Healthcare professionals / Gastroenterology / EXALTTM Model D Single-Use Duodenoscope / Pass-through Payment
    

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)

The CMS guidance on the new device transitional pass-through category is available at:  https://www.cms.gov/files/document/r10166cp.pdf (See Section 7 and Tables 8 & 9)
   

   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?

Proper setting of charges for pass-through devices is important not only for the hospital’s payment for the device today, but also to ensure that the data CMS has for future rate setting under the outpatient prospective payment system is accurate and reflective of true procedure costs, including the true cost of the device.
 

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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