Certification of a medical bill that the amount requested for reimbursement for the Surgical Implant(s) billed under Revenue Code 278 is fifty percent (50%) over the acquisition invoice cost, and Associated Disposable Instrumentation is twenty percent (20%) over the acquisition invoice cost. The documentation for the Associated Disposable Instrumentation must be contained on the invoice for the Implant(s). Shipping and handling is at the actual cost to the provider. Certification as specified in this Chapter may be submitted as follows:
• Via the ASC billing form when submitting claims electronically or by paper;
• Pursuant to a prior written agreement between the ASC and the insurer regarding the reimbursement for Surgical Implant(s), Associated Disposable Instrumentation and shipping and handling; or
• By a signed, written statement accompanying the request for reimbursement declaring that the reimbursement amount requested is the percentage pursuant to the policy of this Manual for Surgical Implant(s), Associated Disposable Instrumentation and shipping and handling.
An ASC electing to submit certification of the Surgical Implant, Associated Disposable Instrumentation and shipping and handling reimbursement amount via the ASC billing form shall place the amount requested for reimbursement in the Form Locator labeled ‘Remarks’.
The ASC shall separately list the abbreviation of each category in the Form Locator 80 of the DWC-90 claim form immediately preceding the amount of expected reimbursement for each category used which is calculated pursuant to this Manual. Each category shall be identified by the modifiers for Surgical Implant(s) (IM), Associated Disposable Instrumentation (DI), and shipping and handling (SH) and the amount of expected reimbursement for each category pursuant to the policy.
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