Notification



Notification Issue Date:



Claim Payment Policy


Title:Robotic-Assisted Surgery

Policy #:11.00.18

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

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.
Guidelines

MEDICARE

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

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. Examples of robotic surgical systems include the da Vinci® Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif.) and the ZEUS™ Robotic Surgical System (Computer Motion, Inc. Goleta, Calif.).

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). Center for Devices and Radiological Health. Computer-assisted (robotic) surgical systems.[FDA Web site]. 11/8/2013. Available at:
http://www.fda.gov/medicaldevices/productsandmedicalprocedures/surgeryandlifesupport/computerassistedroboticsurgicalsystems/default.htm. Accessed November 8, 2013.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. ZEUS® Robotic Surgical System. 510(k) summary. [FDA Web site]. 10/5/01. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf/K003431.pdf. Accessed November 8, 2013.

US Food and Drug Administration (FDA). Center for Devices and Radiological Health. Intuitive Surgical® da Vinci. 510(k) summary. [FDA Web site]. 12/16/09. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf9/K090993.pdf. Accessed November 8, 2013.




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)

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 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

COMMERCIAL AND MEDICARE


Not eligible for separate reimbursement

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



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 01/06/2014
Version Issued Date: 01/06/2014
Version Reissued Date: N/A

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