Medicare
Once coverage eligibility has been confirmed, Medicare provides reimbursement for SYNVISC® and its administration in both the physician's office and hospital outpatient settings.
|
Physician's Office
When SYNVISC is provided in the office setting, Medicare reimburses for it in a number of ways:
- SYNVISC: Medicare reimburses 80% of the allowable amount (Average Selling Price (ASP) + 6%), and the patient or patient's secondary insurer is responsible for the remaining 20%.
If your office has chosen to participate in the Medicare Competitive Acquisition Program (CAP),
you will obtain SYNVISC through the CAP vendor, BioScrip, and you will not bill Medicare for
SYNVISC; BioScrip bills them directly. However, you must continue to bill for the administration
of SYNVISC.
- SYNVISC administration: Payment for physicians' professional services is based on the annual Medicare Physician Fee Schedule (MPFS) for Current Procedural Terminology (CPT) codes, which includes payment rates for the SYNVISC administration code CPT 20610 (arthrocentesis, aspiration, or injection). In addition, when bilateral SYNVISC procedures are performed, physicians receive 150% of the payment amount for CPT 20610. For all professional services, Medicare reimburses 80% of the allowable amount, and the patient or the patient’s secondary insurer is responsible for the remaining 20%.
For billing instructions in the office setting:
Download the Sample CMS-1500 Claim Form (PDF, 225K).
Download more Forms & Sample Letters including a Blank CMS-1500 Claim Form (PDF, 43K).
|
|
Hospital Outpatient Setting
Medicare reimburses separately for SYNVISC when provided in the hospital outpatient setting.
- SYNVISC: Medicare reimburses 80% of the allowable amount (Average Selling Price (ASP) + 6%), and the patient or patient’s secondary insurer is responsible for the remaining 20%.
- SYNVISC administration: Payment for both the hospital and physician services is based on the annual Medicare Physician Fee Schedule (MPFS) for Current Procedural Terminology (CPT) codes, which includes payment rates for the SYNVISC administration code CPT 20610 (arthrocentesis, aspiration, or injection). Both the hospital and the physician receive separate payment for the administration. In addition, when bilateral SYNVISC procedures are performed, providers receive 150% of the payment amount for CPT 20610. For all services, Medicare reimburses 80% of the Medicare Physician Fee Schedule local amount, and the patient or the patient's secondary insurer is responsible for the remaining 20%.
For billing instructions in the hospital outpatient setting:
Download the Sample CMS-1450 or UB92 Claim Form (PDF, 15K).
Download more Forms & Sample Letters including a Blank CMS-1450 or UB92 Claim Form (PDF, 17K).
|
Questions about Medicare reimbursement?
Call SYNVISC ConnectionSM at 1-800-982-8292, M-F, 9 am -6 pm (EST).