SI-BONE, Inc. has received some good news from the Centers for Medicare & Medicaid Services (CMS)…the company, makers of the iFuse Implant System, indicates that CMS has issued its 2016 Hospital Outpatient Prospective Payment System (HOPPS) payment recommendation for MIS SI joint fusion that provides an increased outpatient payment when billing CPT 27279 from $9, 266 to$10, 538 (14% over the current payment amount). And in good news for doctors, CMS has announced that the 2016 Medicare Physician Fee Schedule (MPFS) will have an increase in the physician reimbursement for MIS SI joint fusion procedures when billing CPT 27279 from the current national average of $577 to$722, a 25% increase. Both measures will be effective January 1, 2016.
“With increased reimbursement for both the surgeon and facility, CMS continues to recognize the increasing value of MIS SI joint fusion, ” said Michael Mydra, vice president of Health Outcomes & Reimbursement at SI-BONE, in the November 1, 2015 news release. “We believe that the iFuse Implant System fits strategically with the overall goals of the Affordable Care Act (ACA) by providing a safe, effective, and cost beneficial solution for the treatment of low back pain due to degenerative sacroiliitis and SI joint disruption.”
According to the news release, “In addition to the 2016 hospital outpatient and physician payment increases for MIS SI joint fusion, Medicare Administrative Contractor (MAC) Wisconsin Physician Services (WPS), covering the five states of Iowa, Indiana, Kansas, Michigan, Missouri and Nebraska, published a positive local coverage determination (LCD) that provides coverage beginning December 17. The decision by WPS to establish coverage for the procedure was based on a robust body of clinical evidence, over 95% of which is based on SI-BONE’s iFuse Implant System, that shows significant reduction in pain and improvement in quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption. Also, two additional MACs have released positive draft LCDs for MIS SI joint fusion. The first is National Government Services (NGS) covering ten states including Connecticut, Illinois, Massachusetts, Maine, Minnesota, New Hampshire, New York, Rhode Island, Vermont and Wisconsin and the second is CGS Administrators (CGS) which covers Ohio and Kentucky. Upon finalization of the draft LCDs for NGS and CGS, 49 out of 50 states will cover MIS SI joint fusion providing coverage for 48 million Medicare beneficiaries in the United States.”
“Once these 3 MACs implement coverage, seven of the eight MACs will have positive coverage for MIS SI joint fusion for over 98% of Medicare beneficiaries in the United States. We believe that the clinical and economic evidence supporting the iFuse Implant System as a safe and effective treatment for patients suffering from degenerative sacroiliitis or SI joint disruption has demonstrated that these patients deserve access to the procedure. We look forward to continuing our work to ensure that all patients have access to this important treatment option, ” said Jeffrey Dunn, president and CEO of SI-BONE.
Dunn told OTW, “In this challenging reimbursement environment, we believe our clinical and economic data has been a primary driving force in securing reimbursement for iFuse for people suffering from degenerative sacroiliitis and SI joint disruptions. We believe that seven of the eight MACs will provide positive coverage soon, and our hope is that this will lead to more uniform coverage among private payors so that all appropriate candidates have access to this life-changing procedure.”
