Medicare Learning Network for Outpatient PPS Frequently Asked Questions and Answers (Excerpt)
I. Beneficiary services
Question: Will the Health Care Financing Administration (HCFA) be revising the 2000 Medicare beneficiary handbook or mass mailing a supplemental brochure that describes the revised coinsurance calculations?
Answer: Updated information will be included in the 2001 Medicare Handbook that will be mailed to all beneficiaries in October 2000. More detailed information is available upon request in a separate booklet that can be mailed free of charge if a beneficiary requests additional information.
II. Claims processing/ billing
Question: Is it appropriate for a hospital to bill for visits and procedures that are furnished by nonphysician practitioners? In many hospitals, nurses furnish outpatient services such as counseling sessions, preoperative evaluations, triage sessions, and urinary catheter placements. Also, some hospital-based physical therapists perform nonexcisional wound debridements, and in other hospitals physical and occupational therapists apply casts and strapping devices.
Answer: If the nonphysician practitioners (e.g., nurse practitioners, therapists, etc.) are employees of the hospitals, then these practitioners cannot bill for visits and procedures. As in the case above, these nonphysician practitioners would not be paid for counseling sessions, pre-op evaluations, triage sessions, or urinary catheter placements. The services/procedures provided would be bundled in the visit. However, if the nonphysician practitioner is an independent practitioner, he/she can bill for separate services (e.g., diabetic education), which would be paid separately.
Question: Should a hospital bill the HCPCS Level II code V2785 (corneal tissue processing) if a corneal transplant procedure is terminated before the corneal transplant is completed, but after the donor cornea has been inserted? Or should the hospital simply report the CPT corneal transplant code with the modifier -74 (discontinued surgery after the administration of anesthesia)?
Answer: The hospital should report the CPT corneal transplant code with a modifier -74.
Question: How should the units of service be reported when there are two modifiers reported next to a CPT code?
Answer: The units of service are independent of the modifier on the claim. It should be reported next to the service code.
Question: Please specify by name which prosthetics would be billed by the hospitals under HCPCS Level II code L8699 (prosthetic implant, not otherwise specified). For example, would this code be used to bill for intracoronary stents, and other items without a specific code that are listed in the Balanced Budget Refinement Act (BBRA) conference report?
Answer: To obtain this information, please review the pass-through and new technology list, which is featured on HCFA's Web page (www.hcfa.gov).
Question: How will fiscal intermediaries (FIs) be able to determine that the ordering physician is involved since the claim reports the attending physician?
Answer: It is not necessary to make a distinction.
Question: On a 12X type of bill, which laboratories are included vs. excluded?
Answer: Pathology and blood banking are the primary laboratories included. Additional information can be found in CR1141.
Question: If a claim is submitted with condition code 20 or 21 with both covered and noncovered charges, will it reject?
Answer: Yes.
Question: Should demand bills be submitted by the provider with the charges indicated in the covered and total charge fields or the noncovered and total charge fields?
Answer: The charges should be indicated in the noncovered and total charge fields.
Question: Will Value Code 17 be filled out by the provider or the FI?
Answer: It will be filled out by the FI.
Question: How long will it take to get ambulatory payment classification (APC) claims paid? Providers are concerned that FIs will be backlogged and delay payments even after claims can be processed.
Answer: Contingency planning has begun and will be in place to help providers through this transition period. More details regarding the contingencies will soon be available on the HCFA Web site.
Question: Should corneal tissue be reported with charges or acquisition costs?
Answer: It should be reported with charges.
Question: How will services be treated when HCFA creates two new codes in place of a CPT code? A specific example is for stereotactic radiosurgery (CPT code 61793). (This issue is discussed on p. 18,469 of the April 7, 2000, Federal Register).The rule says that HCFA has created two codes, GO173 and G0174, in place of 61793. The problem is that these codes are not in the CPT manual and thus hospitals will have to go in and manually adjust their systems to add in these new codes. If they code CPT code 61793 on a claim, it appears that it will be rejected (note that code 61793 has a status code of "E" in Addendum B, indicating it has been replaced). It would be nice if the grouper could make this conversion for hospitals (i.e., if a hospital coded 61793, the grouper would automatically convert it to a new code), but I don't think this can be done since there are two new codes and the grouper wouldn't know which one to assign. This seems like a significant burden for hospitals. I think it is important for hospitals to know which other CPT codes this has happened to.
