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1 US Reimbursement GuideThe information with this notice is general reimbursement information only. It is not legal advice, nor is it about how to code, complete or submit any particular claim for payment. Although we supply this information to the best of our current knowledge, it is always the provider s responsibility to determine and submit appropriate codes, charges, modifiers, and bills for services rendered. The coding and reimbursement information is subject to change without notice. Payers or their local branches may have their own coding and reimbursement requirements and policies. Before filing any claims, provider should verify current requirements and policies with their payer. CPT is a trademark of the American Medical Association. Current Procedural Terminology (CPT) is copyright 2017 American Medical healthcare professionals for over 150 yearsVISIONAIRE Patient Matched Cutting GuidesVISIONAIRE patient matched cutting guides use the patient s MRI and X-Ray to determine accurate alignment cuts and implant placement for each patient.

2 However, the surgeon s input on each patient is critical. The surgeon has the ability to make adjustments as he/she sees fit to address the patient s specific anatomy, making this process not only patient specific, but surgeon specific as specific, single-use distal femoral and proximal tibia cutting guides are based off the patient s mechanical axis. Can be used with LEGION , GENESIS II and JOURNEY II Total Knee coding refers to coding classification systems and medical nomenclature. Several coding systems exist with various levels of detail and for various purposes. The health care industry (including providers and insurers) uses coding to indicate the patient s condition (diagnosis) and the treatment of the patient for that diagnosis (procedures). The patient s diagnosis and procedures performed during the hospital stay are described using ICD-10 codes, which must be supported by documentation in the patient record. The ICD-10 code is a significant factor in determining the hospital s reimbursement, as further described under Payment System.

3 Payment SystemIn the hospital [inpatient] environment, the selected ICD-10 diagnosis and procedure codes are converted into a MS-DRG payment code. In the case of total joint replacement in the hospital setting often defines assignment of a particular MS-DRG payment code. For example, MS-DRG codes 461, 462, 469 or 470 stipulate that a major joint procedure was performed. There usually is no additional payment for treatment in the hospital setting outside of the MS-DRG CodingPayment systemAcute care short term hospital Payment for services provided to an inpatient MS-DRGThe Medicare Severity Diagnosis-Related Group (MS-DRG) code set classifies a patient into a DRG group based on the average resources used to treat patients in that for services provided to an outpatientAPC / ASCA mbulatory Payment Classification (APC) is a code set to describe facility outpatient services delivered to a Medicare outpatient. Payment rate is established for each APC code.

4 Depending on the services provided, hospitals may bill for more than one APC per patient care facilityPayment for patient stay in a home care settingCase-Mix GroupsCMG based payment rate includes all nursing and therapy services, medical supplies, aide and medical social services. Durable Medical equipment is excluded. The payment rate is based on case-mix adjustment, outlier payment, nursing facilityPayment for patient stay in a skilled nursing facility RUGPer diem rate covers all costs and is based on case-mix classification system (RUG III).Physicians (inpatient, outpatients)Payment for services provided by physicianCPTC urrent Procedural Terminology (CPT) is a numeric coding system of services and procedures furnished by physicians and other health care professionals and published by American Medical providers (outpatient)Payment for services provided by a non-physician to an outpatientHCPCS Level IIHCPCS Level II is an alpha-numeric coding system for products, supplies, and services used outside of physician offices.

5 HCPCS II codes are often product related. Payment for durable medical equipment (DME) is equal to 80% of the lesser of either actual charge for the item or the fee schedule amount. DMEPOS fee schedule is based on HCPCS Level II codes. VISIONAIRE Cutting Guides US Reimbursement GuideFor coding, payment, coverage and sample letters, please visit the Reimbursement website at Or you can contact us directly at or replacement2017 Medicare Coding, Coverage and Payment Reference SheetVisit the site at to obtain specific geographic payment Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained physician codingCPT codes are used by hospital outpatient departments, ambulatory surgery centers, and physicians to describe professional services and procedures. Based on CY2017 Medicare Physician Fee Schedule national payment rates are as follows: CPT CodeDescriptionPayment20985 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure) resurfacing (total knee arthroplasty)$15327447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)$1,403 Common inpatient codingThe International Classification of Disease tenth revision Procedure Coding System (ICD10-PCS) is a system of medical classification used for procedural codes that track various health interventions taken by medical professionals effective October 1, 2015.

