Physician’s Office

Medicare reimbursement for drugs and biologics administered in the physician’s office is based on average sales price (ASP), which for single-source drugs, is defined as the weighted average of sales of the product’s NDCs across all channels (eg, retail, hospital, and clinic). Volume discounts, prompt pay discounts, cash discounts, charge-backs, and rebates are all taken into account in the calculation of a product’s ASP. Medicare determines an ASP payment per billing unit of the product’s HCPCS code.

Synvisc-One^® and SYNVISC^® (hylan G-F 20) are reimbursed using a blended, multiple-source ASP formula. This means that the ASP-based allowable per HCPCS billing code J7325, for Synvisc-One and SYNVISC, will depend on both products’ ASP amounts, as well as the number of units of each NDC sold during the quarter.

• The Medicare allowable payment for Synvisc-One and SYNVISC is ASP + 6% and is updated quarterly, based on sales in previous quarters.
• Medicare reimburses 80% of the allowed payment amount patient, or patient’s secondary insurer/supplemental plan, is responsible for remaining 20%.

Administration:

• Medicare also provides reimbursement for the administration of Synvisc-One and SYNVISC through the CPT code 20610 (arthrocentesis, aspiration and/or injection of a major joint or bursa)
• State-based rates vary based on geographic wage differences

Bilateral procedures:

• Physicians receive 150% of the payment amount for 20610.
• Medicare reimburses 80% of the allowed payment amount Patient, or patient’s secondary insurer/supplemental plan, is responsible for remaining 20%.

Medicare billing instructions in the office setting:

• Download the Sample CMS-1500 Claim Form (PDF)
• Download the Blank CMS 1500 Claim Form (PDF)
• Download Additional documents

Hospital Outpatient

Within the hospital outpatient department, Synvisc-One and SYNVISC are covered as Separately Covered Outpatient Drugs (SCODs), which are paid at a rate of ASP + 4%. Of this allowable rate, Medicare will reimburse 80%, and the patient or patient’s secondary insurer is responsible for the remaining 20% coinsurance.

Administration:

Medicare also reimburses for the administration of Synvisc-One and SYNVISC when provided in the hospital outpatient setting. Under the OPPS, Medicare reimburses the hospital outpatient department for CPT 20610 (arthrocentesis, aspiration, and/or injection of a major joint or bursa) under a fixed procedure APC payment rate. State payment rates will vary based on geographic wage indices.

Physicians should bill Medicare separately for their professional services given in the hospital outpatient setting that are associated with Synvisc-One and SYNVISC.

Bilateral procedures:

When a bilateral procedure is done, the reimbursement allowable to physicians and hospitals is 150% of the payment for CPT 20610. Of this amount, Medicare will reimburse 80%, and the patient or patient’s secondary/supplemental insurer will reimburse the remaining 20% coinsurance.

Mediicare billing instructions in the HOPD:

• Download the Sample CMS-1450/UB04 Form (PDF)
• Download the Sample CMS-1450/UB04 Form (PDF)
• Download Additional documents

Please refer to Billing Codes for other relevant codes needed to ensure proper claim submission for Synvisc-One and SYNVISC.

Providers maintain responsibility for determining reimbursement and insurance issues related to their patients. Genzyme cannot be responsible for failure to obtain reimbursement.