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Code of Federal Regulations Title 42. Public Health § 42.416.179 Payment and coinsurance reduction for devices replaced without cost or when full or partial credit is received

Current as of January 02, 2025 | Updated by Findlaw Staff

(a) General rule. CMS reduces the amount of payment for a covered surgical procedure for which CMS determines that a significant portion of the payment is attributable to the cost of an implanted device not on pass-through status under subpart G of part 419 of this subchapter when one of the following situations occur:

(1) The device is replaced without cost to the ASC or the beneficiary;

(2) The ASC receives full credit for the cost of a replaced device;  or

(3) The ASC receives partial credit for the cost of a replaced device but only where the amount of the device credit is greater than or equal to 50 percent of the cost of the new replacement device being implanted.

(b) Amount of reduction to the ASC payment for the covered surgical procedure.

(1) The amount of the reduction to the ASC payment made under paragraphs (a)(1) and (a)(2) of this section is calculated in the same manner as the device payment reduction that would be applied to the ASC payment for the covered surgical procedure in order to remove predecessor device costs so that the ASC payment amount for a device with pass-through status under § 419.66 of this subchapter represents the full cost of the device, and no packaged device payment is provided through the ASC payment for the covered surgical procedure.

(2) The amount of the reduction to the ASC payment made under paragraph (a)(3) of this section is 50 percent of the payment reduction that would be calculated under paragraph (b)(1) of this section.

(c) Amount of beneficiary coinsurance. The beneficiary coinsurance is calculated based on the ASC payment for the covered surgical procedure after application of the reduction under paragraph (b) of this section.

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Cite this article: FindLaw.com - Code of Federal Regulations Title 42. Public Health § 42.416.179 Payment and coinsurance reduction for devices replaced without cost or when full or partial credit is received - last updated January 02, 2025 | https://codes.findlaw.com/cfr/title-42-public-health/cfr-sect-42-416-179/

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