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CMSManualSystemDepartmentofHealth&HumanServices(DHHS)Pub100-04MedicareClaimsProcessingCentersforMedicare&MedicaidServices(CMS)Transmittal1487Date:April8,2008ChangeRequest5999Subject:April2008UpdateoftheHospitalOutpatientProspectivePaymentSystem(OPPS)I.
SUMMARYOFCHANGES:ThisRecurringUpdateNotificationdescribeschangesto,andbillinginstructionsforvariouspaymentpoliciesimplementedintheApril2008OPPSupdate.
TheApril2008IntegratedCodeEditor(I/OCE)andOPPSPRICERwillreflecttheHealthcareCommonProcedureCodingSystem(HCPCS),AmbulatoryPaymentClassification(APC),HCPCSModifier,andRevenueCodeadditions,changes,anddeletionsidentifiedinthisnotification.
TheApril2008revisionstotheI/OCEdatafiles,instructions,andspecificationsareprovidedinChangeRequest(CR)5969,"April2008IntegratedOutpatientCodeEditor(I/OCE)SpecificationsVersion9.
1.
"TheattachedRecurringUpdateNotificationappliestoChapter4,Section50.
7.
Inaddition,thisCRincorporateschangesto§260.
1.
1whichwereincludedinCR5893,Transmittal1472,datedMarch6,2008.
New/RevisedMaterialEffectiveDate:April1,2008ImplementationDate:April7,2008Disclaimerformanualchangesonly:Therevisiondateandtransmittalnumberapplyonlytoreditalicizedmaterial.
Anyothermaterialwaspreviouslypublishedandremainsunchanged.
However,ifthisrevisioncontainsatableofcontents,youwillreceivethenew/revisedinformationonly,andnottheentiretableofcontents.
II.
CHANGESINMANUALINSTRUCTIONS:(N/Aifmanualisnotupdated)R=REVISED,N=NEW,D=DELETED-OnlyOnePerRow.
R/N/DChapter/Section/Subsection/TitleR4/TableofContentsR4/10.
11.
8/MethodologyforCalculationofHospitalOverallCCRforHospitalsthatHaveNursingandParamedicalEducationProgramsR4/20.
5/ClarificationofHCPCSCodetoRevenueCodeReportingD4/20.
5.
1/AppropriateRevenueCodestoReportMedicalDevicesThatHaveBeenGrantedPass-ThroughStatusD4/20.
5.
1.
1/PackagedRevenueCodesD4/20.
5.
1.
2/ClarificationRegardingRevenueCodes0274and0290D4/20.
5.
1.
3/ClarificationofHCPCSCodetoRevenueCodeReportingD4/20.
5.
2/HCPCS/RevenueCodeEditsR4/20.
6/UseofModifiersN4/20.
6.
10/UseofHCPCSModifier-FCR4/231.
2/WhenaProviderPaidUndertheOPPSPurchasesBloodorBloodProductsfromaCommunityBloodBankorWhenaProviderPaidUndertheOPPSAssessesaChargeforBloodorBloodProductsCollectedByItsOwnBloodBankThatReflectsMoreThanBloodProcessingandStorageR4/231.
4/BillingforSplitUnitofBloodR4/231.
6/BillingforFrozenandThawedBloodandBloodProductsR4/231.
7/BillingforUnusedBloodR4/260.
1/SpecialPartialHospitalizationBillingRequirementsforHospitals,CommunityMentalHealthCenters,andCriticalAccessHospitalsR4/260.
1.
1/BillReviewforPartialHospitalizationServicesProvidedinCommunityMentalHealthCenters(CMHC)III.
FUNDING:SECTIONA:ForFiscalIntermediariesandCarriers:NoadditionalfundingwillbeprovidedbyCMS;Contractoractivitiesaretobecarriedoutwithintheiroperatingbudgets.
SECTIONB:ForMedicareAdministrativeContractors(MACs):TheMedicareAdministrativeContractorisherebyadvisedthatthisconstitutestechnicaldirectionasdefinedinyourcontract.
CMSdoesnotconstruethisasachangetotheMACStatementofWork.
ThecontractorisnotobligatedtoincurcostsinexcessoftheamountsallottedinyourcontractunlessanduntilspecificallyauthorizedbytheContractingOfficer.
Ifthecontractorconsidersanythingprovided,asdescribedabove,tobeoutsidethecurrentscopeofwork,thecontractorshallwithholdperformanceonthepart(s)inquestionandimmediatelynotifytheContractingOfficer,inwritingorbye-mail,andrequestformaldirectionsregardingcontinuedperformancerequirements.
IV.
ATTACHMENTS:RecurringUpdateNotificationManualInstruction*Unlessotherwisespecified,theeffectivedateisthedateofservice.
CMS/CMM/MCMG/DCOMChangeRequestForm:Lastupdated08November2007Page1Attachment–RecurringUpdateNotificationPub.
100-04Transmittal:1487Date:April8,2008ChangeRequest:5999SUBJECT:April2008UpdateoftheHospitalOutpatientProspectivePaymentSystem(OPPS)EffectiveDate:April1,2008ImplementationDate:April7,2008I.
GENERALINFORMATIONA.
Background:ThisRecurringUpdateNotificationdescribeschangesto,andbillinginstructionsforvariouspaymentpoliciesimplementedintheApril2008OPPSupdate.
TheApril2008IntegratedCodeEditor(I/OCE)andOPPSPRICERwillreflecttheHealthcareCommonProcedureCodingSystem(HCPCS),AmbulatoryPaymentClassification(APC),HCPCSModifier,andRevenueCodeadditions,changes,anddeletionsidentifiedinthisnotification.
TheApril2008revisionstotheI/OCEdatafiles,instructions,andspecificationsareprovidedinChangeRequest(CR)5969,"April2008IntegratedOutpatientCodeEditor(I/OCE)SpecificationsVersion9.
1.
"TheattachedRecurringUpdateNotificationappliestoChapter4,Section50.
7.
B.
Policy:1.
ChangestoProceduretoDeviceEditsforApril2008ProceduretodeviceeditsrequirethatwhenaparticularproceduralHCPCScodeisbilled,theclaimmustalsocontainanappropriatedevicecode.
Failuretopasstheseeditswillresultintheclaimbeingreturnedtotheprovider.
WehavedeletedtheproceduretodeviceeditsforCPTcode36815,retroactivetotheiroriginalimplementationdateofOctober1,2005.
Thecompletelistofupdatededitscanbefoundatwww.
cms.
hhs.
gov/HospitalOutpatientPPS/underdownloads.
2.
ModificationofMethodologyforCalculationofHospitalOverallCost-to-ChargeRatio(CCR)forHospitalsthatHaveNursingandParamedicalEducationProgramsCMSisupdating§10.
11.
8oftheMedicareClaimsProcessingManual,Pub.
100-04,Chapter4,tofurtherrefinethemethodologyofthecalculationofthehospitaloverallCCRforhospitalsthathavenursingandparamedicaleducationprograms.
Specifically,theinstructionsforcalculatingtheCCRforcostcenter6200,non-distinctunitobservationbedsarebeingmodified.
ThisisaprospectivechangethatiseffectiveApril1,2008.
Itisunnecessarytoretroactivelyre-calculateCCRsthatareaffectedbythisinstruction.
3.
BillingforDrugs,Biologicals,andRadiopharmaceuticalsHospitalsarestronglyencouragedtoreportchargesforalldrugs,biologicals,andradiopharmaceuticals,regardlessofwhethertheitemsarepaidseparatelyorpackaged,usingthecorrectHCPCScodesfortheitemsused.
ItisalsoofgreatimportancethathospitalsbillingfortheseproductsmakecertainthattheCMS/CMM/MCMG/DCOMChangeRequestForm:Lastupdated08November2007Page2reportedunitsofserviceofthereportedHCPCScodeareconsistentwiththequantityofadrug,biological,orradiopharmaceuticalthatwasusedinthecareofthepatient.
WeremindhospitalsthatundertheOPPS,ifcommerciallyavailableproductsarebeingmixedtogethertofacilitatetheirconcurrentadministration,thehospitalshouldreportthequantityofeachproduct(reportedbyHCPCScode)usedinthecareofthepatient.
Alternatively,ifthehospitaliscompoundingdrugsthatarenotamixtureofcommerciallyavailableproducts,butareadifferentproductthathasnoapplicableHCPCScode,thenthehospitalshouldreportanappropriateunlisteddrugcode(J9999orJ3490).
Inthesesituations,weremindhospitalsthatitisnotappropriatetobillHCPCScodeC9399.
