Payment Policies

Medicare payment policies are dictated by site of service with the likely sites of service for bone marrow aspiration and/or biopsy being the physician office (non-facility) setting and hospital outpatient (both hospital outpatient and ambulatory surgery center defined as facility setting).

• Office setting: Physicians may have equipment on site with the capability for imaging guidance for use in performing a bone marrow aspiration/biopsy such as ultrasound, fluoroscopy, or CT. In this case the physician can bill for imaging while performing the bone marrow biopsy/aspiration and receive a global payment (consisting of the professional and technical components [TC]).
• Hospital outpatient (ambulatory payment classification – APC ): There is no separate technical payment available for imaging guidance procedures in these settings. Technical payments for imaging guidance are bundled into the APC overall payment. Physicians in these instances can bill separately for their services using the “26” modifier appended to the above imaging codes.

2011 Medicare Reimbursement Rates

The following are the 2011 national average reimbursement rates for bone marrow biopsy and/or aspiration.¹ As well, national average reimbursement rates have been identified for the various imaging modalities that might be required in order to ensure correct needle placement.

2011-2012 Medicare Reimbursement Rates for C1830 (power bone marrow biopsy needle): The pass through payment for the OnControl^TM device is the hospital’s charge for the device, adjusted to the actual cost for the device (based on the hospital specific cost-to-charge ratio), minus the amount included in the APC payment amount for the device. ² In the case of APC 0003 (bone marrow biopsy), the amount included in the APC 0003 payment is $0.00.³.

2011 National Average Medicare payments for bone marrow biopsy/aspiration and imaging

	Office Setting (Non-facility)			Office Setting (Non-facility)
Descriptor	Technical Component (TC)	Professional Component (26)	Global	Technical Component (TC)	Professional Component (26)	Global
CPT Code 38220 Bone Marrow, Aspiration Only	N/A	N/A	$151.19	N/A	$61.50	$257.33
CPT Code 38221 Bone Marrow, Biopsy, Needle or Trocar	N/A	N/A	$163.43	N/A	$75.77	$257.33
HCPCS Code G0364  Bone Marrow Aspiration performed with Bone Marrow Biopsy through the same incision at the same date of service (for Medicare only procedures. Billed in combination with CPT 38221 above)	N/A	$13.36	$ -	N/A	$8.83	$ -
CPT Code 77002 Fluoroscopic guidance for needle placement (e.g. biopsy, aspiration, injection, localization device). When fluoroscopy is used for guidance with bone marrow aspiration and/or biopsy, not separately billable as an APC or ASC payment (e.g. fluoroscopy is bundled into APC 003 payment)	$48.25	$27.52	$75.77	$ -	$27.52	$ -
CPT Code 77012 Computed tomography guidance for needle placement (e.g. biopsy, aspiration, injection, localization device), radiological supervision and interpretation. When CT used for guidance with bone marrow aspiration and/or biopsy, not separately billable as an APC or ASC payment (e.g. CT is bundled into APC 003 payment)	$106.69	$57.08	$163.77	$ -	$57.08	$ -
CPT Code 76942 Ultrasound guidance for needle placement (e.g. biopsy, aspiration, injection, localization device), radiological supervision and interpretation. When ultrasound used for guidance with bone marrow aspiration and/or biopsy, not separately billable as an APC or ASC payment (e.g. Ultrasound is bundled into APC 003 payment)	$164.45	$33.64	$198.09	$ -	$33.64	$ -
HCPCS Code C1830 Power bone marrow biopsy needle	N/A	N/A	N/A	Reimbursement calculation: Charge X C/C ratio. Note: Reimbursement calculation applies to the hospital outpatient setting only. ASC reimbursement of C1830 is Medicare contractor priced. Therefore contact the individual Medicare carrier for specific pricing.

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References