(Medicare Claims Processing Manual)

The list of HCPCS codes designated as sometimes therapy services that may be paid as non-therapy services when furnished to hospital outpatients is displayed in the table below.  Services Designated as Sometimes Therapy that May be Paid as Non -Therapy Services for Hospital Outpatients  HCPCS Code  Long Descriptor  92520  Laryngeal function studies (i.e., aerodynamic testing and acoustic testing)  HCPCS Code  Long Descriptor  97597  Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, pe r session; total wound(s) surface area less than or equal to 20 square centimeters  97598  Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assess ment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters  97602  Removal of devitalized tissue from wound(s), non -selective debridement, without anesthesia (e.g., wet -to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session  97605  Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters  97606  Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters  97607  Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area less than or equal to 50 square centimeters  97608  Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area greater than 50 square centimeters  97610  Low frequency, non -contact, non -thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day   200.10 - Billing for Cost Based Payment for Certified Registered Nurse Anesthetists (CRNA) Services Furnished by Outpatient Prospective Payment System (OPPS) Hospitals (Rev. 3065, Issued: 09- 12-14, Effective: 04 -01-03, Implementation: 12- 15-14)  Payment of outpatient services of CRNAs furnished by small rural hospitals subject to OPPS that qualify for cost based payment under 42 CFR 412.113(c) are made through biweekly interim payments that are calculated based on retrospective adjustments from a settled cost report.   In order for interim payments to be made to these hospitals based on submitted claims, a number of changes were required in the reporting and acceptance of revenue code 0964 Anesthetists (CRNA).  Those changes are as follows:   (1) Hospitals that qualify for cost based CRNA services must report these services under revenue code 0964;   (2) Shared System Maintainer is required to accept revenue code 0964 on type of bill 013X for these hospitals; and   (3) Reporting and acceptance of revenue code 0964 from other OPPS hospitals (without a CRNA pass -through exemption) may not be allowed.   NOTE:   Value code 05 Professional Component Included In Charges and Also Billed Separately to A/B MACs (B), should not be reported with revenue code 0964.  The Integrated Outpatient Code Editor (IOCE) will assign a service indicator of F to revenue code 0964. This allows for cost -based payment for revenue code 0964.  The facility is paid a cost- based interim payment (charges multiplied by the hospitals outpatient interim rate) for the revenue code 0964 charge on the claim, and assume when calculating the interim payment that coinsurance is billed (by the hospital to the beneficiary) in the amount of 20 percent of the submitted charges.  In addition, an adjustment to the hospitals biweekly interim payment amount for cost paid services should exclude any amounts attributable to outpatient hospital CRNA services from all  future biweekly interim payments.  Hospitals shall not bill Healthcare Common Procedure Coding System (HCPCS) when billing for CRNA services.  Beneficiaries are billed for coinsurance for cost based CRNA services billed under revenue code 0964.  Coinsurance is based on 20 percent of the submitted covered charges.  The Part B deductible is applicable.   200.11  Billing Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)   (Rev. 3739, Issued: 03- 17-17, Effective: 01 -01-16, Implementation: 06- 19-17)   Effective January 1, 2016 payment for the service described by CPT code 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face -to-face with the patient, family member(s), and/or surrogate) is conditionally packaged under the OPPS and is consequently assigned to a conditionally packaged payment status indicator of Q1. When this service is furnished with another service paid under the OPPS, payment is packaged; when it is the only service furnished, payment is made separately. CPT code 99498 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when perform ed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)) is an add- on code and therefore payment for the service described by this code is unconditionally pac kaged (assigned status indicator N) in the OPPS in accordance with 42 CFR 419.2(b)(18).   In addition, for services furnished on or after January 1, 2016, Advance Care Planning (ACP) is treated as a preventive service when furnished with an AWV. The Medicare coinsurance and Part B deductible are waived for ACP when furnished as an optional elem ent of an AWV.   