Answer: To our knowledge, this has not happened with any other CPT codes. At this time, this is the only code of its kind.
Question: Why are there no HCPCS Level II "S" codes listed in the Addendum B of the April 7, 2000, Federal Register?
Answer: Level II S codes are non-Medicare codes.
Question: Would it be appropriate for a hospital to append a modifier -25 to a CPT medical visit code, in order to be paid for a medical visit that is rendered in one clinic when on the same day in another hospital department, the same patient had an "S" or "T" indicator procedure performed? This appears to be the only way that a hospital would generate payment for both the medical visit and the procedure/surgical service.
Answer: The hospital must use a combination code that consists of both the visit code and the procedure code with a modifier -25.
Question: Do the finger and toe modifiers apply to radiology CPT codes 73160 and 73660? These codes state "finger(s)" and "toe(s)" in their description, thus it appears as though they already classify one or more fingers, one or more toes being X-rayed on a single hand or a single foot. This should be clarified as soon as possible since many hospitals are planning to report each finger and each toe that is X-rayed thus triggering a plain film APC for each finger and each toe on a single hand/foot.
Answer: The toe modifiers would not apply to radiology CPT code 73660. When determining whether modifiers should be used for the toes and/or fingers, please review the following criteria:
1. Was the code used to report another service? If the answer is YES, then use the code to describe the service. If the answer is NO, then review the code descriptor.
2. Is the code descriptor singular or plural? If it is singular, use the procedure code with the specific modifier. If it is plural and the code descriptor includes more than one X-ray, use the CPT code to appropriately describe the procedure. For example, a patient comes in for a broken middle finger of the left hand. The physician orders an X-ray of the middle finger. The CPT code assigned to this procedure would be 73140-F2. However, if the patient comes in for two broken fingers (middle digit and second digit of the left hand), and the physician orders an X-ray of both digits, then the CPT code assigned would be 73140. This one CPT code would be used for both digits.
3. Determine the anatomic site. If a procedure was done on a specific site but the CPT code descriptor describes a general site, then use a modifier.
Question: Can a hospital use as an official source for the laterality status of a CPT code the bilateral status indicator that is listed in the Medicare Physician Fee Schedule Database at www.hcfa.gov/ stats/pufiles.htm#carrpuf.
Answer: Yes.
Question: Does the APC 090 include the pass-through payment for a pacemaker generator? There is no HCPCS Level II code provided for hospitals to report a pacemaker generator, or should the hospitals report the L8699 for a pacemaker generator?
Answer: This information can be obtained by reviewing the pass-through and new technology list that is featured on HCFA's Web page (www.hcfa.gov).
Question: Does an observation room have to have a HCPCS code?
Answer: HCPCS are not required; however, charges are required.
Question: Do you need charges with each surgical CPT code? If it is an ER charge, does the charge go on the line with the surgical HCPCS code?
Answer: When multiple surgical procedures are performed at the same session, it is not necessary to bill a separate charge for each procedure. It is acceptable to bill a single charge under the revenue code that describes where the procedure was performed (e.g. operating room, treatment room, emergency room, etc.) on the same line as one of the surgical procedure HCPCS codes and bill the other procedures using the appropriate HCPCS code and the same revenue code, but with "0" charges reported in the charge field.
If a surgical procedure is performed in the emergency room, the charge for the procedure must be billed with the emergency room revenue code. If an ER visit occurs on the same day, a charge should be billed for the ER visit and separate charge should be billed for the surgical procedure(s) performed. (Although, as described above, a single charge may be billed for all surgical procedures, if more than one is performed in the ER during the same session.)
We understand that some hospitals currently bill a single ER visit charge, which includes charges for any surgical procedures that are performed in the ER at the time of the ER visit. Under the outpatient prospective payment system (OPPS), HCFA will require that hospitals bill separate charges for ER visits and surgical procedures; however, HCFA will postpone this requirement until Jan. 1, 2001, so that hospitals will have sufficient time to separate charges, if they do not currently do so. To ensure proper payment under the new system, hospitals must bill separate HCPCS codes for the ER visit (using modifier 25) and the surgical procedure(s) even if they do not separate charges between ER visits and surgical procedures during the remainder of calendar year 2000.
