Microsurgery and Robotic Surgery

Reimbursement Policy:
Microsurgery and Robotic Surgery

Effective Date:
June 1, 2020

Purpose:
Provide guidelines for the reimbursement of procedure codes S2900 or 69990. This policy applies to professional providers only.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home PAR
  • ITS Host Medicare Advantage
  • FEP

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Horizon BCBSNJ shall not consider for reimbursement the robotic or microsurgical technique (procedure codes S2900 or 69990) since these codes are not representative of the surgical procedure being performed. Horizon BCBSNJ considers these techniques to be integral to the primary surgical procedure code and not separately reimbursable.

The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall deny procedure code S2900 or 69990.

No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, no patient liability shall apply.

In instances where the provider is not participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
01/27/2020: Policy approved

Policy131_V1.0_01272020