Transcript American Red Cross Reimbursement Update

American Red Cross
and Reimbursement
Reimbursement Update Outpatient Prospective Payment System (OPPS) Billing Guidance
Resulting from April 12, 2001 Program Memorandum
The April 12, 2001 Program Memorandum
Blends Well with Hospitals’ Historic Coding
and Billing Practices for Blood and Blood
Products
Background
On April 12, 2001, the Health Care Financing
Administration (HCFA) published a program
memorandum. This program memorandum
represents HCFA’s official guidance on coding and
billing for blood products under the new Outpatient
Prospective Payment System (OPPS), commonly
known as Ambulatory Payment Classifications or
APCs (see Exhibit A). Below, the American Red
Cross discusses the implications of this guidance
and provides direction to its hospital customers. In
addition, we provide our hospital customers with
materials to support their outpatient coding and
billing efforts.
The program memorandum instructs hospitals who
receive blood from the Red Cross or another nonprofit blood center to pass along the processing and
storage fees assessed by the Red Cross or the blood
center using the 390 revenue code. The program
memorandum further instructs hospitals to bill with
the appropriate blood product-specific HCPCS codes
(i.e., P9016, Red blood cells, leukocyte reduced).
Finally, hospitals can bill for blood related laboratory
tests under the appropriate laboratory revenue code,
either 30X or 31X.
HCFA’s April 12, 2001 Program
Memorandum Makes Official an Earlier
Guidance Posted on the OPPS Website
Below is a summary of how a hospital might bill
Medicare for an outpatient transfusion of
leukoreduced packed red cells, assuming the hospital
receives its blood components from the American
Red Cross. Please refer to Exhibits B & C for
additional detail.
The April 12, 2001 program memorandum is
hopefully the last step in HCFA’s implementation
of OPPS, as it relates to blood and blood
components. The fiscal intermediaries began
paying claims under OPPS starting with dates of
service on or after August 1, 2000. In early
December 2000, HCFA provided its first billing
guidance to hospitals for blood and blood products
via the “Frequently Asked Questions” section of the
OPPS website. The December guidance was
problematic and on February 20, 2001, HCFA
reversed its December guidance by revising the
response to the question posted on the OPPS
website. The April 12, 2001 program memorandum
follows the February 20th web posting very closely.
Medicare Billing for
Outpatient Blood
Revenue
Code
390
Product/
Procedure
Code
P9016
391
34360
1
Description
Packed Red
Cells,
Leukocyte
Reduced
Transfusion,
blood or
blood
1
component
Comment
Bill Per Unit
Bill Once
Per
Day/Visit
_________________________________________________________
1All
Current Procedural Terminology (CPT) five-digit numeric codes and descriptions are Copyright 2000 American Medical Association.
All Rights Reserved.
1
Hospitals Will Not Need to Use “Value Codes” to
Receive the Appropriate Reimbursement.
Who Should I Contact if I Have Additional
Questions or Require Clarification?
Contact Chris Panarites, Reimbursement Officer for
the American Red Cross at 703.312.5724. You can
also e-mail him at [email protected].
The Medicare blood deductible provision is
implemented through the use of value codes and the
381 and 382 revenue codes. Since HCFA instructs
hospitals to use the 390 revenue code for Red Cross
blood, value coding is not required.2
Attachments:
Exhibit A: HCFA Program Memorandum A-01-50
(Selected Text)
Exhibit B: OPPS Coding Guide
Exhibit C: Sample Outpatient Claim Form
What is the Red Cross’ Position on the April 12,
2001 Program Memorandum?
HCFA’s coding and billing guidance represents a
return to historical revenue coding practices for blood
and blood products. However, hospitals do need to be
sure to include the appropriate Level II HCPCS code
on all outpatient Medicare claims. The Red Cross is
in agreement with the program memorandum and has
committed itself to helping its hospital customers bill
as directed.
Disclaimer: The American Red Cross provides
coding and billing advise as a service to its hospital
customers. Red Cross strives to make available the
most current and up-to-date information.
However, the accuracy of each claim for thirdparty payment remains the responsibility of the
provider.
Can Hospitals Submit Claims for Adjustments?
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The effective date of the program memorandum’s
blood billing guidance is August 1, 2000. Therefore,
hospitals can resubmit claims they believe were
inappropriately processed.