TheHCPCScodeC9399,Unclassifieddrugorbiological,isfornewdrugsandbiologicalsthatareapprovedbyFDAonorafterJanuary1,2004,forwhichaHCPCScodehasnotbeenassigned.
a.
DrugsandBiologicalswithPaymentsBasedonAverageSalesPrice(ASP)EffectiveApril1,2008IntheCY2008OPPSfinalrule,itwasstatedthatpaymentsforseparatelypayabledrugsandbiologicalsbasedonaveragesaleprices(ASPs)willbeupdatedonaquarterlybasisaslaterquarterASPsubmissionsbecomeavailable.
IncaseswhereadjustmentstopaymentratesarenecessarybasedonthemostrecentASPsubmissions,wewillincorporatechangestothepaymentratesintheApril2008releaseoftheOPPSPRICER.
TheupdatedpaymentrateseffectiveApril1,2008,willbeincludedintheApril2008updateoftheOPPSAddendumAandAddendumB,whichwillbepostedontheCMSWebsiteshortly.
b.
DrugsandBiologicalswithOPPSPass-ThroughStatusEffectiveApril1,2008FourdrugshavebeengrantedOPPSpass-throughstatuseffectiveApril1,2008.
Thesedrugs,theirdescriptorsandAPCassignmentsareidentifiedinTable1below.
Table1-DrugsandBiologicalswithOPPSPass-ThroughStatusEffectiveApril1,2008HCPCSCodeLongDescriptorAPCStatusIndicatorEffective4/1/08C9241Injection,doripenem,10mg9241GC9240Injection,ixabepilone,1mg9240GC9238Injection,levetiracetam,10mg9238GJ9226Histrelinimplant(SupprelinLa),50mg1142Gc.
NewHCPCSCodesforDrugsandBiologicalsEffectiveApril1,2008ThreenewHCPCScodeshavebeencreatedeffectiveApril1,2008.
ThesenewHCPCScodes,theirdescriptors,OPPSstatusindicatorsandAPCassignmentsarelistedinTable2below.
Table2-NewHCPCSCodesforDrugsandBiologicalsEffectiveApril1,2008HCPCSCodeLongDescriptorAPCStatusIndicatorQ4096Injection,VonWillebrandfactorcomplex,human,ristocetincofactor(nototherwisespecified),peri.
u.
VWF:RCO1213KQ4097Injection,immuneglobulin(Privigen),intravenous,non-lyophilized(e.
g.
,liquid),500mg1214KCMS/CMM/MCMG/DCOMChangeRequestForm:Lastupdated08November2007Page3Q4098Injection,irondextran,50mg1215Kd.
RevisedLongandShortHCPCSCodeDescriptorsforCardiacEchocardiographyServicesCardiacEchocardiographyWithContrastIntheJanuary2008UpdatetotheOPPS(CR5912,datedJanuary18,2008),welistedeightnewC-codesforcardiacechocardiographywithcontrastservices.
Thesecodes,specificallyC8921throughC8928,werelistedinTable14.
Toensureappropriatereportingoftheseservices,wehaverevisedtheshortandlongdescriptorsforC8921throughC8928,whicharereflectedinTable3below,toappropriatelyreflectthoseservicesthateitherusecontrastorareperformedwithoutcontrastfollowedbywithcontrast.
Hospitalsareremindedthatthesecodesshouldbereportedforechocardiogramswithcontrast,andhospitalsareadvisedtoreporttheappropriateunitsoftheHCPCScodesforthecontrastagentsusedintheperformanceoftheechocardiograms.
ThecontrastHCPCSQ-codesassociatedwiththeseservicesshouldbereportedseparately.
Table3-RevisedLongandShortHCPCSCodeDescriptorsforCardiacEchocardiographyServicesHCPCSRevisedShortDescriptorRevisedLongDescriptorC8921TTEworw/ofolw/cont,comTransthoracicechocardiographywithcontrast,orwithoutcontrastfollowedbywithcontrast,forcongenitalcardiacanomalies;completeC8922TTEworw/ofolw/cont,f/uTransthoracicechocardiographywithcontrast,orwithoutcontrastfollowedbywithcontrast;follow-uporlimitedstudyC89232DTTEworw/ofolw/con,coTransthoracicechocardiographywithcontrast,orwithoutcontrastfollowedbywithcontrast,real-timewithimagedocumentation(2d)withorwithoutm-moderecording;completeC89242DTTEworw/ofolw/con,fuTransthoracicechocardiographywithcontrast,orwithoutcontrastfollowedbywithcontrast,materialreal-timewithimagedocumentation(2d)withorwithoutm-moderecording;follow-uporlimitedstudyC89252DTEEworw/ofolw/con,inTransesophagealechocardiography(tee)withcontrast,orwithoutcontrastfollowedbywithcontrast,realtimewithimagedocumentation(2d)(withorwithoutm-moderecording);includingprobeplacement,imageacquisition,interpretationandreportC8926TEEworw/ofolw/cont,congTransesophagealechocardiography(tee)withcontrast,orwithoutcontrastfollowedbywithcontrast,forcongenitalcardiacanomalies;includingprobeplacement,imageacquisition,interpretationandreportC8927TEEworw/ofolw/cont,monTransesophagealechocardiography(tee)withcontrast,orwithoutcontrastfollowedbywithcontrast,formonitoringpurposes,includingprobeplacement,realtime2-dimensionalimageacquisitionandinterpretationleadingtoongoing(continuous)assessmentof(dynamicallychanging)cardiacpumpingfunctionandtotherapeuticmeasuresonanimmediatetimebasisC8928TEEworw/ofolw/con,stresTransthoracicechocardiographywithcontrast,orwithoutcontrastfollowedbywithcontrast,real-timewithimagedocumentation(2d),withorwithoutm-moderecording,duringrestandcardiovascularstresstestusingtreadmill,bicycleexerciseand/orpharmacologicallyinducedstress,withinterpretationandreportCardiacEchocardiographyWithoutContrastHospitalsareremindedtobillforechocardiogramswithoutcontrastinaccordancewiththeCPTcodedescriptorsandguidelinesassociatedwiththeapplicableLevelICPTcode(s)(93303-93350).
CMS/CMM/MCMG/DCOMChangeRequestForm:Lastupdated08November2007Page4e.
RecognitionofMultipleHCPCSCodesForDrugsPriortoJanuary1,2008,theOPPSgenerallyrecognizedonlythelowestavailableadministrativedoseofadrugifmultipleHCPCScodesexistedforthedrug;fortheremainderofthedoses,theOPPSassignedastatusindicator"B"indicatingthatanothercodeexistedforOPPSpurposes.
Forexample,ifdrugXhas2HCPCScodes,1fora1mldoseandasecondfora5mldose,theOPPSwouldassignapayablestatusindicatortothe1mldoseandstatusindicator"B"tothe5mldose.
Hospitalsthenwererequiredtobilltheappropriatenumberofunitsforthe1mldoseinordertoreceivepaymentundertheOPPS.
However,beginningJanuary1,2008,theOPPShasrecognizedeachHCPCScodeforaPartBdrug,regardlessoftheunitsidentifiedinthedrugdescriptor.
HospitalsmaychoosetoreportmultipleHCPCScodesforasingledrug,ortocontinuebillingtheHCPCScodewiththelowestdosagedescriptoravailable.
f.
CorrectReportingofDrugsandBiologicalsWhenUsedAsImplantableDevicesHospitalsarenottobillseparatelyfordrugandbiologicalHCPCScodes,withtheexceptionofdrugsandbiologicalswithpass-throughstatus,whenusingtheseitemsasimplantabledevices(includingasascaffoldoranalternativetohumanornonhumanconnectivetissueormeshusedinagraft)duringsurgicalprocedures.
UndertheOPPS,hospitalsareprovidedapackagedAPCpaymentforsurgicalproceduresthatincludesthecostofsupportiveitems,includingimplantabledeviceswithoutpass-throughstatus.
Whenusingdrugsandbiologicalsduringsurgicalproceduresasimplantabledevices,hospitalsmayincludethechargesfortheseitemsintheirchargefortheprocedure,reportthechargeonanuncodedrevenuecenterline,orreportthechargeunderadeviceHCPCScode(ifoneexists)sothesecostswouldappropriatelycontributetothefuturemediansettingfortheassociatedsurgicalprocedure.
g.
CorrectReportingofUnitsforDrugsHospitalsandprovidersareremindedtoensurethatunitsofdrugsadministeredtopatientsareaccuratelyreportedintermsofthedosagespecifiedinthefullHCPCScodedescriptor.
