CMS Approved Transitional Pass-through Payment Category
The Centers for Medicare & Medicaid Services (CMS) has approved Boston Scientific’s application for a transitional pass-through (TPT) payment category to describe single-use endoscopes, such as the EXALT™ Model D Single-Use Duodenoscope. Effective July 1, 2020, the new device pass-through code (C1748) may be used to bill for EXALT Model D when used in the treatment of Medicare patients in the hospital outpatient setting. This device specific payment is in addition to the ERCP procedural payment.
TRANSITIONAL PASS-THROUGH CODE
| HCPCS | Long Descriptor |
|---|---|
| C1748 | Endoscope, single-use (i.e, disposable), upper GI, imaging/illumination device (insertable) |
REPORTING FOR PROCEDURE AND DEVICE ON A CLAIM
- When physicians perform an endoscopic retrograde cholangiopancreatography (ERCP) procedure on a Medicare patient in the outpatient setting with EXALT Model D, if appropriate, may bill:
- Procedure coding: Appropriate ERCP CPT code(s) plus
- Device HCPCS code: C1748
- Device Revenue Code: EXALT Model D is a single-use sterile device and may be reported using revenue code 272 - sterile supply
PAYMENTS
PROCEDURE PAYMENT
CPT® Code Search Results Web results¹ |
Ambulatory Payment Classification (APC)² | 2020 Medicare National Average Hospital Outpatient Payment³ |
|---|---|---|
| 43260-43264, 43275, 43277-43278 |
5303 - Level 3 Upper GI Procedures | $2,999 |
| 43265, 43274, 43276 |
5331 - Complex GI Procedures | $4,781 |
DEVICE PAYMENT
| CPT® Code | Description | CY2020 APC | Device Offset Amount |
| 43260 | ERCP; diagnostic, including collection of specimen(s) by brushing or washing, when performed | 5303 | $376.68 |
| 43261 | ERCP; with biopsy, single or multiple |
5303 |
$320.30 |
| 43262 | ERCP; with sphincterotomy/papillotomy | 5303 |
$382.68 |
| 43263 | ERCP; with pressure measurement of sphincter of Oddi | 5303 |
$128.36 |
| 43264 | ERCP; with removal of calculi/debris from biliary/pancreatic duct(s) | 5303 |
$376.38 |
| 43265 | ERCP; with destruction of calculi, any method (eg., mechanical, electrohydraulic, lithotripsy) | 5331 |
$816.09 |
| 43274 | ERCP; with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent | 5331 |
$1,287.96 |
| 43275 | ERCP; with removal of foreign body(s) or stent(s) from biliary/pancreatic duct(s) | 5303 |
$323.30 |
| 43276 | ERCP; with removal and exchange of stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged | 5331 |
$1,392.66 |
| 43277 | ERCP; with trans-endoscopic balloon dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct | 5303 |
$483.45 |
| 43278 | ERCP; with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed | 5303 |
$452.56 |
Why is it important for a hospital to properly set charges for pass-through devices?
Commercial payers are not required to follow CMS payment levels, however, some may choose to do so. It is recommended to reach out to commercial payers to understand commercial payer reimbursement for EXALT Model D.
For additional coding and reimbursement information, contact your local Endoscopy Field Reimbursement Manager or the Endoscopy Reimbursement Help Desk at ENDOFRM@bsci.com or (508) 683-4510.
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