We encourage our hospital customers to pull a sample
of outpatient Medicare claims involving blood from
the fall/winter of 2000. Hospital billing staff should
determine if, 1) the hospital coded and billed
correctly, and 2) the fiscal intermediary processed the
claims appropriately. If problems are discovered
among the sampled claims, hospitals should review all
outpatient Medicare claims involving blood and
resubmit claims for adjustments, as appropriate.
_________________________________________________________
2Some
fiscal intermediaries may request value coding even with the 390 revenue code to track units and the blood deductible. The Red
Cross recommends that hospitals check with their fiscal intermediary’s provider relations department if questions arise regarding value
coding.
2
Exhibit A
Department of Health and Human
Services (DHHS)
Program
Memorandum
Intermediaries
HEALTH
CARE
FINANCING
ADMINISTRATION (HCFA)
Transmittal A-01-50
Date: APRIL 12, 2001
CHANGE REQUEST 1585
SUBJECT: Further Guidance Regarding Billing Under the Outpatient Prospective Payment
System (OPPS)
The purpose of this Program Memorandum (PM) is to provide further guidance related to specific areas of billing
under OPPS and to incorporate several Questions and Answers previously posted on the Internet.
Proper Billing for Blood Products and Blood Storage and Processing
When a hospital purchases blood or blood products from a community blood bank, or runs its own blood bank and
assesses a charge for the blood or blood product, they report blood and blood products in Revenue Code Series 38X
"Blood" along with the appropriate blood HCFA Common Procedure Coding System (HCPCS) code. The amount
billed should reflect the hospital’s charge.
When a hospital does not pay for the blood or blood product, it often incurs an administrative cost from a
community blood bank for the bank’s processing, storage and related expenses. In this situation, the hospital bills
the charge associated with these blood bank storage and processing costs in Revenue Code 390 "Blood
Storage/Processing" and reports the HCPCS code assigned to the blood or blood product and the number of units
transfused. Payment is based on the Ambulatory Payment Classification (APC) to which the HCPCS code is
assigned, times the number of units transfused.
If a hospital purchases blood, or blood products, or runs its own blood bank, it is not appropriate to bill both the
blood or blood product in Revenue Code series 38X and an additional blood bank storage and processing charge in
Revenue Code 390.
A transfusion APC will be paid to the hospital for transfusing blood once per day, regardless of the number of units
transfused. Hospitals should bill for transfusion services using Revenue Code 391 "Blood Administration" and
HCPCS code 36430 through 36460. The hospital may also bill the laboratory Revenue Codes (30X or 31X) along
with the HCPCS codes for blood typing and cross matching and other laboratory services related to the patient who
receives the blood.
Following sections of this PM omitted by Red Cross Reimbursement Officer. See official PM for full text.
Proper Billing of Outpatient Surgical Procedures
Inpatient Part B Services
3
Appropriate Revenue Codes to Report Medical Devices That Have Been Granted Pass-Through Status
HCPCS Clarification
Removal of HCPCS/Revenue Code Edits
The effective date for this PM is as follows :
 For surgical procedures, claims with dates of service on or after July 1, 2001;
 For blood procedures, claims with dates of service on or after August 1, 2000; and
 For removal of edits that match revenue codes to HCPCS and the edit requirement of pass-through
medical devices, January 1, 2002.
The implementation date for this PM is August 2000 for blood, July 1, 2001, for surgical procedures, and
January 1, 2002 for remaining items.
These instructions should be implemented within your current operating budget.
This PM may be discarded after January 1, 2003.
If you have any questions, please contact your regional office.