Thatis,unitsshouldbereportedinmultiplesoftheunitsincludedintheHCPCSdescriptor.
Forexample,ifthedescriptionforthedrugcodeis6mg,and6mgofthedrugwasadministeredtothepatient,theunitsbilledshouldbe1.
Asanotherexample,ifthedescriptionforthedrugcodeis50mgbut200mgofthedrugwasadministeredtothepatient,theunitsbilledshouldbe4.
Providersandhospitalsshouldnotbilltheunitsbasedonthewaythedrugispackaged,stored,orstocked.
Thatis,iftheHCPCSdescriptorforthedrugcodespecifies1mganda10mgvialofthedrugwasadministeredtothepatient,bill10units,eventhoughonly1vialwasadministered.
HCPCSshortdescriptorsarelimitedto28characters,includingspaces,soshortdescriptorsdonotalwayscapturethecompletedescriptionofthedrug.
Therefore,beforesubmittingMedicareclaimsfordrugsandbiologicals,itisextremelyimportanttoreviewthecompletelongdescriptorsfortheapplicableHCPCScodes.
4.
HCPCSCodeG0377HCPCScodeG0377,AdministrationofvaccineforPartDdrug,thatwasineffectfor2007isdiscontinuedforCY2008.
TheApril2008I/OCEwillimplementthischangeeffectiveJanuary1,2008.
HospitalsshouldnolongerbereportingthisserviceunderOPPS,asthisserviceiscoveredunderthePartDbenefitbeginningin2008.
CMS/CMM/MCMG/DCOMChangeRequestForm:Lastupdated08November2007Page55.
UseofHCPCSModifiersWeupdatedtheMedicareClaimsProcessingManual,Pub100-04,Chapter4,§20.
6toreflecttheadditionofHCPCSmodifiers–FBand–FCeffectiveJanuary1,2007,andJanuary1,2008,respectively.
Weadded§20.
6.
10,whichincludesthedefinitionofthemodifier-FC("Partialcreditreceivedforreplaceddevice").
OPPShospitalsmustreportthe-FCmodifierforcasesinwhichthehospitalreceivesapartialcreditof50percentormoreofthecostofanewreplacementdeviceunderwarranty,recall,orfieldaction.
Thehospitalmustappendthe-FCmodifiertotheprocedurecode(notthedevicecode)thatreportstheservicesprovidedtoreplacethedevice.
6.
ClarificationofHCPCSCodetoRevenueCodeReportingWeupdatedtheMedicareClaimsProcessingManual,Pub.
100-04,Chapter4,§20.
5toreflectthat,generally,CMSdoesnotinstructhospitalsontheassignmentofHCPCScodestorevenuecodesforservicesprovidedunderOPPSsincehospitals'assignmentsofcostsvary.
Whereexplicitinstructionsarenotprovided,providersshouldreporttheirchargesundertherevenuecodethatwillresultinthechargesbeingassignedtothesamecostcentertowhichthecostofthoseservicesareassignedinthecostreport.
PreviouslanguageprovidingguidanceonHCPCScodeandrevenuecodebillingwasdeleted.
7.
ClarificationofManualInstructionsRegardingBillingandPaymentforBloodandBloodProductsUndertheOPPSWeupdatedtheMedicareClaimsProcessingManual,Pub100-04,Chapter4,§§231.
2-231.
7toprovideimportantclarificationsregardingbillingforbloodandbloodproducts.
In§231.
2,wespecifytherequirementthatthesamelineitemdateofservice,thesamenumberofunits,thesameHCPCScode,andHCPCSmodifierBLmustbereportedonbothlines,appliestoallOPPSprovidersthattransfuseblood.
Wealsoclarifythat,inordertoensurecorrectapplicationoftheMedicareblooddeductible,providersshouldreportchargesforwholeunitsofpackedredcellsusingRevenueCode381(Packedredcells),andshouldreportchargesforwholeunitsofwholebloodusingRevenueCode382(Wholeblood).
RevenueCodes381and382shouldbeusedonlytoreportchargesforpackedredcellsandwholeblood,respectively.
Thebloodcodingrequirementsdiscussedin§231.
2donotapplytobloodandbloodproductscarryingonlyaprocessingandstoragefee;whenbillingonlyforbloodprocessingandstorage,OPPSprovidersshouldfollowthecodingrequirementsoutlinedin§231.
1.
RevenueCode380isnotavalidrevenuecodeforMedicarebilling.
In§231.
4,weclarifythatprovidersshouldbillsplitunitsofpackedredcellsandwholebloodusingRevenueCode389(Otherblood),andshouldnotuseRevenueCodes381(Packedredcells)or382(Wholeblood).
Providersshouldbillsplitunitsofotherbloodproductsusingtheapplicablerevenuecodesforthebloodproducttype,suchas383(Plasma)or384(Platelets),ratherthan389.
ReportingrevenuecodesaccordingtothesespecificationswillensuretheMedicarebeneficiary'sblooddeductibleisappliedcorrectly.
In§231.
6weprovideachartofbloodandbloodproductsindicatingwhetherprovidersshouldbillseparatelyforfreezingandthawingusingtheavailableCPTcodes.
In§231.
7,wespecifythatwherebloodorabloodproductissplitorirradiatedspecificallywiththeintentoftransfusiontoabeneficiarybutisnotthenused,thehospitalmaybillfortheservicesofsplittingorirradiatingtheunitofblood,butmaynotbillfortheHCPCScodeforthebloodproductthatwasnottransfused.
Thedateofservicemustbethedateonwhichthedecisionnottousethebloodwasmadeandindicatedinthepatient'smedicalrecord.
WheretheunitofbloodissplitorirradiatedandCMS/CMM/MCMG/DCOMChangeRequestForm:Lastupdated08November2007Page6storedwithoutspecificintentiontoadministerittoaMedicarebeneficiaryatthetimeofsplittingorirradiationandisnotsubsequentlytransfused,thereisnoservicetobereported.
8.
OutpatientPartialHospitalizationProgramServicesWeareupdatingtheMedicareClaimsProcessingManual,Pub.
100-04,Chapter4,§§260.
1and260.
1.
1toreflectourcurrentpoliciesforOutpatientPartialHospitalizationProgramServices.
9.
CoverageDeterminationsThefactthatadrug,device,procedureorserviceisassignedaHCPCScodeandapaymentrateundertheOPPSdoesnotimplycoveragebytheMedicareprogram,butindicatesonlyhowtheproduct,procedure,orservicemaybepaidifcoveredbytheprogram.
Fiscalintermediaries/Medicareadministrativecontractorsdeterminewhetheradrug,device,procedure,orotherservicemeetsallprogramrequirementsforcoverage.
Forexample,fiscalintermediariesdeterminethatitisreasonableandnecessarytotreatthebeneficiary'sconditionandwhetheritisexcludedfrompayment.
II.
BUSINESSREQUIREMENTSTABLEUse"Shall"todenoteamandatoryrequirementNumberRequirementResponsibility(placean"X"ineachapplicablecolumn)Shared-SystemMaintainersA/BMACDMEMACFICARRIERRHHIFISSMCSVMSCWFOTHER5999.
1MedicarecontractorsshallinstalltheApril2008OPPSPricer.
XXXXCOBC5999.
2MedicarecontractorsshallupdatetheoverallCCRtoincludethecostsforcostcenter6200fromworksheetD-1PartIVforallhospitals,excludingthecostsfornursingandparamedicaleducationprograms,atthenextscheduledCCRupdate.
SeetheattachedMedicareClaimsProcessingManual,Pub.
100-04,Chapter4forthemanualchangeto§10.
11.
8.
XXXCOBCIII.
PROVIDEREDUCATIONTABLENumberRequirementResponsibility(placean"X"ineachapplicablecolumn)Shared-SystemMaintainersA/BMACDMEMACFICARRIERRHHIFISSMCSVMSCWFOTHER5999.
3AprovidereducationarticlerelatedtothisinstructionwillbeavailableatXXXCOBCCMS/CMM/MCMG/DCOMChangeRequestForm:Lastupdated08November2007Page7NumberRequirementResponsibility(placean"X"ineachapplicablecolumn)Shared-SystemMaintainersA/BMACDMEMACFICARRIERRHHIFISSMCSVMSCWFOTHERhttp://www.
cms.
hhs.
gov/MLNMattersArticles/shortlyaftertheCRisreleased.
Youwillreceivenotificationofthearticlereleaseviatheestablished"MLNMatters"listserv.
Contractorsshallpostthisarticle,oradirectlinktothisarticle,ontheirWebsiteandincludeinformationaboutitinalistservmessagewithinoneweekoftheavailabilityoftheprovidereducationarticle.
