Friday, May 20, 2016

ASC - HOW Determining Surgical Implant(s) Acquisition Cost

When determining the acquisition cost for Surgical Implant(s), the ASC shall subtract any and all price reductions, offsets, discounts, adjustments and/or refunds which accrue to, or are factored into, the final net cost to the ASC, only if they appear on the acquisition invoices, before increasing the invoice amount by the percentage factors described in the Surgical Implant(s) Reimbursement in this Chapter.

In order to receive reimbursement for Surgical Implant(s) and their associated costs, the ASC must either:

• Certify in writing on the DWC-90 billing form, in Form Locator 80, that the total requested reimbursement by each category of Surgical Implant(s), Associated Disposable Instrumentation, and Shipping & Handling has been determined in accordance with the reimbursement percentages defined by the policy in this Chapter. Each such total amount requested for reimbursement must be listed separately on the DWC-90 claim form in the Form Locator 80 labeled “Remarks”, using each of the modifiers prescribed in this Manual and their associated total dollar amounts of requested reimbursement pursuant to this chapter; or

• Submit copies of the Implant Log or Tracking sheet from the operating room to the insurer along with the acquisition invoice(s) that substantiate the cost of the items(s) billed. Charges for Surgical Implant(s) that are not properly certified, not separately identified by each category, or submitted without invoices and implant logs as described above shall constitute undocumented charges and shall not be reimbursed.


Instructions contained in 69L-7.602(4)(b)6, F.A.C, the Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule, shall be used to bill Surgical Implant(s), Associated Disposable Instrumentation, and shipping and handling in Form Locator 42 of the Form DFS-F5-DWC-90 (UB-04) C claim form. The Workers’ Compensation unique procedure codes and their required modifiers stated above shall be billed on separate lines in Form Locator 44.

Verification of Surgical Implant(s) Costs and Charges

The ASC certification of the amount requested for reimbursement, whether in writing, by prior written agreement with the insurer, or by the billing form, and the ASC compliance with the billing requirements in this Manual and Rule 69L-7.602, F.A.C., (The Workers’ Compensation Medical Services Billing, Filing and Reporting Rule) shall be subject to verification through audit and medical record review.

Upon request by the Division, an insurer or its designee to conduct an audit or medical record review, the ASC shall produce a copy of the implant acquisition invoice for the requestor at no charge or make the original documents available for an on-site review, or elsewhere by mutual agreement, within thirty (30) days of the request.

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