g:\shared\hosp mark\chrisp\OPPS impl\Blood PM_A-01-50_AC.doc
Red Cross note: the coding
guidance goes back to APC
implementation, August 2000
4
Coding Guide for ARC Products and Services
Under Medicare’s Outpatient Prospective Payment System (APCs)
Exhibit B
(Revised February 22, 2001)
APC
Level II
HCPCS Code
1
(Transitional)
Level II
HCPCS Code
2
(Permanent)
0949
N/A
P9023
0950
N/A
P9010
0952
0953
N/A
N/A
P9012
P9013
0954
N/A
P9016
0955
N/A
P9017
0956
0957
N/A
N/A
P9018
P9019
0958
0959
N/A
N/A
0960
Revenue
Code
Value
3
Codes
390
N/A
390
N/A
390
390
N/A
N/A
390
N/A
390
N/A
Plasma protein fraction, each unit
Platelets, each unit
390
390
N/A
N/A
P9020
P9021
Platelet rich plasma, each unit
Red blood cells, each unit
390
390
N/A
N/A
N/A
P9022
390
N/A
0961
Q0156
N/A
390
N/A
0962
Q0157
N/A
390
N/A
0961
N/A
P9041
390
N/A
0962
N/A
P9042
390
N/A
1009
C1009
P9044
Red blood cells, washed, each unit
Infusion, albumin (human), 5%, 500
ml
Infusion, albumin (human), 25%, 50
ml
Infusion, albumin (human), 5%, 50 ml
Infusion, albumin (human), 25%, 10
ml
Plasma, cryoprecipitate reduced, each
unit
390
N/A
1010
C1010
N/A
390
N/A
1011
C1011
N/A
390
N/A
C1012
P9033
Platelets, leukocytes reduced,
irradiated, each unit
390
N/A
C1013
P9031
Platelets, leukocytes reduced, each
unit
390
N/A
4
1012 (C)
0954 (P)
4
1013 (C)
0954 (P)
1
Description
Plasma, pooled multiple donor,
solvent/detergent treated, frozen, each
unit
Blood (whole), for transfusion, per
unit
Cryoprecipitate, each unit
Fibrinogen unit
Red blood cells, leukocytes reduced,
each unit
Fresh frozen plasma (single donor),
each unit
Blood, leukocytes reduced, CMVnegative
Platelets, pheresis, leukocytes
reduced, HLA-matched
Transitional C-codes will ultimately be discontinued; however, HCFA has not yet established termination
dates for these codes.
2
Codes in italics became effective January 1, 2001.
3
Value codes should not be used with revenue code 390.
4
For these services, the APC codes for the transitional codes are different than those for the permanent
codes; “(C)” indicates a transitional C-code, while “(P)” indicates a permanent P-code.
Coding Guide for ARC Products and Services
Under Medicare’s Outpatient Prospective Payment System (APCs)
(Revised February 22, 2001)
APC
Level II
HCPCS Code
(Transitional)
Level II
HCPCS Code
(Permanent)
1014 (C)4
9501 (P)
C1014
P9035
1016
C1016
1017
Revenue
Code
Value
Codes
Platelets, pheresis, leukocytes
reduced, each unit
390
N/A
N/A
Blood, leukocytes reduced,
frozen/deglycerolized/washed
390
N/A
C1017
N/A
Platelets, pheresis, leukocytes
reduced, CMV-negative
390
N/A
1018 (C)4
9504 (P)
C1018
P9040
Red blood cells, leukocytes reduced,
irradiated, each unit
390
N/A
1019 (C)4
9501 (P)
C1019
P9037
Platelets, pheresis, leukocytes
reduced, irradiated, each unit
390
N/A
9500
C9500
P9032
Platelets, irradiated, each unit
390
N/A
9501
C9501
P9034
390
N/A
9502
C9502
P9036
Platelets, pheresis, each unit
Platelets, pheresis, irradiated, each
unit
390
N/A
9503
C9503
N/A
Fresh frozen plasma, donor retested,
each unit
390
N/A
9504
C9504
P9039
Red blood cells, deglycerolized, each
unit
390
N/A
9505
C9505
P9038
Red blood cells, irradiated, each unit
390
N/A
Description
6
Exhibit C: Sample UB-92 Paper Claim
Form for Hospital Outpatient Procedures
Bill Type: Hospitals use to
distinguish between inpatient
and outpatient claims.