Question: If three EKGs are performed, will all three be paid using modifier 76?
Answer: Yes.
Question: Do type "S" procedures that have modifiers get discounted?
Answer: Type S procedures are not subject to multiple procedure discounting (with the exception of aborted procedures). In other words, if a type S procedure is billed with modifier 50, the procedure should receive a 200% payment because it is not a type "T" and is, therefore, not subject to discounting.
Question: In many smaller, rural hospitals, the recovery rooms close at a certain time. The patients remaining in recovery are then moved to an observation area to complete their recovery. Please explain how this should be billed under OPPS.
Answer: Both recovery room and observation costs are packaged into the payment rate for the surgery. There is no separate payment. If a hospital moves patients into observation in the circumstance described, it is not a covered observation service. Observation has to be ordered on a patient-specific basis. Outpatient observation must be for the purpose of determining whether an individual patient will recover sufficiently to be discharged or must be admitted; it is not to be used as a substitute for recovery room services. If that individual determination is made, the charges for observation can be shown on the claim, and those charges will be used in setting the price of the procedure when APC rates are updated. There is still no separate payment for the observation.
Question: Based on what we learned in the reimbursement training session, drugs will be paid at 95% of the average wholesale price (AWP), but the first claims example shows revenue code 250 with no HCPCS code. Should we train the providers to use revenue code 636 and HCPCS codes for drugs, or is this not a claims issue?
Answer: Only drugs and biologicals approved for transitional pass-through payment will be paid at 95% of the AWP. An initial list of these items is included in Addendum K of the April 7, 2000, outpatient PPS final rule, and an updated list was posted to the HCFA Web site on May 12, 2000. Most drugs are packaged into the APC payment rates and are to be billed using revenue code 250. A HCPCS code is not required for packaged drugs. Certain high-cost drugs that are not packaged (e.g., tissue plasminogen activator/activase or TPA) but are paid as separate APCs as well as drugs approved for transitional pass-through payments that will be paid based on the AWP must be billed with revenue code 636 and the appropriate HCPCS code.
Question: Regarding observation services, if for some reason these services are denied, what impact would this have on reimbursement since such services are packaged?
Answer: The denial would not affect the APC payment because observation services are packaged. However, the decision would impact outlier and transitional corridor payments.
Question: If there is an ER visit and procedures are performed, such as minor surgical procedures, will all services be billed as line items with revenue code 450 or will each service be reported by the appropriate revenue center?
Answer: Report the appropriate revenue center code for each service based on where the service was performed. Surgical procedures can be billed in revenue code 450.
Question: Could you please document in writing which of the Part B inpatient services are and are not subject to OPPS?
Answer: The following services are paid under outpatient PPS when provided to an inpatient who does not qualify for Part A payment:
• diagnostic X-ray tests and other diagnostic tests (excluding clinical diagnostic laboratory tests);
• X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;
• surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations (splints and casts, etc., include dental splints);
• implantable prosthetic devices;
• pneumococcal vaccine and its administration, hepatitis B vaccine and its administration;
• certain preventive screening services (pelvic exams, screening sigmoidoscopies, screening colonoscopies, bone mass measurements, prostate screening.)
NOTE: Payment for some of these services is packaged into the payment rate of other, separately payable, services.
The following services are paid under other payment methods when provided to an inpatient who does not qualify for Part A payment:
• clinical diagnostic laboratory tests, prosthetic devices other than implantable ones and other than dental which replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices;
• leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes, including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patient's physical condition;
• outpatient physical therapy, outpatient occupational therapy, and outpatient speech pathology services;
• ambulance services;
• screening Pap smears, screening fecal occult blood tests, and screening mammography.
Question: Can hospitals HCPCS code all drugs and biologicals packaged using revenue code 636, if they choose, or are they limited to the published list?
Answer: Packaged drugs can be billed with revenue code 250. Packaged drugs billed in revenue Code 250 may be HCPCS coded. Drugs that will receive separate APC payments or transitional pass-through payments must be billed with revenue code 636 and HCPCS coded.
Question: Are critical access hospitals (CAHs) exempt from the codes that are deemed inpatient services?
