Outpatient implantable devices

If the hospital is contracted under the hospital Outpatient Surgery Fee Schedule, specific implantable devices are eligible for additional reimbursement. These select approved implantable devices, listed and updated periodically through Provider bulletins, are reimbursed separately at the hospital’s invoice cost. Please refer to the Outpatient Implantable Device List. 

How to bill implantable devices 

Submit the claim electronically through standard channels. Bill the implant using revenue code 0275 or 0278, as appropriate. Charges must also be assigned to implants. These devices will be reimbursed separately at the Provider’s cost, as documented on the manufacturer’s invoice (shipping and sales tax excluded). The implant revenue code and charges must be billed on the initial claim submission. They will not be added when the request for implant reimbursement is submitted.

After the base claim is paid, submit the following documentation via fax to Facility Payment at 215-238-7088:

 operative report 

 implant record 

 implant manufacturer’s invoice (not purchase order) 

Note: The purchase order is not acceptable in lieu of the manufacturer’s invoice. It may be submitted in addition to the manufacturer’s invoice to clarify a date discrepancy. Also, a manufacturer’s invoice received with handwritten amounts will not be considered acceptable documentation.

Generally, we will not accept an invoice with a date greater than the date of surgery as applicable documentation. However, it may be your hospital’s billing practice to request a device with a purchase order, receive the device and use it during surgery, and then be billed by the manufacturer after the actual surgery date. If this is the case, include both the invoice and purchase order for documentation, and specify that this is your hospital’s practice.

For certain implants that are purchased on consignment or ordered in bulk (e.g., drug-eluting stents), a representative copy of the manufacturer’s invoice that reflects the cost per unit, units per order (e.g., pack, case, box), and model number and/or clear description of the implantable device will be considered acceptable documentation. We will also require that the patient-specific serial number of the implantable device be recorded in the implant record.

To facilitate processing, include a cover sheet that contains a summary of the required information, including:

 Member name

 Member ID number 

 Member claim number 

 implant type 

 invoice amount 

Implant record

The implant record is required to verify the model and serial number of the implantable device. This information can be found on the implant labels that are attached to the implant record. The facility should place these labels on the operative report, purchase order, or on one of the following:

 cardiac catheterization report 

 implantable device registration form 

 intra-operative nursing record 

 medical device or issue tracking form 

 operative notes 

 progress notes

You may submit one of these forms in lieu of the implant record as long as they include the implant label, indicating the implant’s model and serial number, and a brief description of the device. With the exception of radioactive seeds, implantable devices include implant labels from the manufacturer.

Implant requests received without all required documentation will not be considered for reimbursement.

 Please note that originally submitted requests for implant payments will be processed in accordance with the timely filing provisions of your Agreement.

Reimbursement exceptions 

The following are examples of circumstances where implantable devices are not eligible for reimbursement:

 The base surgery claim has been denied or has not yet been paid. 

 The type of device is not specified on approved listing.

 There is insufficient documentation. 

 IBC is not the primary payer.