Reimbursement usually means receiving money in repayment for money you have already spent, or an expense you have already incurred. It is a term used in a wide variety of ways in business and personal life, but it has a different meaning in healthcare.
Healthcare providers are paid by insurance or government payers, such as Medicare through a system of reimbursement.
- They provide medical services to a patient and then file for reimbursement for those services with the insurance company or government agency. It’s not the patient who is paying out of pocket and getting reimbursed, it is the doctor providing the service and awaiting reimbursement.
- Whenever you have a medical procedure performed or health care service provided, it is coded in your medical record for tracking and billing. CPT codes and HCPCS codes are related systems of medical coding required for providers and insurers to send information electronically.
- You can look up a procedure by code to see how much Medicare reimburses your doctor or hospital to perform it.
- A private insurance company negotiates their own reimbursement schedules with providers and hospitals.
Even with health insurance, patients may have to pay a co-pay for a medical procedure, or may have to pay out of pocket for procedures not covered by insurance or Medicare.
Reimbursement for HIFU under Medicare
- In July 2017, a reimbursement code went into effect for HIFU ablation of the prostate.
- This code, called a c-code, is specifically for patients covered under Medicare and only applies to a hospital outpatient facility or ambulatory surgery center (ASC).
- At this time, it does not apply to commercial insurers.
- It does not apply to procedures performed in a physician’s office or to a physician’s services.
- The c-code is C9747, Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU), including image guidance.
What does this mean for you and the HIFU procedure?
When a man undergoes HIFU, much like other medical procedures, there are a variety of healthcare providers providing services in order to carry out the treatment. When you choose HIFU with HIFU Prostate Services, this includes:
- The facility (hospital, outpatient facility etc.) where the procedure takes place.
- The physician who performs the HIFU procedure.
- The anesthesiologist who administers anesthesia
- Concierge Patient Support Services
Each of these providers has a specific cost associated with providing their services.
What services does the code cover?
- This code applies only to the facility. This means that it will only reimburse the hospital or surgery center for services provided.
What is NOT covered with this code?
- Treating physician fees
- Anesthesiologist fees
- Concierge patient support services
As a Medicare patient, what can I expect to pay out of pocket for my HIFU procedure?
- As a Medicare patient, you may seek reimbursement for the facility cost using C-Code C9747. However, this only represents a portion of the overall cost of HIFU.
- You will still be responsible for all out of pocket expenses outside the facility cost.
- This out of pocket expense may vary but will probably be in the range of $9,000-12,000.
Medical Coding: What is the difference between a CPT Code and a C-Code?