Answer: Yes. CAHs, however, are subject to the observation policy, which states that observation is not a means to perform inpatient surgery on an outpatient basis. The FIs may look to the inpatient list to assist them in local medical review decisions.
Question: What about revenue code 760, post-procedure radiology and ASC? This is routine monitoring time. Revenue code 760 would be used if complications arose beyond the "routine" for that particular procedure time. Revenue code 762 is true observation not "routine" monitoring, so what about 760?
Answer: The revenue codes 760-769 are packaged, whether they represent treatment room charges or observation charges.
Question: With the delay in the effective date to 8/01/00, we assume this means service dates on/after 8/1/00. Is this true?
Answer: Yes, the delay will apply to claims with dates of service 8/1/00 and later.
Question: Will providers be given an extension to file elections for reduced coinsurance to 7/01/00 as a result of the delay?
Answer: Yes, providers will be given an extension to file elections for reduced coinsurance to 7/01/00 as a result of the delay.
Question: Will HCFA be publishing this delay to FIs officially through the CR process?
Answer: Yes, HCFA will be publishing the delay to FIs officially through the CR process. It will be reflected in CRs 1220 and 1229.
III. Coverage
Question: Is there a new designated drugs and biologicals list coming out soon?
Answer: HCFA hopes to have this out in June. (Question and answer posted 5/24/00.)
Question: Why weren't coronary stents included under devices?
Answer: Devices that came on the market prior to 1996 were packaged in with the APC. However, devices that came on the market after 1996 that applied for new technology and were approved were issued a c-code. For a list of new technology devices, see HCFA's Web page at www.hcfa.gov.
IV. Medical review
Question: Does Medical Review need to perform a complex medical review on claims suspended due to the OCE partial hospitalization edits?
Answer: Additional information on medical review will be included in the clarification of PM A-00-23 that will be released shortly. The OCE PHP edits do not absolutely require complex review if a determination to pay can be made without review or with only routine review.
Question: Since observation services are bundled into APC payments, does Medical Review review these services for medical necessity? If the observation room services are not medically necessary, does Medical Review deny the line and send the claim through the OCE again? Observation is a major problem. PRO groups are looking at this in their sixth scope of work.
Answer: When OPPS begins, Medical Review should not focus their review on observation rooms, but should review them for medical necessity if pulled during random review. If the observation services are not reasonable and necessary, they should still be denied. All claims will go through the OCE again after medical review, however, denial of observation room changes does not affect the reimbursement. These denials will affect future APC rates.
Question: While HCFA states this will not affect workload, with claims returning to the OCE after MR review, there is the increased ability to less workload due to claims being errored out by the OCE. A workload adjustment should be considered. Another reason for workload adjustment is the increased PHP claims that will come to MR for review. These are very time-consuming.
Answer: We recognize the shift in workload due to PPS and will be monitoring closely.
V. Payment
Question: Is the average wholesale price for drugs, biologicals, etc., going to be from a frozen point in time or will they be updated?
Answer: They will be updated on an annual basis. January 2001 will be the next time it is updated. When it is updated, HCFA will make the list of average wholesale prices available.
Question: Payment rates on the Federal Register go to two decimal places, but the downloadable spreadsheet goes to five or six places. Which one will actually be used?
Answer: Two decimal places will be used.
Question: How are new providers treated for TOPS?
Answer: There are default rates available for the new providers.
Question: Where does the deductible get applied first: the APC services or the non-APC services?
Answer: It is applied to the APC services first.
Question: Is the 776 coinsurance cap wage adjusted?
Answer: It is a flat amount and not wage-adjusted.
Question: HCFA's Web site contains an updated list of transitional pass-through items and new technology services under OPPS. The provider is wanting a more complete definition of the C codes listed so they can determine whether they have those products. Where did these C codes come from? We can't locate them in the HCPCS level II manual.
Answer: We (policy staff and coders in CHPP) assigned the C codes in a very short period in April. Especially for devices, they are too short to be meaningful. We have written long descriptors, and they are going to be on the HCFA Web site shortly. They will include more information about the manufacturer, type of device, and model.
Please forward additional questions to [email protected].
Source: Health Care Financing Administration, Baltimore. Web: www.hcfa.gov/medlearn/faqs.htm.
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