Macroplastique® Reimbursement

iStock_000075361169_Edited.jpgReimbursement for Macroplastique when used to treat intrinsic sphincter deficiency related to female stress incontinence.

Cogentix Medical has compiled this coding information for your convenience. This information is gathered from third-party sources and is subject to change without notice. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. It is always the provider’s responsibility to determine medical necessity and submit appropriate codes, modifiers, and charges for services rendered. Please contact your local carrier/payer for interpretation of coding and coverage. Cogentix Medical does not promote the use of its products outside their FDA cleared or approved labeling.

Macroplastique Coverage

All Medicare Carriers and most private insurance payers cover Macroplastique as a urethral bulking treatment for adult females with Stress Urinary Incontinence (SUI) primarily due to intrinsic sphincter deficiency (ISD). It is recommended that you get approval from the patient's insurance company before treatment begins. Medicare does not require prior authorization.

Macroplastique Billing Codes

Macroplastique is indicated for transurethral injection in the treatment of adult women diagnosed with stress urinary incontinence (SUI) primarily due to intrinsic sphincter deficiency (ISD).

ICD-10 CM8 – Diagnosis Codes

It is the physician's responsibility to select the most accurate diagnosis code(s) to describe a patient's condition. The following diagnosis codes may be applicable for Macroplastique; however, some medical policies may specify which diagnosis codes support medical necessity.

N36.421 Intrinsic sphincter deficiency
(must appear as primary diagnosis)

N39.31 Stress incontinence, female

Physician and Facility Coding

OFFICE - Site of Service 11

CPT® Code2 Total Non
Facility
RVUs3
Medicare
National
Allowed
Amount3,4
Physician Coding    
51715 - Endoscopic injection of implant material into the submucosal tissue of the urethra and/or bladder neck 8.31 $298.24
HCPCS Code    
L86065- Synthetic implant urinary 1ml NA

$189.10 - $252.13 per ml

  • HCPCS Code L8606 is for 1 ml. Two syringes of Macroplastique (up to 5 ml) are recommended for each procedure.
  • Providers do not need to be a DME supplier to bill their local Medicare carrier for HCPCS code L8606.

OUT PATIENT - Site of Service 22

CPT® Code Total Facility RVUs3 Medicare
National
Allowed
Amount3,4
Physician Coding    
51715 - Endoscopic injection of implant material into the submucosal tissue of the urethra and/or bladder neck 5.77 $207.08
Facility Coding    
51715 - Endoscopic injection of implant material into the submucosal tissue of the urethra and/or bladder neck APC 5374 $2,542.56
HCPCS Code    
L86065 - Synthetic implant urinary 1ml NA Billing requirements only; no additional payment
  • HCPCS Code L8606 is for 1 ml. Up to 5 ml of Macroplastique (2 syringes) are recommended.
  • Providers do not need to be a DME supplier to bill their local Medicare carrier for HCPCS code L8606.

ASC - Site of Service 24

CPT® Code Total Facility
RVUs3
Medicare
National
Allowed
Amount3,4
Physician Coding    
51715 - Endoscopic injection of implant material into the submucosal tissue of the urethra and/or bladder neck 5.77 $207.08
Facility Coding    
51715 - Endoscopic injection of implant material into the submucosal tissue of the urethra and/or bladder neck NA $1,181.53

1. Macroplastique is FDA approved to treat adult female stress urinary incontinence (SUI) primarily due to intrinsic sphincter deficiency (ISD). The FDA does not specify diagnosis codes.
2. CPT® is a registered trademark of the American Medical Association. All rights reserved. No fee schedules, basic units, relative values, or related listing are included in CPT.
3. 42 CFR Parts 403, 405, 410 et al. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare and Medicaid and Medicaid Innovation Models & Other Revisions to Part B for CY 2017; Final Rule, November 15, 2016.
4. "Allowed Amount" is the payment Medicare determines to be the maximum allowance for any Medicare-covered service. Actual payment will be based on the geographically adjusted maximum allowed amount less any applicable deductible, coinsurance, etc.
5. In the physician office setting, the Medicare Administrative Contractor for Part B has jurisdiction for this implantable prosthetic device
6. 2017 Durable Medical Equipment Prosthetics/Orthotics and Supplies Fee Schedule (DMEPOS). Source: https://www.cms.gov/medicare/medicare-fee-for-service-payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule 
7. 42 CFR Parts 405, 410, 412, et al. Medicare  Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; short hospital stays; Transition For Certain Medicare-Dependent. Small Rural Hospitals Under the Hospital Inpatient Prospective Payment System. Provider Administrative Appeals and Judicial Review; Final Rule, November 14, 2016.
8. The implementation date for ICD-10 is October 1, 2015