APP ROVE D OMB NO. 0938-0279
Anytown Hospital
20 Hospital Drive
Anytown, USA
2
4 TYPE
OF B ILL
3 PATIENT CONTROL NO.
5 FED. TAX NO.
6 STATE MENT COVERS PERIOD
FROM
THROUGH
7 COV D.
8 N-C D.
9 C-I D.
10 L-R D.
11
09012001 09012001
13 PATIENT A DDRESS
12 PATI ENT NAME
123 Main Street, Anytown, Anystate 12345
Smith, Jane
14 BI RTHDATE
15 SE X 16 MS
A DM ISS ION
1 7 DAT E
18 HR
19 T YPE
20 SRC
CONDI TION CODES
21 D HR 22 S TAT 23 M EDI CA L RECORD NO.
24
01201928 F
32
OCCURENCE
CODE
DATE
33
OCCURENCE
CODE
34
DAT E
OCCURENCE
CODE
35
DATE
OCCURENCE
CODE
DATE
36
OCCURENCE S PAN
CODE
FROM
25
27
28
29
30
31
37
A
B
B
A
T HRO UG H
a
Value Codes:
b
26
C
C
38
39
OCCURENCE
CODE
Not used with 390 revenue code.
40
AM OUNT
VALUE CODE S
CODE
41
AM OUNT
VALUE CODE S
CODE
AM OUNT
a
a
b
b
c
c
d
42 REV. CD.
390
391
300
1
2
3
4
43 DE SCRI PTION
44 HCPCS/ RATE S
BLOOD STOR/PROC, GENERAL
BLOOD ADMINISTRATION
LABORATORY, GENERAL
d
45 SERV. DATE
P9016
36430
86900
46 SERV. UNITS
09012001
09012001
09012001
47 TOTA L CHARGES
3
1
1
750
200
25
48 NON-COVERED CHA RGE S
49
00
00
50
1
2
3
4
5
5
6
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Service Units:
Revenue Codes:
HCPCS/CPT Codes:
Enter appropriate
revenue codes for all
services provided.
Enter HCPCS code P9016
for Red blood cells,
leukoreduced.
Per HCFA’s 4/12/01program
memorandum, bill for the blood
product(s) with 390 revenue
code, bill for the blood
transfusion procedure using
391 revenue code, and bill for
any lab tests with 30X or 31X.
Enter CPT code 36430 for
transfusion procedure.
7
8
Enter the appropriate number
that represents the multiple of
the administered units. Use
only whole numbers.
9
10
11
12
13
Blood administration (36430) should
be billed per visit/session, not per
unit transfused.
Enter CPT code 86900 for
lab test performed, blood
typing ABO, in this case.
14
15
16
17
18
19
20
20
21
21
22
22
23
23
50 PAYE R
52 RE L
INFO
51 PROVI DE R NO.
53 ASG
BEN
54 PRIOR PAYME NTS
55 ES T. AM OUNT DUE
56
xxxxxx
A
B
C
DUE FROM PATIENT
57
58 INSURED'S NAME
A
59 P. RE L
60 CERT. - SS N - HI C - ID NO.
61 GROUP NAME
62 INSURANCE GROUP NO.
Diagnosis
Codes:
012-34-5678
Smith, Jane
B
A
B
Enter appropriate primary and secondary ICD-9-CM diagnosis codes.
Under APCs, they will not impact payment. Relevant diagnosis codes
include: 285.9 Anemia. 66 EM PLOYER LOCATION
C
C
A
A
B
B
C
O THER DIAG. CO DES
67 PR IN. DIA G. CD .
68 CO DE
69 CODE
70 CODE
71 CODE
72 CODE
73 CODE
Procedure Codes:
74 CODE
75 CO DE
C
76 ADM DIA G. CD.
77 E-CODE
78
285.9
79 P. C.
80
P RI NCIP LE PROCE DURE
CODE
DATE
99.04 09012001
OTHER PROCE DURE
CODE
C
a
b
c
d
DATE
81
OTHE R PROCEDURE
CODE
DATE
A
OTHER PROCE DURE
CODE
D
DATE
OTHE R PROCEDURE
CODE
DATE
OTHE R PROCEDURE
CODE
DATE
Enter appropriate ICD-9-CM procedure code(s).
Under APCs, they will not impact payment.
OT HER P HY S. ID
Relevant procedure codes include:
A
99.04 Transfusion of packed
cells.
82 ATTE NDING PHYS . ID
B
83
E
84 REMA RKS
OT HER P HY S. ID
85 PROV IDER REPRES ENTATI VE
x
UB-92 HCFA-1450
a
b
a
b
a
b
B
86 DATE
I CE RTI FY THE CERT IFICATI ONS ON THE REVE RS E APP LY TO THIS BILL AND ARE MADE A PART HE REOF.
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