Reimbursement

Reimbursement

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Reimbursement

This information is provided as a courtesy for illustration purposes only. This does not in any way guarantee actual payment. Your local insurers may pay under their own guidelines. Review all information with your medical billing professionals.

2021 Reimbursement Guides

Frequently Asked Questions

Q. Is there a HCPCS code for Spot Ex or EverLift?
A. There is no HCPCS code specific for Spot Ex or EverLift. Providers should bill the appropriate CPT code(s) to properly reflect the procedures performed.

Q. Will payers, including Medicare, cover Spot Ex or EverLift?
A. Currently, we are unaware of medical policies that restrict coverage for Spot Ex or EverLift or procedures that typically include Spot Ex or EverLift. Health plans generally cover procedures that are considered reasonable and medically necessary. We suggest contacting the patient’s specific payer to understand their coverage guidelines for a particular item or service in advance of performing the procedure.

Q. Why is there no ASC payment for the unlisted procedures above?
A. For Medicare claims, procedures described by unlisted CPT codes are excluded from ASC payment

Q. Which modifiers should be used when billing CPT codes?
A. Modifiers are utilized to help describe specific circumstances related to the patient. The appropriate modifiers to potentially utilize will depend on the patient’s condition, the procedure(s) being performed and payer-specific billing policies.

Q. Does Medicare pay separately for the use of Spot Ex or EverLift?
A. Medicare reimbursement is based on the procedure performed. CPT coding of submucosal injection includes when Spot Ex is utilized for tattooing or EverLift is used for lifting, and the payment rates are inclusive.

Q. Which CPT code do I use for billing when Spot Ex or EverLift is utilized?
A. The correct CPT code is based on where the submucosal injection procedure is performed. The AMA provides additional information and clarification on correct CPT coding, including in the CPT 2021 Professional Edition that provides a Colonoscopy Decision Tree, which may be useful. We suggest contacting your billing staff for additional information on the most appropriate CPT codes to utilize.

Q. Do I get paid separately when Spot Ex or EverLift is used in different locations?
A. The payment for Spot Ex and EverLift is incorporated into the various submucosal injection procedure CPT codes listed previously in this guide. These codes are based on the location in the colon where the procedure is being performed. If multiple locations are marked with Spot Ex within the same area in the colon (as defined by CPT coding), the procedure of a submucosal injection is reported only once. If more than one location is marked with Spot Ex or lifted with EverLift in the colon (as defined by CPT coding), the appropriate CPT codes for submucosal injection in the different areas may be reported.