Reimbursement

When LCP AI is utilized in the hospital outpatient site of service, reimbursement is determined by the Hospital Outpatient Prospective Payment System (OPPS). Procedures are assigned to the applicable Ambulatory Payment Classification (APC) for the CPT code used to describe the service. Generally, Medicare assigns CPT codes into groups where the codes are similar in terms of clinical characteristics and resource costs. Alternatively, New Technology APCs, like that under which the Optellum® technology is reimbursed, are defined on the basis of cost. Under APCs, payment is determined by the services and procedures provided as reported by the CPT code.²

The Medicare payment amounts listed do not reflect adjustments for deductible, co-payment, coinsurance, sequestration or any other reductions. All payment amounts listed are based on national averages and will vary by geographical locations. Facilities should review their contracts and negotiated rates for each of their Commercial insurers to determine what their appropriate reimbursement will be.

CPT codes assigned to a status indicator S are not subject to multiple procedure discounting and are paid at 100% of the current OPPS payment rate.

Category III CPT codes do not have any assigned relative value units (RVUs) and therefore there is no fee schedule payment rate established for physician payment under Medicare. Payment for physician services is at the discretion of the individual Medicare contractor.

Note: Reimbursement from commercial payers will vary due to individual negotiated contractual agreements between the provider and the payer. Providers are encouraged to check with their individual payers regarding payment for specific services and procedures.