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Reimbursement / Regulatory

CMS Issues 2016 Hospital Outpatient Prospective Payment System Recommendation for MIS SI Joint Fusion -

Centers for Medicare & Medicaid Services (CMS) issued its 2016 Hospital Outpatient Prospective Payment System (HOPPS) recommendation for MIS SI joint fusion, effective 1/1/16, providing an outpatient payment of $10,538 when billing CPT 27279. This is an increase of $1,272 (+14%) over the current payment of $9,266.

Further, CMS will increase physician reimbursement for MIS SI joint fusion procedures when billing CPT 27279 from the current national average of $577 to $722, +25%.

SI-BONE also noted that, in addition to last week’s announcement regarding Wisconsin Physicians Service Insurance, two more Medicare Administrative Contractors released positive draft local coverage determinations (LCDs) for MIS SI joint fusion: National Government Services, covering ten states (Connecticut, Illinois, Massachusetts, Maine, Minnesota, New Hampshire, New York, Rhode Island, Vermont and Wisconsin) and CGS Administrators, covering Ohio and Kentucky.

Upon finalization of the draft LCDs for NGS and CGS, 49 out of 50 states will cover MIS SI joint fusion, providing coverage for 48 million U.S. Medicare beneficiaries.

Source: SI-BONE, Inc.

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