Speaker: Surgeons should understand how to bill for orthobiologics
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Key takeaways:
- Platelet-rich plasma, bone marrow aspirate and adipose tissue will not be reimbursed as these are investigational products.
- Orthobiologic products approved by the FDA may not be reimbursed by payers.
LAS VEGAS — In addition to discussing the use of orthobiologics with patients, surgeons need to understand how to bill for orthobiologics, according to a presenter here.
“Corticosteroids and [hyaluronic acid] HA are generally reimbursed, but there are still about 15 states that have no coverage decisions for HA,” Brian J. Cole, MD, MBA, FAANA, said in his presentation at the combined Arthroscopy Association of North America and Biologic Association Specialty Day at the American Academy of Orthopaedic Surgeons Annual Meeting.
Cole noted that third-party payers will not reimburse platelet-rich plasma, bone marrow aspirate and adipose tissue, as these are considered investigational and have unproven benefit. Medicare also does not consider these products as covered services, and while an advance beneficiary notice is not required, Cole said it is considered best practice.
“Keep in mind, just because new technologies that you are seeing from on the horizon are approved by the FDA, it does not guarantee reimbursement,” Cole said.
In addition, Cole noted there is a distinct difference between billing orthobiologics as a surgical procedure vs. an office-based procedure. For office-based procedures, Cole said orthobiologics are considered fee-for-service for all payers.
He added orthobiologic procedures that are inclusive of the surgical procedure can be treated as office-based care for government payers that follow the National Correct Coding Initiative (NCCI). However, contracted providers may not be following CMS and NCCI guidelines and can be financially treated the same as office-based patients for either CMS or private care, according to Cole.
“In the office or in surgery, just check policies. Follow the coverage guidelines. If there is no coverage for an offer or policy to the patient, that helps to support the notion that it can be self-pay,” Cole said.
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Cole BJ. How do I bill for biologics in my practice? What is the cost? Presented at: American Academy of Orthopaedic Surgeons Annual Meeting. March 7-11, 2023; Las Vegas.
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