Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Use of a Robotic-Assisted Surgical System
Policy #:ma11.057a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company considers the use of a robotic surgical system to be an integral part of the primary surgical procedure and is, therefore, not eligible for separate reimbursement consideration whether billed alone or in conjunction with other services.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

BILLING REQUIREMENTS

Procedure codes representing surgical techniques requiring the use of a robotic surgical system are add-on codes which should be reported in addition to the primary procedure; however, they are not eligible for reimbursement whether billed alone or in conjunction with other services. Participating providers may not bill members for this service.

In accordance with the Centers for Medicare and Medicaid Services (CMS), Modifier-22 (Increased Procedural Services) cannot be appended to a primary procedure code to indicate use of a robotic surgical system.
Policy Guidelines


Description

Robotic surgical systems allow surgeons to use robotic devices to perform minimally invasive surgical procedures that require precision and control. With robotic surgery, a three-dimensional magnification of the surgical site is obtained via a tiny camera that is inserted into the individual's body. The surgeon uses voice-activated software or remote-control technology to direct the movement of the surgical instruments as the procedure is performed with the use of robotic arms, device(s), or system(s). Robotic-assisted surgery can be used for various types of surgery, including the removal of the prostate; non-cardiac chest procedures involving the lungs, esophagus, and a blood vessel inside the chest cavity; and certain procedures involving surgical incisions into the heart, such as mitral valve repair.
References

Centers for Medicare and Medicaid Services (CMS).CMS Manual System. Pub. 100-04: Medicare Claims Processing. Transmittal 1566. Final addenda [CMS Web site]. 10/1/08. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1566CP.pdf. Accessed November 8, 2013.

US Food and Drug Administration (FDA). Caution When Using Robotically-Assisted Surgical Devices In Women's Health Including Mastectomy And Other Cancer-Related Surgeries: FDA Safety Comunication. [FDA Web site]. 2/28/2019. Available at:
https://www.fda.gov/medical-devices/safety-communications/caution-when-using-robotically-assisted-surgical-devices-womens-health-including-mastectomy-and. Accessed September 4, 2019.

US Food and Drug Administration (FDA). Computer-Assisted Sugical Systems.[FDA Web site]. 3/13/2019. Available at:
https://www.fda.gov/medical-devices/surgery-devices/computer-assisted-surgical-systems. Accessed September 4, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)





Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)




HCPCS Level II Code Number(s)



S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)



Revenue Code Number(s)



Coding and Billing Requirements






Policy History

11/04/2019This policy has been reviewed in accordance with the Company's continued position on Robotic Assisted Surgeries. Language has been added to the billing requirements to reflect continued position and to address Modifier 22.




Version Effective Date: 11/04/2019
Version Issued Date: 11/04/2019
Version Reissued Date: N/A