Inaddition,theprovidereducationarticleshallbeincludedinyournextregularlyscheduledbulletin.
ContractorsarefreetosupplementMLNMattersarticleswithlocalizedinformationthatwouldbenefittheirprovidercommunityinbillingandadministeringtheMedicareprogramcorrectly.
IV.
SUPPORTINGINFORMATIONSectionA:Foranyrecommendationsandsupportinginformationassociatedwithlistedrequirements,usetheboxbelow:Use"Should"todenotearecommendation.
X-RefRequirementNumberRecommendationsorothersupportinginformation:CR5969April2008IntegratedOutpatientCodeEditor(I/OCE)SpecificationsVersion9.
1SectionB:Forallotherrecommendationsandsupportinginformation,usethisspace:V.
CONTACTSPre-ImplementationContact(s):MarinaKushnirova;marina.
kushnirova@cms.
hhs.
govPost-ImplementationContact(s):RegionalOfficeVI.
FUNDINGSectionA:ForFiscalIntermediaries(FIs),Carriers,andRegionalHomeHealthCarriers(RHHIs):NoadditionalfundingwillbeprovidedbyCMS;contractoractivitiesaretobecarriedoutwithintheiroperatingbudgets.
SectionB:ForMedicareAdministrativeContractors(MACs):CMS/CMM/MCMG/DCOMChangeRequestForm:Lastupdated08November2007Page8TheMedicareAdministrativeContractorisherebyadvisedthatthisconstitutestechnicaldirectionasdefinedinyourcontract.
CMSdoesnotconstruethisasachangetotheMACStatementofWork.
ThecontractorisnotobligatedtoincurcostsinexcessoftheamountsallottedinyourcontractunlessanduntilspecificallyauthorizedbytheContractingOfficer.
Ifthecontractorconsidersanythingprovided,asdescribedabove,tobeoutsidethecurrentscopeofwork,thecontractorshallwithholdperformanceonthepart(s)inquestionandimmediatelynotifytheContractingOfficer,inwritingorbye-mail,andrequestformaldirectionsregardingcontinuedperformancerequirements.
MedicareClaimsProcessingManualChapter4-PartBHospital(IncludingInpatientHospitalPartBandOPPS)TableofContents(Rev.
1487,04-08-08)TransmittalsforChapter4CrosswalktoOldManuals20.
5–ClarificationofHCPCSCodetoRevenueCodeReporting20.
6.
10-UseofHCPCSModifier-FC10.
11.
8-MethodologyforCalculationofHospitalOverallCCRforHospitalsthatHaveNursingandParamedicalEducationPrograms(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)DonotincludedepartmentalCCRsandchargesforservicesnotsubjecttotheOPPS(suchasphysical,occupationalandspeechlanguagetherapies,clinicaldiagnosticlaboratoryservices,ambulance,ruralhealthclinicservices,non-implantableDME,etc.
)incalculatingthehospital'scostsorcharges.
See§10.
11.
10forthelocationofthelistoftheexactcostcentersthatshouldbeincludedintheoverallCCR.
Step1--Determiningcostsforeachdepartment:FromWorksheetB,Part1–Column27,deductthenursingandparamedicaleducationcostsfoundontheapplicablelineinColumns21,and24ofWorksheetB,PartItocalculateacostforeachcostcenter.
Exception:Thecostsfor6200arenotcalculatedonthisworksheet.
Forcostcenter6200,non-distinctunitobservationbeds,usethecostreportedonWorksheetD-1,PartIV,line85,anddeductthenursingandparamedicaleducationcostsfoundonWorksheetD-1,PartIV,line89andsubscripts,column5.
SeeStep3below.
Step2–Determiningchargesforeachdepartment:FromworksheetC,Part1–Column8(sumofcolumns6and7),identify"totalcharges.
"Step3–DeterminingtheCCRsforeachdepartmentwithoutnursingandparamedicaleducationcosts:Foreachline,dividethecostsfromStep1bythechargesfromStep2toacquireCCRsforeachline,withoutinclusionofnursingandparamedicaleducationcosts.
Exception:Forcostcenter6200,non-distinctunitobservationbeds,usethecostreportedonWorksheetD-1,PartIV,line85,anddeductthenursingandparamedicaleducationcostsfoundonWorksheetD-1,PartIV,line89andsubscripts,column5.
.
Step4–DeterminingOverallCosts:MultiplytheCCRinstep3bytheMedicareoutpatientchargesforthatcostcenter(andsubscriptsthereof)fromWorksheetDPartV,Columns2,3,4,and5(andsubscriptsthereof).
SumthecostscalculatedforeachcostcentertoarriveatMedicareoutpatientcostofservicessubjecttoOPPS.
Step5–DeterminingOverallCharges:CalculatechargesbysummingtheMedicareoutpatientchargesfromFormCMS2552-96,WorksheetD,PartV,Columns2,3,4,and5(andsubscriptsthereof)foreachcostcenter(andsubscriptsthereof)thatreflectservicesubjecttotheOPPS.
Step6–CalculatingtheOverallCCR:DividethecostsfromStep4bythechargesfromstep5tocalculatethehospital'sMedicareoutpatientCCR.
20.
5-ClarificationofHCPCSCodetoRevenueCodeReporting(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)Generally,CMSdoesnotinstructhospitalsontheassignmentofHCPCScodestorevenuecodesforservicesprovidedunderOPPSsincehospitals'assignmentofcostvary.
Whereexplicitinstructionsarenotprovided,providersshouldreporttheirchargesundertherevenuecodethatwillresultinthechargesbeingassignedtothesamecostcentertowhichthecostofthoseservicesareassignedinthecostreport.
20.
6-UseofModifiers(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)TheIntegratedOutpatientCodeEditor(I/OCE)acceptsallvalidCPTandHCPCSmodifiersonOPPSclaims.
DefinitionsforthefollowingmodifiersmaybefoundintheCPTandHCPCSguides:LevelI(CPT)Modifiers-25,-27,-50,-52,-58,-59,-73,-74,-76,-77,-78,-79,-91LevelII(HCPCS)Modifiers-CA,-E1,-E2,-E3,-E4,-FA,-FB,-FC,-F1,-F2,-F3,-F4,-F5,-F6,-F7,-F8,-F9,-GA,-GG,-GH,-GY,-GZ,-LC,-LD,-LT,-QL,-QM,-RC,-RT,-TA,-T1,-T2,-T3,-T4,-T5,-T6,-T7,-T8,-T9Asindicatedin§20.
6.
2,modifier-50,whileitmaybeusedwithdiagnosticandradiologyproceduresaswellaswithsurgicalprocedures,shouldbeusedtoreportbilateralproceduresthatareperformedatthesameoperativesessionasasinglelineitem.
ModifiersRTandLTarenotusedwhenmodifier-50applies.
Abilateralprocedureisreportedononelineusingmodifier-50.
Modifier-50appliestoanybilateralprocedureperformedonbothsidesatthesamesession.
NOTE:Useofmodifiersappliestoservices/proceduresperformedonthesamecalendarday.
Othervalidmodifiersthatareusedunderotherpaymentmethodsarestillvalidandshouldcontinuetobereported,e.
g.
,thosethatareusedtoreportoutpatientrehabilitationandambulanceservices.
Modifiersmaybeappliedtosurgical,radiology,andotherdiagnosticprocedures.
Providersmustuseanyapplicablemodifierwhereappropriate.
Providersdonotuseamodifierifthenarrativedefinitionofacodeindicatesmultipleoccurrences.
EXAMPLES:Thecodedefinitionindicatestwotofourlesions.
Thecodeindicatesmultipleextremities.
Providersdonotuseamodifierifthenarrativedefinitionofacodeindicatesthattheprocedureappliestodifferentbodyparts.
EXAMPLES:Code11600(Excisionmalignantlesion,trunks,arms,orlegs;lesiondiameter0.
5cm.
orless)Code11640(Excisionmalignantlesion,face,ears,eyelids,nose,lips;lesiondiameter0.
5cm.
orless)Modifiers-GN,-GO,and-GPmustbeusedtoidentifythetherapistperformingspeechlanguagetherapy,occupationaltherapy,andphysicaltherapyrespectively.
Modifier-50(bilateral)appliestodiagnostic,radiological,andsurgicalprocedures.
Modifier-52appliestoradiologicalprocedures.
Modifiers-73,and-74applyonlytocertaindiagnosticandsurgicalproceduresthatrequireanesthesia.
Followingaresomegeneralguidelinesforusingmodifiers.
