Case Management

Ask the expert: Knee and hip implants

Case Management Insider, December 29, 2015

The answer to this reader question was provided by Ronald Hirsch, MD, FACP, CHCQM, vice president, Regulations and Education Group for AccretivePAS in Chicago.

Q: What is the protocol for a physician at a critical access hospital (CAH) who does knee and/or hip implants? More specifically, if a physician attempts to use a sterile implant, but the implant is not used (i.e., wrong size, malfunctioning product, the wrong implant was ordered), is there any way that the physician/facility can get refunded for a product that cannot be used, but because it is a sterile DME, cannot be used on another patient? I am looking for some sort of documentation for this type of scenario.

First, the physician never charges for the implant unless he or she also owns the hospital. This is purely a facility issue. Second, a malfunctioning part should be sent back to the manufacturer and the facility should not be charged. If the wrong implant was ordered, that should be discovered before the surgery commences as part of the pre-op process and also returned to the manufacturer without charge. If an implant is opened and tried and did not fit, and the implant is not returned for credit, the hospital should include that implant on the claim. The documentation in the medical record should indicate that the first implant was tried and did not fit, with a note explaining what may have led to the mismatch, to support billing for two. Since CAHs are paid on a cost plus basis, the hospital should get reimbursed for the cost of both implants.

This represents the best response based on general Medicare policy and should not be considered official guidance from CMS or any official contractor.

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