Attention Insurers, Claims Offices and Adjusters: See important information regarding proper reimbursement of implants per the Medical Fee Schedule.

Proper Reimbursement of Implants Per the Georgia Workers' Compensation Medical Fee Schedule Guidelines

• Background
  When CMS introduced the J1 status indicator for device intensive codes back in 2015, the Board subtracted the cost of the implants from the Georgia fee.  Since that time, the Georgia Workers’ Compensation Medical Fee Schedule guidelines have stated that facilities should submit the wholesale invoice with the bill for reimbursement at cost.  Additionally, the Fee Schedule does not require that any specific code be used for the implant.  

• Resource
  Please refer to the wording on pages 14 and 455 of the 2026 Georgia Workers’ Compensation Medical Fee Schedule:

  [2026 Georgia Workers’ Compensation Medical Fee Schedule – p. 14]:
  Implants/Allografts/Instrumentation:  Certain outpatient procedures are assigned a comprehensive APC and designated as status indicator J1 and/or payment indicator J8. The OP/ASC MAR for the CPT® codes that are designated as status indicator J1 or payment indicator J8 have been adjusted in this fee schedule to remove the portion of the APC payment associated with the cost of the device/implant/allograft/instrumentation, as per the CMS OPPS APC offset file.  Devices/implants/allografts/instrumentation shall be reimbursed at cost if the wholesale vendor invoice for this item is included with the facility bill. This additional charge above the OP/ASC MAR, taking into account reasonable cost, medical necessity, and appropriateness, shall be negotiated in advance with the payer. See Section XIV: Inpatient Hospital Payment Schedule and Section XV: Outpatient Services – Hospital/ASC for additional information.

  [2026 Georgia Workers’ Compensation Medical Fee Schedule – p. 455]:
  Implants:  For the purpose of this fee schedule, implants are defined as devices (e.g., metal, plastic, ceramic, or other materials) or tissues (e.g., skin, bone, or other body tissues) that are surgically implanted, embedded, inserted, or otherwise applied that replace and act as missing body parts permanently or, in some cases, removed when they are no longer needed (e.g., screws to repair broken bones). It also includes any related equipment needed to operate, program, and recharge the implant (e.g., neurostimulators, pacemakers, and batteries). Tools and incidental supplies used for surgical implantation procedures (e.g., drill bits) are not reimbursable.  Hospitals and ASCs shall submit a hard copy of the wholesale vendor invoice for the implants at the cost to the hospital or ASC. In some cases, vendor invoices list multiple items; therefore, a copy of a multiple-item vendor invoice shall be acceptable. In this case, the payer shall calculate reimbursement for items used per procedure. Clarification of which implant is used for each procedure billed will facilitate reimbursement.  Only the actual invoiced cost of the item(s) shall be reimbursed. Tax, handling, and freight charges included in the hospital’s or ASC’s invoice cost shall not be reimbursed. See Section IV: General Reimbursement Requirements for more information on certain high-cost, device-intensive related outpatient procedures designated as status indicator J1.

• Many bill review companies are not following the Georgia Workers’ Compensation Medical Fee Schedule guidelines.  If you are using a third-party bill review company (and paying in accordance with the Georgia Workers’ Compensation Medical Fee Schedule), it is your responsibility to reimburse implants according to the Georgia Workers’ Compensation Medical Fee Schedule guidelines.

• Late Payment Penalties:  Please note that if payment has not been made according to the Georgia Workers’ Compensation Medical Fee Schedule guidelines, a late payment penalty will apply.  Refer to page 20 below:

  [2026 Georgia Workers’ Compensation Medical Fee Schedule – p. 20]:
  Late Payment
  All reasonable medical, surgical, hospital, and pharmacy goods and services shall be payable by the employer or its workers’ compensation insurer within 30 days of receipt of such charges and reports required by the Board. In the event that any documents or other information needed to process the claim or any portion thereof have not been provided to the employer or insurer, an explanation of benefits with payment information indicating why the charge has been reduced or disallowed shall be provided by the employer/insurer within 30 days of receipt of such charges.  If any charges for health care goods or services, for which all Board-required information is provided, are not paid within the 30-day period, penalties shall be added to such charges and paid at the same time as and in addition to the charges claimed for such services. (Refer to O.C.G.A. §34-9-203 and Board Rule 203 for complete rules and regulations.)

• If you are using a third-party bill review company, you should make sure you are using an updated Georgia Workers’ Compensation Medical Fee Schedule.  The Georgia Workers’ Compensation Medical Fee Schedule is updated annually on April 1st and can be purchased through our vendor FAIR Health.