BILLING A4263, A4550, A4338 with E & M code

Medicare Guidelines


A/B MACs (B) make a separate payment for supplies furnished in connection with a procedure only when one of the two following conditions exists:

A. HCPCS code A4300 is billed in conjunction with the appropriate procedure in the Medicare Physician Fee Schedule Data Base (place of service is physician’s office). However, A4550, A4300, and A4263 are no longer separately payable as of 2002.
Supplies have been incorporated into the practice expense RVU for 2002. Thus, no payment may be made for these supplies for services provided on or after January 1, 2002.

B. The supply is a pharmaceutical or radiopharmaceutical diagnostic imaging agent (including codes A4641 through A4647); pharmacologic stressing agent (code J1245); or therapeutic radionuclide (CPT code 79900). Other agents may be used which do not have an assigned HCPCS code. The procedures performed are:

• Diagnostic radiologic procedures (including diagnostic nuclear medicine) requiring pharmaceutical or radiopharmaceutical contrast media and/or pharmacologic stressing agent;

• Other diagnostic tests requiring a pharmacologic stressing agent;

• Clinical brachytherapy procedures (other than remote after-loading high intensity brachytherapy procedures (CPT codes 77781 through 77784) for which the expendable source is included in the TC RVUs); or



• Therapeutic nuclear medicine procedures.



Can A4263 be billed in an ASC setting

Ans : Yes. We can.

Note : If permanent silicone-type plugs are used, you should bill for the supply using A4263 (permanent, long-term, nondissolvable lacrimal duct implant, each). This is a sterile supply, so you should bill even if the procedure was not completed.   HCPCS code A4300 is billed in conjunction with the appropriate procedure in the Medicare Physician Fee Schedule Data Base (place of service is physician‟s office). However, A4550, A4300, and A4263 are no longer separately payable as of 2002.


Can A4338 be billed with an E&M code

Ans : No.

Note : If hospital outpatient staff perform a surgical procedure on a patient in which temporary bladder catheterization is necessary and use a catheter described by HCPCS code A4338 (Indwelling catheter; Foley type, two-way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each), the hospital should not report A4338 because the catheter was used as a supply and would be paid through OPPS payment for the surgical procedure. The hospital should include the charge associated with the urinary catheter on the claim.


Surgical Trays: Bundling Denials

Denial Reason, Reason/Remark Code(s)

B15 Bundling: Payment adjusted because this procedure/service requires that a qualifying service/procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.


HCPCS code: A4550

Resolution/Resources

This code is listed as 'Status B' in the Medicare Physician Fee Schedule Database (MPFSDB), which means that payment for this service is always included in payment for other services performed on the same date that are reimbursed under the Medicare Physician Fee Schedule

Q: Will UnitedHealthcare Community Plan separately reimburse HCPCS supply code A4550 (Surgical trays) when submitted with another Evaluation and Management (E/M) service and/or procedure code?

A: UnitedHealthcare Community Plan follows CMS guidelines with respect to reimbursement for surgical trays (supply). Office medical supplies including surgical trays are considered to be part of a physician's practice expense. Therefore, reimbursement for a surgical tray is included in the practice expense portion of the relative value unit for the medical or surgical service. HCPCS supply code A4550 is considered included in the Evaluation and Management (E/M) service and/or the
procedure performed in the physician's or other health care professional's office. Please see UnitedHealthcare Community Plan’s B Bundle policy for additional information regarding code A4550.


Surgical Trays Separate reimbursement is allowed for surgical trays (A4550) when submitted with the following CPT service codes: 28297 – 28299; 32000; 37609; 38500; 43200; 43220; 43226; 43234-43235; 43239; 43247; 43250-43251; 43458; 45378-43580; 45382-45385; 49080- 49081; 51720; 52000; 52007; 52010; 52204-52260; 52270-52281; 52283; 52290 -52310; 53020; 54057-54060; 54100; 54700; 55250; 57520; 58120; 62270; 96440; 96445; 96450. Please Note: Separate reimbursement for a surgical tray (A4550) is allowed on claims where only A4550 and the surgical CPT code that qualifies for a surgical tray (see list above) are billed. Adding additional codes to the claim may alter the payment of the surgical tray.



Other third party payors may reimburse for supplies typically by using the CPT code 99070. Some payors will reimburse for the epidural tray as supplies using the code A4550. At contract negotiation it should be clarified as to what supplies are reimbursed separately and how to bill these supplies: line itemized with the  Original 12-contents of the tray (A4550) (or purchased separately), or one line item with 99070. Additional supplies may include Omnipaque (Low Osmolar Contrast Material), although payment for this depends on the carrier. Providers need to be extremely aware as to what supplies are already included in a tray and not list those separately again in a line item or as part of the miscellaneous 99070.






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