Routine Medical Supplies Coverage and Guidelines

By: Sheila Haynes – Coding and Compliance Manager

Correct coding and code definitions apply in all circumstances and to all provider types. Whenever a code is billed which includes another service or supply, whether by code definition or by coding guidelines, the included service or supply is not eligible for separate reimbursement.

Supplies For Professional Services

Supplies and Services Included in the Practice Expense Allowance

1. 1. The Centers for Medicare and Medicaid Services (CMS) establishes and determines a relative value unit (RVU) for procedure codes and publishes this information on the Medicare Physician Fee Schedule Database (MPFSDB).
   2. The practice expense portion of the RVU includes medical and surgical supplies and equipment commonly furnished and that are a usual part of the surgical or medical procedures.
   3. Additional charges for routine supplies and/or equipment used for a surgical procedure or during an office visit or office procedure are not appropriate and not eligible for separate reimbursement.
   4. Payment is included in the reimbursement for the primary procedure code.
   5. The practice expense portion of the RVU for Medical and/or surgical supplies includes such items as:
      • Surgical trays (e.g. A4550, and other HCPCS codes)
      • Syringes, needles, biopsy needles, local anesthetic, saline irrigation or flush supplies, etc.
      • Bandages, dressings, gloves, IV catheters and supplies, etc.
      • Other specific supplies needed for each procedure

Separately Reporting Additional Supplies and Materials

1. 1. In those cases when supplies and materials are provided which the provider feels are clearly over and above those usually included with the office visit or other services rendered and require separate reporting on the claim:
      • Supply Code 99070: For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non- specific CPT code 99070 (supplies and materials, except spectacles, provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)) is considered a bundled service and is not reimbursable by Medicare and most commercial payers.
      • CMS and most commercial payers expect supplies and materials to be billed with HCPCS Level II codes to ensure that the most specific code available is billed, and to enable accurate claims processing.
      • Unlisted codes should be submitted accompanied by a clear and specific description for the item or service being billed (i.e. product label or invoice).

Separate Reimbursement for Additional Supplies and Materials

1. 1. 1. The supplies and materials billed with a HCPCS Level II code may or may not be eligible for benefits depending on the member’s contract with the specific payer.
      2. If the supplies and materials are “covered” they still may or may not be eligible for separate reimbursement based on the CMS status indicators.
         • Procedure codes designated with status indicator B (Bundled code) and/or P(Bundled/Excluded codes) on the Medicare Physician Fee Schedule Database (MPFSDB) are not eligible for separate reimbursement by CMS and most commercial payers.
         • In the definition of these status indicators, CMS has indicated reimbursement for these codes is bundled into the allowance (RVU) for the physician service with which it is associated or connected (“incident to”).
      3. When in doubt, check with the payer for member specific contract benefits

Coding and Billing Guidelines

1. 1. When coding for services or supplies, the most specific and comprehensive code available should be selected to report the service or item.
   2. Select the code which accurately identifies the service performed or the item supplied.
   3. Do not select a CPT or HCPCS code which merely approximates the supply provided.
   4. If no such specific code exists, then report the service or item using the appropriate unlisted procedure or service code.
   5. Sometimes the same supply item may be described by both a CPT (Level I HCPCS) code and a HCPCS (Level II HCPCS) code. When this occurs, there are rules to follow to determine which code is correct to use to report the service or supply.
      • When both a CPT and a HCPCS Level II code have virtually identical descriptions for a procedure, service, or item, the CPT code should be used.
      • If the descriptions are not identical, (e.g. the CPT code description is generic, whereas the HCPCS Level II code is more specific), the Level II code should be used.
      • The exception to this rule is if the more specific HCPCS Level II code is in a grouping of codes that is designated for use by a specific government agency or program which does not apply to this member’s claim. (i.e., H-codes and T- codes are developed specifically for state Medicaid Agencies.)