Theyareintheformofquestionstobeconsidered.
Iftheanswertoanyofthefollowingquestionsisyes,itisappropriatetousetheapplicablemodifier.
1.
WillthemodifieraddmoreinformationregardingtheanatomicsiteoftheprocedureEXAMPLE:Cataractsurgeryontherightorlefteye.
2.
WillthemodifierhelptoeliminatetheappearanceofduplicatebillingEXAMPLES:Usemodifier77toreportthesameprocedureperformedmorethanonceonthesamedateofservicebutatdifferentencounters.
Usemodifier25toreportsignificant,separatelyidentifiableevaluationandmanagementservicebythesamephysicianonthesamedayoftheprocedureorotherservice.
Usemodifier58toreportstagedorrelatedprocedureorservicebythesamephysicianduringthepostoperativeperiod.
Usemodifier78toreportareturntotheoperatingroomforarelatedprocedureduringthepostoperativeperiod.
Usemodifier79toreportanunrelatedprocedureorservicebythesamephysicianduringthepostoperativeperiod.
3.
WouldamodifierhelptoeliminatetheappearanceofunbundlingEXAMPLE:CPTcodes90765(Intravenousinfusion,fortherapy,prophylaxis,ordiagnosis(specifysubstanceordrug);initial,upto1hour)and36000(Introductionofneedleorintracatheter,vein):Ifprocedure36000wasperformedforareasonotherthanaspartoftheIVinfusion,modifier-59wouldbeappropriate.
20.
6.
10-UseofHCPCSModifier-FC(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)EffectiveJanuary1,2008,thedefinitionofmodifier-FCis"Partialcreditreceivedforreplaceddevice.
"SeetheMedicareClaimsProcessingManual,Pub100-04,Chapter4,§61.
3forinstructionsregardingchargesforitemsbilledwiththe-FCmodifier.
OPPShospitalsmustreportthe-FCmodifierforcasesinwhichthehospitalreceivesapartialcreditof50percentormoreofthecostofanewreplacementdeviceunderwarranty,recall,orfieldaction.
Thehospitalmustappendthe-FCmodifiertotheprocedurecode(notthedevicecode)thatreportstheservicesprovidedtoreplacethedevice.
231.
2-WhenaProviderPaidUndertheOPPSPurchasesBloodorBloodProductsfromaCommunityBloodBankorWhenaProviderPaidUndertheOPPSAssessesaChargeforBloodorBloodProductsCollectedByItsOwnBloodBankThatReflectsMoreThanBloodProcessingandStorage(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)IfanOPPSproviderpaysfortheactualbloodorbloodproductitself,inadditiontopayingforprocessingandstoragecostswhenbloodorbloodproductsaresuppliedbyeitheracommunitybloodbankortheOPPSprovider'sownbloodbank,theOPPSprovidermustseparatethechargefortheunit(s)ofbloodorbloodproduct(s)fromthechargeforprocessingandstorageservices.
TheOPPSproviderreportschargesforthebloodorbloodproductitselfusingRevenueCodeseries038X(excluding0380,whichisnotavalidrevenuecodeforMedicarebilling)withtheLIDOS,thenumberofunitstransfused,andtheappropriatebloodproductHCPCScodeandHCPCSmodifierBL.
TheOPPSproviderreportschargesforprocessingandstorageservicesonaseparatelineusingRevenueCode0390or0399withtheLIDOS,thenumberofunitstransfused,andtheappropriatebloodproductHCPCScodeandHCPCSmodifierBL.
ThesameLIDOS,thesamenumberofunits,thesameHCPCScode,andHCPCSmodifierBLmustbereportedonbothlines.
ThisrequirementappliestoallOPPSprovidersthattransfuseblood.
EffectiveforservicesfurnishedonorafterJuly1,2005,theI/OCEwillreturntoprovidersanyclaimthatreportsachargeforbloodorbloodproductsusingRevenueCode038XwithoutaseparatelineforprocessingandstorageservicesusingRevenueCode0390or0399.
Moreover,inordertoprocesstopayment,bothlinesmustreportthesamelineitemdateofservice,thesamenumberofunits,andthesameHCPCScodeaccompaniedbymodifierBL.
PaymentforbloodandbloodproductsisbasedontheAmbulatoryPaymentClassification(APC)GrouptowhichitsHCPCScodeisassigned,multipliedbythenumberofunitstransfused.
Unitsofwholebloodorpackedredcellsforwhichonlyprocessingandstoragechargesarereportedarenotsubjecttotheblooddeductible.
TheMedicareblooddeductibleisapplicableonlyiftheOPPSproviderpurchaseswholebloodorpackedredcellsfromacommunitybloodblankoriftheOPPSproviderassessesachargethatreflectsmorethanbloodprocessingandstorageforwholebloodorpackedredcellscollectedbyitsownsbloodbank.
Ifthebeneficiaryhasnotalreadyfulfilledtheannualblooddeductibleorreplacedtheblood,OPPSpaymentwillbemadeforprocessingandstoragecostsonly.
Thebeneficiaryisliableforthebloodportionofthepaymentastheblooddeductible.
InordertoensurecorrectapplicationoftheMedicareblooddeductible,providersshouldreportchargesforwholeunitsofpackedredcellsusingRevenueCode381(Packedredcells),andshouldreportchargesforwholeunitsofwholebloodusingRevenueCode382(Wholeblood).
RevenueCodes381and382shouldbeusedonlytoreportchargesforpackedredcellsandwholeblood,respectively.
Pleasenotethatthebloodcodingrequirementsdiscussedinthissectiondonotapplytobloodandbloodproductscarryingonlyaprocessingandstoragefee;whenbillingonlyforbloodprocessingandstorage,OPPSprovidersshouldfollowthecodingrequirementsoutlinedin§231.
1.
EXAMPLE:AnOPPSproviderpurchases2unitsofleukocyte-reducedredbloodcellsfromacommunitybloodbankandincursachargefortheredcellsthemselves,andachargeforthebloodbank'sprocessingandstorageoftheredbloodcellunit.
TheOPPSproviderfurtherincurscostsrelatedtoadditionalprocessingandstorageoftheredbloodcellunitsaftertheOPPSproviderhasreceivedthe2units.
AMedicarebeneficiaryistransfusedthetwounitsofleukocyte-reducedredbloodcells.
TheOPPSprovidershouldreportthechargesfor2unitsofP9016byseparatelybillingtheredbloodcellchargesandthetotalprocessingandstoragechargesincurred.
Thechargesfortheredbloodcellunitsaretobereportedononelinewiththedatethebloodwastransfused,RevenueCodeseries038X(excluding380),2units,HCPCScodeP9016,andmodifierBL.
Thetotalchargesforprocessingandstoragearetobereportedonthesameclaim,onaseparateline,showingthedatethebloodwastransfused,RevenueCode390or399,2units,HCPCScodeP9016,andmodifierBL.
NotethatHCPCSmodifierBLisreportedonbothlines.
231.
4-BillingforSplitUnitofBlood(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)HCPCScodeP9011wascreatedtoidentifysituationswhereoneunitofbloodorabloodproductissplitandsomeportionoftheunitistransfusedtoonepatientandtheotherportionsaretransfusedtootherpatientsortothesamepatientatothertimes.
Whenapatientreceivesatransfusionofasplitunitofbloodorbloodproduct,OPPSprovidersshouldbillP9011forthebloodproducttransfused,aswellasCPT86985(Splitting,bloodproducts)foreachsplittingprocedureperformedtopreparethebloodproductforaspecificpatient.
ProvidersshouldbillsplitunitsofpackedredcellsandwholebloodusingRevenueCode389(Otherblood),andshouldnotuseRevenueCodes381(Packedredcells)or382(Wholeblood).
Providersshouldbillsplitunitsofotherbloodproductsusingtheapplicablerevenuecodesforthebloodproducttype,suchas383(Plasma)or384(Platelets),ratherthan389.
ReportingrevenuecodesaccordingtothesespecificationswillensuretheMedicarebeneficiary'sblooddeductibleisappliedcorrectly.
EXAMPLE:OPPSprovidersplitsoffa100ccaliquotfroma250ccunitofleukocyte-reducedredbloodcellsforatransfusiontoPatientX.
Thehospitalthensplitsoffan80ccaliquotoftheremainingunitforatransfusiontoPatientY.
Atalatertime,theremaining70ccfromtheunitistransfusedtoPatientZ.
InbillingfortheservicesforPatientXandPatientY,theOPPSprovidershouldreportthechargesbybillingP9011and86985inadditiontotheCPTcodeforthetransfusionservice,becauseaspecificsplittingservicewasrequiredtoprepareasplitunitfortransfusiontoeachofthosepatients.
