patient's eligibility to ensure that the patient is still covered by this payer.

STEP 6: APPEAL

If authorization is denied, the physician and patient must decide if the decision will be appealed. For an appeal you will need to:

? Request information from the payer regarding their appeal process. ? Send an appeal letter and required materials as directed. Verify receipt of materials. ? File the appeal within the time limits set by the payer as listed in the denial letter. ? Patient can also submit a personal appeal to the payer and can contact their employer for assistance.

QUESTIONS?

Customers using VIA Disc can contact VIVEX Reimbursement Support at 404.618.6195 or reimbursement@.

Disclaimer: VIVEX Biologics uses reasonable efforts to provide accurate information herein, but this information should not be construed as providing clinical advice, dictating reimbursement policy, guaranteeing coverage, or as a substitute for the judgment of a health care provider. It is always the health care provider's responsibility to determine the appropriate codes, charges for services, and use of modifiers for services rendered and to verify coverage with payers, including the applicability of any non-coverage policies that may exist. Reimbursement laws, regulations, and payer policies change frequently without notice, and VIVEX Biologics assumes no responsibility for the timeliness, accuracy, or completeness of the information provided. It is highly recommended that health care providers consult with their payers, coding specialists, and/or legal counsel regarding coverage, coding, and payment issues.

1. CPT Copyright 2021 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. 2. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Tenth Revision, Clinical Modification

(ICD-10-CM). . Updated October 1, 2020 3. The payment rate for APC 5115 (Level 5 Musculoskeletal Procedures) can be found in Addendum A of the CY 2021 OPPS/ASC final rule. 4. The Ambulatory Surgical Center payment can be found in Addendum AA -Final ASC Covered Surgical Procedures for CY 2021

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Trademarks TM and Registered Trademarks ? of 2021 VIVEX Biologics , Inc. Copyright ? 2021 VIVEX Biologics, Inc. All rights reserved.

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