[] Genzyme Corporate [] Genzyme Websites
  • Reimbursement Questions?

  • Make the SYNVISC Connection.
    Call: 1-800-982-8292
    Fax: 1-800-508-8083

  • 2010 Coding Changes

  • New unique code for SYNVISC® and Synvisc-One® for 2010.

    Learn More

Medicare Reimbursement

Physician’s Office

Medicare reimbursement for drugs and biologics administered in the physician’s office is based on average sales price (ASP), which for single-source drugs, is defined as the weighted average of sales of the product’s NDCs across all channels (eg, retail, hospital, and clinic). Volume discounts, prompt pay discounts, cash discounts, charge-backs, and rebates are all taken into account in the calculation of a product’s ASP. Medicare determines an ASP payment per billing unit of the product’s HCPCS code.

Synvisc-One® and SYNVISC® (hylan G-F 20) are reimbursed using a blended, multiple-source ASP formula. This means that the ASP-based allowable per HCPCS billing code J7325, for Synvisc-One and SYNVISC, will depend on both products’ ASP amounts, as well as the number of units of each NDC sold during the quarter.

  • The Medicare allowable payment for Synvisc-One and SYNVISC is ASP + 6% and is updated quarterly, based on sales in previous quarters.
  • Medicare reimburses 80% of the allowed payment amount patient, or patient’s secondary insurer/supplemental plan, is responsible for remaining 20%.

Administration:

  • Medicare also provides reimbursement for the administration of Synvisc-One and SYNVISC through the CPT code 20610 (arthrocentesis, aspiration and/or injection of a major joint or bursa)
  • State-based rates vary based on geographic wage differences

Bilateral procedures:

  • Physicians receive 150% of the payment amount for 20610.
  • Medicare reimburses 80% of the allowed payment amount Patient, or patient’s secondary insurer/supplemental plan, is responsible for remaining 20%.

Medicare billing instructions in the office setting:

 

Hospital Outpatient

Within the hospital outpatient department, Synvisc-One and SYNVISC are covered as Separately Covered Outpatient Drugs (SCODs), which are paid at a rate of ASP + 4%. Of this allowable rate, Medicare will reimburse 80%, and the patient or patient’s secondary insurer is responsible for the remaining 20% coinsurance.

Administration:

Medicare also reimburses for the administration of Synvisc-One and SYNVISC when provided in the hospital outpatient setting. Under the OPPS, Medicare reimburses the hospital outpatient department for CPT 20610 (arthrocentesis, aspiration, and/or injection of a major joint or bursa) under a fixed procedure APC payment rate. State payment rates will vary based on geographic wage indices.

Physicians should bill Medicare separately for their professional services given in the hospital outpatient setting that are associated with Synvisc-One and SYNVISC.

Bilateral procedures:

When a bilateral procedure is done, the reimbursement allowable to physicians and hospitals is 150% of the payment for CPT 20610. Of this amount, Medicare will reimburse 80%, and the patient or patient’s secondary/supplemental insurer will reimburse the remaining 20% coinsurance.

Mediicare billing instructions in the HOPD:

Please refer to Billing Codes for other relevant codes needed to ensure proper claim submission for Synvisc-One and SYNVISC.

Providers maintain responsibility for determining reimbursement and insurance issues related to their patients. Genzyme cannot be responsible for failure to obtain reimbursement.

Indication

SYNVISC® (hylan G-F 20) and Synvisc-One® (hylan G-F 20) are indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non pharmacologic therapy and simple analgesics, e.g., acetaminophen.

Important Safety Information

SYNVISC and Synvisc-One are contraindicated in patients with known hypersensitivity to hyaluronan products or patients with infections in or around the target knee. Use caution when injecting SYNVISC or Synvisc-One in patients allergic to avian proteins, feathers, or egg products; who have evidence of venous or lymphatic stasis in the leg to be treated; or who have severe inflammation in the knee to be treated.

Patients should be advised to avoid strenuous or prolonged weight-bearing activities for approximately 48 hours after treatment. Aspiration of any effusion prior to injection is highly recommended. Strict adherence to aseptic technique must be followed to avoid joint infection. The safety and effectiveness of SYNVISC and Synvisc-One have not been established in children or in pregnant or lactating women. It is unknown whether SYNVISC or Synvisc-One is excreted in human milk.

For SYNVISC
In clinical trials, the most commonly reported adverse events were transient local pain, swelling, and/or effusion in the injected knee. In some cases, these symptoms have been extensive. Other side effects such as rash have been reported rarely.

View the Complete Prescribing Information for SYNVISC (PDF)

For Synvisc-One
The most commonly reported related local adverse events were transient, mild-to-moderate arthralgia, arthritis, arthropathy, injection site pain and joint effusion. No serious adverse events were reported in clinical trials in knees injected with Synvisc-One. Serious local adverse events have been reported only rarely in post-marketing use.  Repeat treatment did not affect the safety profile. In the pivotal clinical trial, there was one related systemic event of syncope. The most common systemic side effects irrespective of relationship to Synvisc-One were headache, back pain, nasopharyngitis and influenza. Systemic adverse event profiles were similar between patients in the Synvisc-One and Saline Control groups.

View the Complete Prescribing Information for Synvisc-One (PDF)