However,theOPPSprovidershouldreportonlyP9011andtheCPTcodeforthetransfusionserviceforPatientZbecausenoadditionalsplittingwasnecessarytopreparethesplitunitfortransfusiontoPatientZ.
TheOPPSprovidershouldbillRevenueCode0389foreachsplitunitoftheleukocyte-reducedredbloodcellsthatwastransfused.
231.
6-BillingforFrozenandThawedBloodandBloodProducts(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)Insituationswhereabeneficiaryreceivesatransfusionoffrozenbloodorabloodproductwhichhasbeenfrozenandthawedforthepatientpriortothetransfusion,anOPPSprovidermaybillthespecificHCPCScodewhichdescribesthefrozenandthawedproduct,ifaspecificcodeexists,inadditiontotheCPTcodeforthetransfusion.
.
IfaspecificHCPCScodeforthefrozenandthawedbloodorbloodproductdoesnotexist,thentheOPPSprovidershouldbilltheappropriateHCPCScodeforthebloodproduct,alongwithCPTcodesforfreezingand/orthawingservicesthatarenotreflectedinthebloodproductHCPCScode.
EXAMPLE:IfanOPPSprovidertransfusestheproductdescribedbyP9057(redbloodcells,frozen/deglycerolized/washed,leukocytesreduced,irradiated,eachunit),itwouldnotbeappropriatetobilladditionalCPTcodesforfreezingand/orthawingsincechargesforfreezingandthawingshouldbeincludedinthechargeforP9057.
Ifabloodproducthasbeenfrozenand/orthawedinpreparationforatransfusion,butthepatientdoesnotreceivethetransfusionofthebloodproduct,theOPPSprovidermaybillthepatientfortheCPTcodethatdescribesthefreezingand/orthawingservicesspecificallyprovidedforthepatient.
Similartobillingforautologousbloodcollectionwhenbloodisnottransfused,theOPPSprovidershouldbillthefreezingand/orthawingservicesonthedatewhentheOPPSprovideriscertainthebloodproductwillnotbetransfused(e.
g.
,dateofaprocedureordateofoutpatientdischarge),ratherthanonthedateofthefreezingand/orthawingservices.
ThefollowingchartofbloodandbloodproductsindicateswhetherprovidersshouldbillseparatelyforfreezingandthawingusingtheavailableCPTcodes.
HCPCS/CPTShortDescriptorBillingofFreezing/ThawingP9010WholebloodfortransfusionFreezingandthawingareseparatelybillableP9011BloodsplitunitFreezingandthawingareseparatelybillableP9012CryoprecipitateeachunitFreezingandthawingcodesnotseparatelybillableP9016RBCleukocytesreducedAlternativeP-codeforfrozen/thawedproductavailableP9017Plasma1donorfrzw/in8hrFreezingandthawingcodesnotseparatelybillableP9019Platelets,eachunitFreezingandthawingareseparatelybillableP9020PlaeletrichplasmaunitFreezingandthawingareseparatelybillableP9021RedbloodcellsunitAlternativeP-codeforfrozen/thawedproductavailableP9022WashedredbloodcellsunitFreezingandthawingareseparatelybillableP9023Frozenplasma,pooled,sdFreezingandthawingcodesnotseparatelybillableP9031PlateletsleukocytesreducedFreezingandthawingareseparatelybillableP9032Platelets,irradiatedFreezingandthawingareseparatelybillableP9033PlateletsleukoreducedirradFreezingandthawingareseparatelybillableP9034Platelets,pheresisFreezingandthawingareseparatelybillableP9035PlateletpheresleukoreducedFreezingandthawingareseparatelybillableP9036PlateletpheresisirradiatedFreezingandthawingareseparatelybillableP9037PlatepheresleukoreduirradFreezingandthawingareseparatelybillableP9038RBCirradiatedFreezingandthawingareseparatelybillableP9039RBCdeglycerolizedFreezingandthawingcodesnotseparatelybillableP9040RBCleukoreducedirradiatedAlternativeP-codeforfrozen/thawedproductavailableP9043Plasmaproteinfract,5%,50mlConceptnotapplicableP9044CryoprecipitatereducedplasmaFreezingandthawingcodesnotseparatelybillableP9048Plasmaproteinfract,5%,250mlConceptnotapplicableP9050Granulocytes,pheresisunitConceptnotapplicableP9051Blood,l/r,cmv-negFreezingandthawingareseparatelybillableP9052Platelets,hla-m,l/r,unitFreezingandthawingareseparatelybillableP9053Plt,pher,l/rcmv-neg,irrFreezingandthawingareseparatelybillableP9054Blood,l/r,froz/degly/washFreezingandthawingcodesnotseparatelybillableP9055Plt,aph/pher,l/r,cmv-negFreezingandthawingareseparatelybillableP9056Blood,l/r,irradiatedFreezingandthawingareseparatelybillableP9057RBC,frz/deg/wsh,l/r,irradFreezingandthawingcodesnotseparatelybillableP9058RBC,l/r,cmv-neg,irradFreezingandthawingareseparatelybillableP9059Plasma,frzbetween8-24hourFreezingandthawingcodesnotseparatelybillableP9060FrfrzplasmadonorretestedFreezingandthawingcodesnotseparatelybillable231.
7-BillingforUnusedBlood(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)WhenbloodorbloodproductswhichtheOPPSproviderhascollectedinitsownbloodbankorreceivedfromacommunitybloodbankarenotused,processingandstoragecostsincurredbythecommunitybloodbankandtheOPPSprovidercannotbechargedtothebeneficiary.
However,certainpatient-specificbloodpreparationcostsincurredbytheOPPSprovider(e.
g.
,bloodtypingandcross-matching)canbechargedtothebeneficiaryunderRevenueCodeSeries30Xor31X.
Patient-specificpreparationchargesshouldbebilledonthedatestheserviceswereprovided.
ProcessingandstoragecostsforunusedbloodproductsshouldbereportedascostsundercostcentersforbloodontheOPPSprovider'sMedicareCostReport.
Thesearecoststhatarenotconsideredpatient-specificbloodpreparationservices.
CostsforunusedbloodproductswhichhavebeenpurchasedalsoshouldbereportedascostsundercostcentersforbloodontheMedicareCostReport.
Wherebloodorabloodproductissplitorirradiatedspecificallywiththeintentoftransfusiontoabeneficiarybutisnotthenused,thehospitalmaybillfortheservicesofsplittingorirradiatingtheunitofblood,butmaynotbillfortheHCPCScodeforthebloodproductthatwasnottransfused.
Thedateofservicemustbethedateonwhichthedecisionnottousethebloodwasmadeandindicatedinthepatient'smedicalrecord.
WheretheunitofbloodissplitorirradiatedandstoredwithoutspecificintentiontoadministerittoaMedicarebeneficiaryatthetimeofsplittingorirradiationandisnotsubsequentlytransfused,thereisnoservicetobereported.
260.
1-SpecialPartialHospitalizationBillingRequirementsforHospitals,CommunityMentalHealthCenters,andCriticalAccessHospitals(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)MedicarePartBcoverageisavailableforhospitaloutpatientpartialhospitalizationservices.
A.
BillingRequirementSection1861oftheActdefinestheservicesunderthepartialhospitalizationbenefitinahospital.
Section1866(e)(2)oftheActrecognizesCMHCsas"providersofservices"butonlyforfurnishingpartialhospitalizationservices.
See§261.
1.
1forCMHCpartialhospitalizationbillreviewdirections.
HospitalsandCAHsreportconditioncode41inFLs24-30(orelectronicequivalent)toindicatetheclaimisforpartialhospitalizationservices.
Theymustalsoreportarevenuecodeandthechargeforeachindividualcoveredservicefurnished.
Inaddition,hospitaloutpatientdepartmentsarerequiredtoreportHCPCScodes.
CAHsarenotrequiredtoHCPCScodeforthisbenefit.
Undercomponentbilling,hospitalsarerequiredtoreportarevenuecodeandthechargeforeachindividualcoveredservicefurnishedunderapartialhospitalizationprogram.
Inaddition,hospitaloutpatientdepartmentsarerequiredtoreportHCPCScodes.
Componentbillingassuresthatonlythosepartialhospitalizationservicescoveredunder§1861(ff)oftheActarepaidbytheMedicareprogram.
Allhospitalsarerequiredtoreportconditioncode41inFLs24-30toindicatetheclaimisforpartialhospitalizationservices.
