1. Developing a Strategic Reimbursement Plan
Second Annual Medical Device Regulatory, Reimbursement and Compliance Conference
Jill Rathbun
Galileo Consulting Group, Inc.
March 29, 2007

2. Reimbursement: A “Three-Legged Stool”
Coding
Reimbursement
Coverage
Payment

3. Coding CPT – 4 Standard within healthcare industry
In 2000, CPT set as national standard under HIPAA of 1996 to report physician procedures and services
CPT codes must be used for electronic transactions
Inclusion in CPT does not necessarily mean insurance coverage
About 7500 CPT codes included in Medicare’s Physician Fee Schedule
Need Clinical Vignette of the steps in the procedures where the device is used

4. Coding Categories of CPT Codes:
Category I Codes -Describe a service or procedure identified by a five –digit code and a descriptor
Category II Codes – Performance Measurement
Category III Codes – Emerging Technology

5. HCPCS Codes
The Federal Government develops and maintains HCPCS Level II Codes
Any supplier or manufacturer can submit a request for coding modifications
Deadline is once a year, January 3rd or the first business day in January.

6. Payment Questions to ask: Sight of Service
Physician Office
Hospital Outpatient
Hospital Inpatient
SNF
Home
Supply or separately payable device
Included in procedure payment
Additional payment above procedure
Health Care Personnel Involved
Previous Pricing of other devices in same class – who is typical

7. Payment Practice Expense RVUs APC Separately Payable Capitation
Cost or Cost plus
Capitation
DRG
Home Health Rates
SNF Rates
PT/OT Cap

8. Coverage Medicare Medicaid Private Insurance Coverage Limits
General Medical Reasonableness
National Coverage Determination
Local Coverage Determination
Medicaid
Private Insurance
Coverage Limits

9. Things to Think About Risk/Reward of Reimbursement
Investment of Resources and Time to Achieve End
Partners
Impact on Sales Strategy and Adoption

10. Working with Medical Societies
Identifying specialties that will use the device
Understanding who the leaders are in each society and the internal relationships and personalities
Where Societies Can Help You:
CPT Code Applications
Consensus Statements
CAC Members
Private Insurance

11. Questions?
Contact Information:
Jill Rathbun, Galileo Consulting Group, Inc.