CurrentPremera BluecrossPolicy CP PP 397.vL.7.

Robotic Surgical System and Computer Assisted Navigation Codes (S2900, 20985, 0054T, 0055T)

Defines Premera Blue Cross payment policy for robotic surgical system and computer-assisted navigation add-on codes for musculoskeletal surgical services and explains billing/reimbursement treatment for professional and facility claims across Premera lines of business.

Policy Summary

PayerPremera Bluecross

PolicyRobotic Surgical System and Computer Assisted Navigation Codes (S2900, 20985, 0054T, 0055T)

Policy CodePolicy CP PP 397.vL.7.

Change TypeClarification / Organizational edits

Effective Date

Next Review Date

Key ActionSubmit medical records when appending modifier 22 to support requests for additional payment for increased procedural services.

SourceLink

POLICY UPDATE CHANGES

Appended statement that appending modifier 22 to represent use of robotic or computer-assisted techniques is not a guarantee of additional payment and requires submission of medical records for clinical review.

Clarified that the policy pertains to professional services billed on CMS-1500/837P and facility services billed on UB-04/837I (previous versions varied).

Created separate Codes/Coding Guidelines section and moved codes/descriptions into it.

4CPT/HCPCS codes referenced

NonePolicy exceptions

MultipleAnnual review dates listed

Payment Integrity Oversight CommitteePolicy owner/reviewer

Coverage and Billing Rules

Coverage and billing rules

Policy position on reimbursement for add-on robotic and navigation codes:

ALL of the following

Robotic system services and computer-assisted navigation for musculoskeletal surgical services are techniques used to perform the main surgical procedure and not a separate service (codes S2900, 20985, 0054T, 0055T).
When these add-on codes are billed, they are considered bundled/included as part of the primary surgical procedure and are not separately reimbursable whether billed separately or in conjunction with a primary procedure.
Codes marked with '+' are add-on codes and must be billed with an appropriate primary procedure.
Appending modifier 22 (Increased Procedural Services) to a surgical code for the sole purpose of representing the use of robotic or computer-assisted surgical techniques does not warrant or guarantee additional payment.

Policy Summary

PayerPremera Bluecross

PolicyRobotic Surgical System and Computer Assisted Navigation Codes (S2900, 20985, 0054T, 0055T)

Policy CodePolicy CP PP 397.vL.7.

Change TypeClarification / Organizational edits

Effective Date

Next Review Date

Key ActionSubmit medical records when appending modifier 22 to support requests for additional payment for increased procedural services.

SourceLink

On This Page

Codes and Billing Notes

Robotic and computer-assisted navigation add-on codesCPT | HCPCS | mixedCovered

S2900	Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)
20985	Computer assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure)
0054T	Computer assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on fluoroscopic images (List separately in addition to code for primary procedure)
0055T	Computer assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on CT/MRI images (List separately in addition to code for primary procedure)

Add-on designation notemixed

+	Denotes an add-on code which must be billed with an appropriate primary procedure

Add-on requirement

Add-on requirementCodes marked with '+' are add-on codes and must be billed with an appropriate primary procedure.

Examples of add-on codes in this policy+0054T, +0055T are explicitly identified as add-on codes that list separately in addition to the primary procedure.

Billing instructionAdd-on codes should be submitted in conjunction with the primary procedure code on the claim form (CMS-1500/837P or UB-04/837I).

Documentation, Prior Authorization, and Modifier Use

Prior Authorization

Prior Authorization / Documentation Requirement for Modifier 22

Prior authorization/documentation required when appending modifier 22 (Increased Procedural Services). Appending modifier 22 to a surgical code solely to indicate the use of a robotic surgical system or computer-assisted navigation does not guarantee additional payment. Submission of complete medical records is required whenever modifier 22 is billed so the clinical review can determine whether documentation supports payment for increased procedural services.

Affected codes: S2900, 20985, 0054T (robotic/computer-assisted technique/add-on codes)
When modifier 22 is appended: provider must submit medical records for clinical review to support increased procedural services
Modifier 22 appended solely to represent use of robotic or computer-assisted techniques is not sufficient to guarantee additional payment

Key Definitions

Add-on code (definition)

DefinitionAn add-on code denotes a procedure 'listed separately in addition to code for primary procedure' and is intended to represent an adjunct technique or component rather than a standalone service.

NotationIn this policy '+ = Denotes an add-on code', indicating the code must be billed with an appropriate primary procedure.

Policy treatmentWhen add-on codes (e.g., S2900, 20985, 0054T, 0055T) are billed they are considered bundled/included in the primary surgical procedure and are not separately reimbursable unless documentation supports otherwise.

Modifier 22 (definition)

Modifier 22 meaningModifier 22 indicates increased procedural services (Increased Procedural Services).

Limitation on paymentAppending modifier 22 to represent use of robotic or computer-assisted techniques does not warrant or guarantee additional payment.

Documentation requirementSubmission of medical records is required when submitting modifier 22 for clinical review to determine if increased procedural services are supported to warrant additional payment.