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Workers’ Compensation Board

New York State
Workers' Compensation Board
328 State Street  Schenectady, New York 12305
Governor Andrew M. Cuomo

Subject No. 046-471

Reimbursement for Spinal Surgery Implants Reinstated

Date: October 14, 2011

On September 23, 2011, Governor Cuomo signed into law Bill A. 6686-B / S. 4559-B as Chapter 517 of the Laws of 2011, which provides for separate reimbursement of implantable hardware and instrumentation used in spinal surgeries covered by workers' compensation. Since 2006, Workers' Compensation Law § 13(a-1) had provided for separate reimbursement of the implant costs in addition to the case payment which sunset on April 1, 2011. The new law extends the provision from April 1, 2011 to April 1, 2012.

The law provides for full reimbursement of the documented invoice cost of implantable hardware and instrumentation used in spinal surgeries that fall within one of the following All Patients Refined Diagnostic Related Groups (APR-DRGs):

23   spinal procedures

303   dorsal and lumbar fusion procedures for curvature of back

304   dorsal and lumbar fusion procedures except for curvature of back

310   intervertebral disc excision and decompression

321   cervical spinal fusion and other back/neck procedures excluding disc excision/decompression

The hospital is entitled to full payment of the case rate under the Inpatient Fee Schedule determined by the APR-DRG plus the documented invoice cost of the implants and an additional 10% of the invoice cost up to $350. The implant cost is to be recorded using revenue code 278 on the claim and should not be included in the total cost for purposes of determining eligibility for an outlier payment.

Hospitals are entitled to seek reimbursement for implants used in qualifying surgeries that occurred on or after April 1, 2011. The law will expire on April 1, 2012 as noted, and can be found in the link to the Bill above.

If you have additional questions, you may contact the Bureau of Health Management at (800) 781-2362.


Robert E. Beloten