Hospitalsusebilltype13XandCAHsusebilltype85X.
Thefollowingspecialproceduresapply.
Billsmustcontainanacceptablerevenuecode.
Theyareasfollows:RevenueCodeDescription0250DrugsandBiologicals043XOccupationalTherapy0900BehavioralHealthTreatment/Services0904ActivityTherapy0910Psychiatric/PsychologicalServices(DatesofServicepriortoOctober16,2003)0914IndividualTherapy0915GroupTherapy0916FamilyTherapy0918Testing0942EducationTrainingHospitalsotherthanCAHsarealsorequiredtoreportappropriateHCPCScodesasfollows:RevenueCodeDescriptionHCPCSCodeRevenueCodeDescriptionHCPCSCode043XOccupationalTherapy*G01290900BehavioralHealthTreatment/Services90801,90802,908990904ActivityTherapy(PartialHospitalization)**G01760910PsychiatricGeneralServices(DatesofServicepriortoOctober16,2003)90801,90802,908990914IndividualPsychotherapy90816,90817,90818,90819,90821,90822,90823,90824,90826,90827,90828,9082990845,90865,or908800915GroupTherapy90849,90853,or908570916FamilyPsychotherapy90846,90847,or908490918PsychiatricTesting96101,96102,96103,96116,96118,96119,or961200942EducationTraining***G0177TheFIwilledittoassurethatHCPCSarepresentwhentheaboverevenuecodesarebilledandthattheyarevalidHCPCScodes.
TheFIwillnoteditformatchingtherevenuecodetoHCPCS.
*ThedefinitionofcodeG0129isasfollows:Occupationaltherapyservicesrequiringskillsofaqualifiedoccupationaltherapist,furnishedasacomponentofapartialhospitalizationtreatmentprogram,persession(45minutesormore).
**ThedefinitionofcodeG0176isasfollows:Activitytherapy,suchasmusic,dance,artorplaytherapiesnotforrecreation,relatedtocareandtreatmentofpatient'sdisablingmentalproblems,persession(45minutesormore).
***ThedefinitionofcodeG0177isasfollows:Trainingandeducationalservicesrelatedtothecareandtreatmentofpatient'sdisablingmentalhealthproblems,persession(45minutesormore).
CodesG0129andG0176,areusedonlyforpartialhospitalizationprograms.
CodeG0177maybeusedinbothpartialhospitalizationprogramandoutpatientmentalhealthsettings.
Revenuecode250doesnotrequireHCPCScoding.
However,Medicaredoesnotcoverdrugsthatcanbeself-administered.
EdittoassurethatHCPCSarepresentwhentheaboverevenuecodesarebilledandthattheyarevalidHCPCScodes.
DonoteditforthematchingofrevenuecodetoHCPCS.
B.
ProfessionalServicesTheprofessionalserviceslistedbelowwhenprovidedinallhospitaloutpatientdepartmentsareseparatelycoveredandpaidastheprofessionalservicesofphysiciansandotherpractitioners.
Theseprofessionalservicesareunbundledandthesepractitioners(otherthanphysicianassistants(PA)billtheMedicarePartBcarrierdirectlyfortheprofessionalservicesfurnishedtohospitaloutpatientpartialhospitalizationpatients.
ThehospitalcanalsoserveasabillingagentfortheseprofessionalsbybillingthePartBcarrierontheirbehalfundertheirbillingnumberfortheirprofessionalservices.
TheprofessionalservicesofaPAcanbebilledtothecarrieronlybythePAsemployer.
Thefollowingdirectprofessionalservicesareunbundledandnotpaidaspartialhospitalizationservices.
Physicianservicesthatmeetthecriteriaof42CFR415.
102,forpaymentonafeeschedulebasis;Physicianassistant(PA)servicesasdefinedin§1861(s)(2)(K)(i)oftheAct;Nursepractitionerandclinicalnursespecialistservices,asdefinedin§1861(s)(2)(K)(ii)oftheAct;andClinicalpsychologistservicesasdefinedin§1861(ii)oftheAct.
Theservicesofotherpractitioners(includingclinicalsocialworkersandoccupationaltherapists),arebundledwhenfurnishedtohospitalpatients,includingpartialhospitalizationpatients.
Thehospitalmustbillyouforsuchnonphysicianpractitionerservicesaspartialhospitalizationservices.
Makepaymentfortheservicestothehospital.
PAservicescanonlybebilledbytheactualemployerofthePA.
TheemployerofaPAmaybesuchentitiesorindividualssuchasaphysician,medicalgroup,professionalcorporation,hospital,SNF,ornursingfacility.
Forexample,ifaphysicianistheemployerofthePAandthePArendersservicesinthehospital,thephysicianandnotthehospitalwouldberesponsibleforbillingthecarrieronFormCMS-1500fortheservicesofthePA.
C.
OutpatientMentalHealthTreatmentLimitationTheoutpatientmentalhealthtreatmentlimitationmayapplytoservicestotreatmental,psychoneurotic,andpersonalitydisorderswhenfurnishedbyphysicians,clinicalpsychologists,NPs,CNSs,andPAstopartialhospitalizationpatients.
However,theoutpatientmentalhealthtreatmentlimitationdoesnotapplytosuchmentalhealthtreatmentservicesbilledtotheintermediarybyaCMHCorhospitaloutpatientdepartmentaspartialhospitalizationservices.
D.
ReportingofServiceUnitsHospitalsreportnumberoftimestheserviceorprocedure,asdefinedbytheHCPCScode,wasperformed.
CAHsreportthenumberoftimestherevenuecodevisitwasperformed.
YoumustRTPclaimsthatcontainmorethanoneunitforHCPCScodesG0129perday.
NOTE:Serviceunitsarenotrequiredtobereportedfordrugsandbiologicals(RevenueCode250).
E.
LineItemDateofServiceReportingHospitalsotherthanCAHsarerequiredtoreportlineitemdatesofserviceperrevenuecodelineforpartialhospitalizationclaims.
Thismeanseachservice(revenuecode)providedmustberepeatedonaseparatelineitemalongwiththespecificdatetheservicewasprovidedforeveryoccurrence.
LineitemdatesofservicearereportedinFL45"ServiceDate"(MMDDYY).
See§260.
5foradetailedexplanation.
F.
PaymentBeginningwithservicesprovidedonorafterAugust1,2000,forhospitaloutpatientdepartments,makepaymentunderthehospitaloutpatientprospectivepaymentsystemforpartialhospitalizationservices.
ApplyPartBdeductible,ifany,andcoinsurance.
G.
DataforCWFandPS&RIncluderevenuecodes,HCPCS/CPTcodes,units,andcoveredchargesinthefinancialdatasection(fields65a-65j),asappropriate.
Reportthebilledchargesinfield65h,"Charges,"oftheCWFrecord.
IncludeinthefinancialdataportionofthePS&RUNIBILL,revenuecodes,HCPCS/CPTcodes,units,andcharges,asappropriate.
260.
1.
1-BillReviewforPartialHospitalizationServicesProvidedinCommunityMentalHealthCenters(CMHC)(Rev.
1487,Issued:04-08-08,Effective:04-01-08,Implementation:04-07-08)A.
GeneralMedicarePartBcoverageforpartialhospitalizationservicesprovidedbyCMHCsisavailableeffectiveforservicesprovidedonorafterOctober1,1991.
B.
SpecialRequirementsSection1866(e)(2)oftheActrecognizesCMHCsas"providersofservices"butonlyforfurnishingpartialhospitalizationservices.
Applicableproviderrangesare1400-1499,4600-4799,and4900-4999.
C.
BillingRequirementsTheCMHCsbillforpartialhospitalizationservicesonFormCMS-1450orelectronicequivalentunderbilltype76X.
TheFIsfollowbillreviewinstructionsinChapter25exceptforthoselistedbelow.
Theacceptablerevenuecodesareasfollows:CodeDescription0250DrugsandBiologicals043XOccupationalTherapy0900BehavioralHealthTreatments/Services0904ActivityTherapy0910Psychiatric/PsychologicalServices(DatesofServicepriortoOctober16,2003)0914IndividualTherapy0915GroupTherapy0916FamilyTherapy0918Testing0942EducationTrainingTheCMHCsarealsorequiredtoreportappropriateHCPCScodesasfollows:RevenueCodesDescriptionHCPCSCode043XOccupationalTherapy(PartialHospitalization)*G01290900BehavioralHealthTreatments/Services90801,90802,908990904ActivityTherapy(PartialHospitalization)**G01760910PsychiatricGeneralServices(DatesofServicepriortoOctober16,2003)90801,90802,90899RevenueCodesDescriptionHCPCSCode0914IndividualPsychotherapy90816,90817,90818,90819,90821,90822,90823,90824,90826,90827,90828,90829,90845,90865,or908800915GroupPsychotherapy90849,90853,or908570916FamilyPsychotherapy90846,90847,or908490918PsychiatricTesting96101,96102,96103,96116,96118,96119,or961200942EducationTraining***G0177TheFIsedittoassurethatHCPCSarepresentwhentheaboverevenuecodesarebilledandthattheyarevalidHCPCScodes.