6 Below you will find the ICD10-PCS that may apply to patients undergoing the Knee Replacement procedure is:ICD10 DescriptionMedicare DRG Payment8E0 YXBZC omputer Assisted Procedure of lower extremityN/A0 SRC0 SRD0 SRT0 SRU0 SRV0 SRWR eplacement/Knee joint, rightReplacement/Knee joint, leftReplacement/Knee joint, femoral surface, rightReplacement/Knee joint, femoral surface, leftReplacement/Knee joint, tibial surface, rightReplacement/Knee joint, tibial surface, left469, 470 The fifth character on the ICD10-PCS will represent approach (open, external approach or percutaneous endoscopic)The sixth character indicates whether any device was used and remained at the end of the procedure ( , synthetic substitute, metal, )Diagnosis-related groups (DRG) are used to reimburse hospitals for inpatient stays. Each inpatient stay is assigned a DRG that is determined according to the principal diagnosis, major procedures, discharge status, and complicating secondary diagnoses.

7 Each DRG is assigned a flat payment rate, which is adjusted according to the individual hospital s teaching status, disproportionate share services for treating low-income patients, and location in urban versus rural regions, etc. Note that DRGs do not include payment for physician services, which are coded and reimbursed are three levels of severity in most DRG categories: 1. MCC Major Complication/Comorbidity, which ref lect the highest level of severity; 2. CC Complication/Comorbidity, which is the next level of severity; and 3. Non-CC Non-Complication/Comorbidity, which do not significantly affect severity of illness and resource on CY2017 Medicare DRG national payment rates are as follows:DRGD escriptionDRG Cross Reference469 Major joint replacement or reattachment of lower extremity w mcc$17,912470 Major joint replacement or reattachment of lower extremity w/o mcc$11,252 Private InsurersPrivate insurers cover hospital inpatient services that are considered medically necessary and within the benefit structure of the patient s health insurance coverage.

8 Payment for the Knee Replacement procedure may be based on a percentage of the billed or allowed charges, per diem, or on a negotiated payment rate. Check with your payer organizations to determine the payment methodology for the Knee Replacement replacement (continued)Common imaging codingCPT codes are used by hospital outpatient departments, ambulatory surgery centers, Independent Diagnostic Testing Facility (IDTF), and physicians to describe professional services and procedures. Based on CY2017 Medicare Imaging Fee Schedule national payment rates are as follows:CPT CodeDescriptionIDTF & Physician PaymentOPPS73721 Magnetic resonance ( Proton) imaging, any joint of lower extremity; w/o contrast material $240$29673721-26 Professional component$70$7073721-TCTechnical component$170$22673562 Radiologic examination, knee; 3 views$36$6973562-26 Professional component$10$1073562-TCTechnical component$26$6073564 Radiologic examination, knee; complete, 4 or more views$40$12473564-26 Professional component$11$1173564-TCTechnical component$29$11373565 Radiologic examination, knee.

9 Both knees, standing, anteroposterior$36$6973565-26 Professional component$9$973565-TCTechnical component$27$6077073 Bone length studies (orthoroentgenogram, scanogram)$36$7577073-26 Professional Component$15$1577073-TCTechnical Component$22$60 Modif ierDescriptor-26 Professional Component: Certain procedures are a combination of professional and technical CTechnical Component: Certain procedures are a combination of professional and technical billing without a modif ier, this means the services performed included both reimbursement for diagnostic imaging procedures is comprised of a professional component, the amount paid for the physician s interpretation and report, and a technical component, the amount paid for all other services (including staff ing and equipment costs).When combined and paid to the same individual or entity, this amount is often referred to as the total or global Cutting Guides US Reimbursement GuideFor coding, payment, coverage and sample letters, please visit the Reimbursement website at Or you can contact us directly at or VISIONAIRE Patient Match Instrument inquires should be directed to VISIONAIRE Support at 1-800-262-3536 Option 1 or mail to: 1 The content contained in this communication is not intended or written to be used or to constitute any legal or regulatory advice or guidance.

10 Please consult your payer or regulatory advisor with questions relating to this material or your specific situation related thereto. 2 For further information or questions regarding CMS National Coverage Determination, see generally or contact CMS. 3 See page 28, 4 MRI Disclaimer1:The Centers for Medicare & Medicaid Services (CMS) established a National Coverage Determination (NCD) for MRIs. The NCD outlines the parameters for coverage and non-coverage. Specifically, the NCD states that MRI is considered medically efficacious for a number of diagnostic uses and that the descriptions (in the NCD) should be used as general guidelines or examples of what may be considered covered rather than as a restrictive list of specific covered indications. It goes on to note that CMS has determined that imaging of cortical bone and calcifications, and procedures involving spatial resolution of bone and calcifications, are not considered reasonable and necessary indications and are therefore non-covered.