The codes for the optional ACP services furnished as part of an AWV are 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face -to-face with the patient, family member(s) and/or surrogate;) and an add- on code 99498 (each additional 30 minutes (List separately in addition to code for primary procedure)). When ACP services a re provided as a part of an AWV, practitioners would report CPT code 99497 (and add- on CPT code 99498 when applicable) for the ACP services in addition to either of the AWV codes (G0438 or G0439).   The deductible and coinsurance for ACP will only be waived when billed on the same day and on the same claim as an AWV (code G0438 or G0439), and must also be furnished by the same provider. Waiver of the deductible and coinsurance for ACP is limited to on ce per year. Payment for an AWV is limited to once per year. If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance will be applied to the ACP.   Also see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 280.5.1 for more information.   230 - Billing and Payment for Drugs and Drug Administration  (Rev. 573, Issued: 06- 03-05, Effective: 01 -01-05, Implementation: 06- 01-05)  This section provides billing guidance and payment instructions for hospitals when providing drugs and drug administration services in the hospital outpatient department.   230.1 - Coding and Payment for Drugs and Biologicals, and Radiopharmaceuticals (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  This section provides hospitals with coding instructions and payment information for drugs paid under OPPS.  For additional information on coding and payment for drugs and biologicals under the OPPS, see the Medicare Claims Processing Manual, Chapter 17 Drugs and Biologicals.   230.2 - Coding and Payment for Drug Administration  (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)  A. Overview   Drug administration services furnished under the Hospital Outpatient Prospective Payment System (OPPS) during CY 2005 were reported using CPT codes 90780, 90781, and 96400- 96459.   Effective January 1, 2006, some of these CPT codes were replaced with more detailed CPT codes incorporating specific procedural concepts, as defined and described by the CPT manual, such as initial, concurrent, and sequential.  Hospitals are instructed to use the full set of CPT codes, including those codes referencing concepts of initial, concurrent, and sequential, to bill for drug administration services furnished in the hospital outpatient department beginning January 1, 2007.  In addition, hospitals are instructed to continue billing the HCPCS codes that most accurately describe the service(s) provided.   Hospitals are reminded to bill a separate Evaluation and Management code (with modifier 25) only if a significant, separately identifiable E/M service is performed in the same encounter with OPPS drug administration services.   B. Billing for Infusions and Injections   Beginning in CY 2007, hospitals were instructed to use the full set of drug administration CPT codes (90760- 90779; 96401- 96549), (96413 -96523 beginning in CY 2008) (96360-96549 beginning in CY 2009) when billing for drug administration services provided in the hospital outpatient department.  In addition, hospitals are to continue to bill HCPCS code C8957 (Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump) when appropriate.  Hospitals are expected to report all drug administration CPT codes in a manner consistent with their descriptors, CPT instructions, and correct coding principles.  Hospitals should note the conceptual changes between CY 2006 drug administration codes effective under the OPPS and the CPT codes in effect beginning January 1, 2007, in order to ensure accurate billing under the OPPS.  Hospitals should report all HCPCS codes that describe the drug administration services provided, regardless of whethe r or not those services are separately paid or their payment is packaged.   Medicares general policy regarding physician supervision within hospital outpatient departments meets the physician supervision requirements for use of CPT codes 90760-90779, 96401- 96549, (96413- 96523 beginning in CY 2008).  (Reference:  Pub.100- 02, Medicare Benefit Policy Manual, Chapter 6, 20.4.)   Drug administration services are to be reported with a line item date of service on the day they are provided.  In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounte r where observation services span more than 1 calendar day.  C. Payments For Drug Administration Services   For CY 2007, OPPS drug administration APCs were restructured, resulting in a six- level hierarchy where active HCPCS codes have been assigned according to their clinical coherence and resource use.  Contrary to the CY 2006 payment structure that bundled payment for several instances of a type of service (non -chemotherapy, chemotherapy by infusion, non- infusion chemotherapy) into a per -encounter APC payment, structure introduced in CY 2007 provides a separate APC payment for each reported unit of a separately  payable HCPCS code.