TheydonoteditforthematchingofrevenuecodestoHCPCS.
*ThedefinitionofcodeG0129isasfollows:Occupationaltherapyservicesrequiringtheskillsofaqualifiedoccupationaltherapist,furnishedasacomponentofapartialhospitalizationtreatmentprogram,persession(45minutesormore).
**ThedefinitionofcodeG0176isasfollows:Activitytherapy,suchasmusic,dance,artorplaytherapiesnotforrecreation,relatedtothecareandtreatmentofpatient'sdisablingmentalhealthproblems,persession(45minutesormore).
***ThedefinitionofcodeG0177isasfollows:Trainingandeducationalservicesrelatedtothecareandtreatmentofpatient'sdisablingmentalhealthproblems,persession(45minutesormore).
CodesG0129andG0176areusedonlyforpartialhospitalizationprograms.
CodeG0177maybeusedinbothpartialhospitalizationprogramandoutpatientmentalhealthsettings.
Revenuecode0250doesnotrequireHCPCScoding.
However,drugsthatcanbeself-administeredarenotcoveredbyMedicare.
HCPCSincludesCPT-4codes.
CMHCsreportHCPCScodesinFL44,"HCPCS/Rates.
"HCPCScodereportingiseffectiveforclaimswithdatesofserviceonorafterApril1,2000.
TheFIsaretoadvisetheirCMHCsoftheserequirements.
CMHCsshouldcompletetheremainingitemsonFormCMS-1450inaccordancewiththebillcompletioninstructionsinChapter25.
Theprofessionalserviceslistedbelowareseparatelycoveredandarepaidastheprofessionalservicesofphysiciansandotherpractitioners.
Theseprofessionalservicesareunbundledandthesepractitioners(otherthanphysicianassistants(PAs))billtheMedicarePartBcarrierdirectlyfortheprofessionalservicesfurnishedtoCMHCpartialhospitalizationpatients.
TheCMHCcanalsoserveasabillingagentfortheseprofessionalsbybillingthePartBcarrierontheirbehalffortheirprofessionalservices.
TheprofessionalservicesofaPAcanbebilledtothecarrieronlybythePAsemployer.
Thefollowingprofessionalservicesareunbundledandnotpaidaspartialhospitalizationservices:Physicianservicesthatmeetthecriteriaof42CFR415.
102,forpaymentonafeeschedulebasis;PAservices,asdefinedin§1861(s)(2)(K)(i)oftheAct;Nursepractitionerandclinicalnursespecialistservices,asdefinedin§1861(s)(2)(K)(ii)oftheAct;and,Clinicalpsychologistservices,asdefinedin§1861(ii)oftheAct.
Theservicesofotherpractitioners(includingclinicalsocialworkersandoccupationaltherapists)arebundledwhenfurnishedtoCMHCpatients.
TheCMHCmustbilltheFIforsuchnonphysicianpractitionerservicesaspartialhospitalizationservices.
TheFImakespaymentfortheservicestotheCMHC.
ThePAservicescanbebilledonlybytheactualemployerofthePA.
TheemployerofaPAmaybesuchentitiesorindividualsasaphysician,medicalgroup,professionalcorporation,hospital,SNF,ornursingfacility.
Forexample,ifaphysicianistheemployerofthePAandthePArendersservicesintheCMHC,thephysicianandnottheCMHCwouldberesponsibleforbillingthecarrieronFormCMS-1500fortheservicesofthePA.
D.
OutpatientMentalHealthTreatmentLimitationTheoutpatientmentalhealthtreatmentlimitationmayapplytoservicestotreatmental,psychoneurotic,andpersonalitydisorderswhenfurnishedbyphysicians,clinicalpsychologists,NPs,CNSs,andPAstopartialhospitalizationpatients.
However,theoutpatientmentalhealthtreatmentlimitationdoesnotapplytosuchmentalhealthtreatmentservicesbilledtotheFIaspartialhospitalizationservices.
E.
ReportingofServiceUnitsVisitsshouldnolongerbereportedasunits.
Instead,CMHCsreportinthefield,"ServiceUnits,"thenumberoftimestheserviceorprocedure,asdefinedbytheHCPCScode,wasperformedwhenbillingforpartialhospitalizationservicesidentifiedbyrevenuecodeinsubsectionC.
EXAMPLE:Abeneficiaryreceivedpsychologicaltesting(HCPCScode96100,whichisdefinedin1hourintervals)foratotalof3hoursduringoneday.
TheCMHCreportsrevenuecode0918,HCPCScode96100,and"3".
WhenreportingserviceunitsforHCPCScodeswherethedefinitionoftheproceduredoesnotincludeanyreferencetotime(eitherminutes,hoursordays),CMHCsshouldnotbillforsessionsoflessthan45minutes.
TheFIreturnstotheproviderclaimsthatcontainmorethanoneunitforHCPCScodeG0129orthatdoesnotcontainserviceunitsforagivenHCPCScode.
TheCMHCneednotreportserviceunitsfordrugsandbiologicals(RevenueCode0250)NOTE:InformationregardingtheclaimformlocatorsthatcorrespondwiththesefieldsandatabletocrosswalktheCMS-1450formlocatorstothe837transactionisfoundinChapter25.
F.
LineItemDateofServiceReportingDatesofserviceperrevenuecodelineforpartialhospitalizationclaimsthatspantwoormoredates.
Thismeanseachservice(revenuecode)providedmustberepeatedonaseparatelineitemalongwiththespecificdatetheservicewasprovidedforeveryoccurrence.
Lineitemdatesofservicearereportedin"ServiceDate".
Seeexamplesbelowofreportinglineitemdatesofservice.
Theseexamplesareforgrouptherapyservicesprovidedtwiceduringabillingperiod.
FortheHIPAA837,FIsreportasfollows:RecordTypeRevenueCodeHCPCSDatesofServiceUnitsTotalCharges61091590849199805051$8061091590849199805292$160ForthehardcopyFormCMS-1450,FIsreportasfollows:RevenueCodeHCPCSDatesofServiceUnitsTotalCharges0915908490505981$800915908490529982$160NOTE:InformationregardingtheclaimformlocatorsthatcorrespondwiththesefieldsandatabletocrosswalktheCMS-1450formlocatorstothe837transactionisfoundinChapter25.
TheFIsreturntoproviderclaimsthatspantwoormoredatesifalineitemdateofserviceisnotenteredforeachHCPCScodereportedorifthelineitemdatesofservicereportedareoutsideofthestatementcoversperiod.
LineitemdateofservicereportingiseffectiveforclaimswithdatesofserviceonorafterJune05,2000.
G.
PaymentSection1833(a)(2)(B)oftheActprovidesthestatutoryauthoritygoverningpaymentforpartialhospitalizationservicesprovidedbyaCMHC.
FIsmadepaymentonareasonablecostbasisuntilOPPSwasimplemented.
ThePartBdeductibleandcoinsuranceapplied.
PaymentprinciplesapplicabletopartialhospitalizationservicesfurnishedinCMHCsarecontainedin§2400oftheMedicareProviderReimbursementManual.
FIsaretofurnisheachCMHCwithonecopyofthatmanual.
TheFIsmakepaymentonaperdiembasisunderthehospitaloutpatientprospectivepaymentsystemforpartialhospitalizationservices.
CMHCsmustcontinuetomaintaindocumentationtosupportmedicalnecessityofeachserviceprovided,includingthebeginningandendingtime.
NOTE:Occupationaltherapyservicesprovidedtopartialhospitalizationpatientsarenotsubjecttotheprospectivepaymentsystemforoutpatientrehabilitationservices,andthereforethefinanciallimitationrequiredunder§4541oftheBalancedBudgetAct(BBA)doesnotapply.
H.
MedicalReviewTheFIsfollowmedicalreviewguidelinesintheMedicareProgramIntegrityManual.
I.
CoordinationWithCWFSeeChapter27.
Alleditsforbilltype74Xapply,exceptprovidernumberranges4600-4799areacceptableonlyforservicesprovidedonorafterOctober1,1991.