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New York State
Workers' Compensation Board
OFFICE OF THE CHAIR
20 Park Street   Albany, New York 12207
Subject No. 046-166

PAYMENTS TO HOSPITALS FOR SPINAL PROCEDURES

Supersedes Subject No. 046-158,
NYSIF Payments To Hospitals For Spinal Procedures, dated May 31, 2006

Date: October 25, 2006

While the Chair of the Workers' Compensation Board is charged with establishing fee schedules for most medical treatment received by individuals eligible for benefits under the Workers' Compensation Law, Volunteer Firefighters' Benefit Law or Volunteer Ambulance Workers' Benefit Law, the Chair does not establish the fee schedule for reimbursement for inpatient hospital services. Pursuant to Public Health Law § 2807 (4) the Commissioner of Health must submit to the Chair a schedule of hospital inpatient reimbursement rates computed in accordance with Public Health Law § 2807-c (1) for an established rate period for payments pursuant to the Workers' Compensation Law, Volunteer Firefighters' Benefit Law and Volunteer Ambulance Workers' Law. The reimbursement amounts to general hospitals, pursuant to Public Health Law § 2807-c (1) (a) and (b-1), are case based payments per discharge for each diagnosis-related group (DRG) established in accordance with paragraph (a) of subdivision (3) of § 2807-c. Diagnosis-related group, as defined in 10 N.Y.C.R.R. § 86-1.50 (a), is the classification system used by the Medicare program under Title XVIII of the Social Security Act for purposes of reimbursing hospitals under the Federal prospect payment, except for variations set forth in the regulations of the Commissioner of Health.

It is not uncommon for workers' compensation, volunteer firefighter or volunteer ambulance worker claimants to suffer spinal injuries. To treat these spinal injuries it is sometimes necessary to perform spinal surgery and use in such surgery implantable hardware and instrumentation. The use of the hardware and instrumentation results in higher costs that are not covered by the statutorily required reimbursement methodology.

On August 16, 2006, bill A. 8840 / S. 5728 as Chapter 592 of the Laws of 2006, which amended the Workers' Compensation Law regarding the reimbursement of general hospitals for the use of implantable hardware and instrumentation in spinal surgeries, was enacted.. Specifically, Workers' Compensation Law § 13 is amended by adding a new subdivision (a-1) to read as follows:

(a-1) Notwithstanding the provisions of subdivision four of section twenty-eight hundred seven and subdivision one of section twenty-eight hundred seven-c of the public health law, payments to general hospitals for AP-DRGs 755-758 (spinal fusion; back and neck procedures), 806-807 (combined anterior and posterior spinal fusions), 836-837 (spinal procedures), and 864-865 (cervical spinal fusion) shall be at the rates of payment determined pursuant to section twenty-eight hundred seven-c of the public health law for state government agencies, excluding adjustments pursuant to subdivision fourteen-f of such section twenty-eight hundred seven-c, plus the provider's documented cost for any implantable hardware or instrumentation, which should be recorded under revenue code 278 on the claim, plus an additional ten percent of such documented cost not to exceed a maximum of three hundred fifty dollars. (emphasis added).

In other words when procedures relating to the DRGs listed are performed, the general hospital is to be reimbursed for the following: (a) the DRG; (b) the documented cost of the instrumentation and hardware used in the surgery, and (c) 10% of the documented cost, not to exceed $350.00.

This bill was signed into law on August 16, 2006 and is scheduled to expire on March 31, 2011. The new law not only had an immediate effective date, but, having become law after April 1, 2006, it is "deemed to have been in full force and effect on and after April 1, 2006." Therefore, for any procedures relating to the DRGs listed above and performed on and after April 1, 2006, the general hospital is entitled to the increased reimbursements. General hospitals where such procedures were performed may submit supplemental claims for the additional reimbursement. The additional reimbursement may only be requested when the actual surgery was performed on or after April 1, 2006; additional reimbursement is not available for surgeries performed prior to April 1, 2006.

The following link can be used to find Frequently Asked Questions regarding this Subject Number: http://www.wcb.ny.gov/content/main/SubjectNos/SpinalSurgeryImplantsQA.pdf adobe pdf .

For further information and for answers to any questions, please contact Joe Salamone, Director of Health Management at (518) 474-2686 or joe.salamone@wcb.ny.gov.