(Medicare Claims Processing Manual)

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 fur nished as an optional element 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 f orms, 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 f or primary procedure)). When ACP services are 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 once per year. P ayment 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 procedur al 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 remind ed 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   Beginnin g 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 hos pital 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 ef fective 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 whether 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 encounter where observation services span more than 1 calendar day.   C. Payments For Drug Administration Services   For CY 2007, OPPS drug administrati on 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 typ e 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.   Hospitals should note that the transition to the full set of CPT drug administration codes provides for conceptual differences when reporting, such as those noted below.   In CY 2006, hospitals were instructed to bill for the first hour (and any additional hours) by each type of infusion service (non- chemotherapy,  chemotherapy by infusion, non- infusion chemotherapy).  Beginning in CY 2007, the first hour concept no longer exists. CPT codes in CY 2007 and beyond allow for only one initial service per encounter, for eac h vascular access site, no matter how many types of infusion services are provided; however, hospitals will receive an APC payment for the initial service and separate APC payment(s) for additional hours of infusion or other drug administration services pr ovided that are separately payable.    In CY 2006, hospitals providing infusion services of different types (non-chemotherapy, chemotherapy by infusion, non- infusion chemotherapy) received payment for the associated per -encounter infusion APC even if these i nfusions occurred during the same time period.  Beginning in CY 2007, hospitals should report only one initial drug administration service, including infusion services, per encounter for each distinct vascular access site, with other services through the same vascular access site being reported via the sequential, concurrent or additional hour codes.  Although new CPT guidance has been issued for reporting initial drug administration services, Medicare contractors shall continue to follow the guidance given  in this manual.  (NOTE:  This list above provides a brief overview of a limited number of the conceptual changes between CY 2006 OPPS drug administration codes and CY 2007 OPPS drug administration codes -  this list is not comprehensive and does not include  all items hospitals will need to consider during this transition)   For APC payment rates, refer to the most current quarterly version of Addendum B on the CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/.   D. Infusions Started Outside the Hos pital   Hospitals may receive Medicare beneficiaries for outpatient services who are in the process of receiving an infusion at their time of arrival at the hospital (e.g., a patient who arrives via ambulance with an ongoing intravenous infusion initiated b y paramedics during transport).  Hospitals are reminded to bill for all services provided using the HCPCS code(s) that most accurately describe the service(s) they provided.  This includes hospitals reporting an initial hour of infusion, even if the hospit al did not initiate the infusion, and additional HCPCS codes for additional or sequential infusion services if needed.   231 - Billing and Payment for Blood, Blood Products, and Stem Cells and Related Services  Under the Hospital Outpatient Prospective Payme nt System (OPPS) (Rev. 1702, Issued: 03- 13-09, Effective: 04- 01-09, Implementation: 04- 06-09)  231.1 - When a Provider Paid Under the OPPS Does Not Purchase the Blood or Blood Products That It Procures from a Community Blood  Bank, or When a Provider Paid Under the OPPS Does Not Assess a Charge for Blood or Blood Products Supplied by the Providers Own Blood Bank Other Than Blood Processing and Storage  (Rev. 1702, Issued: 03- 13-09, Effective: 04- 01-09, Implementation: 04- 06-09)  When an OPPS provider furnishes blood or a blood product collected by its own blood bank for which only processing and storage costs are assessed, or when an OPPS provider procures blood or a blood product from a community blood bank for which it is charged only the processing and storage costs incurred by the community blood bank, the OPPS provider bills the processing and storage charges using Revenue Code 0390 (Blood Processing/Storage), 0392 (Blood Processing/Storage; Processing and Storage),  or 0399 (Blood Processing /Storage; Other Processing and Storage), along with the appropriate blood HCPCS code, the number of units transf used, and the line item date of service (LIDOS).  Processing and storage costs may include blood product collection, safety testing, retyping, pooling, irradiating, leukocyte -reducing, freezing, and thawing blood products, along with the costs of blood del ivery, monitoring, and storage.  In general, such categories of processing costs are not patient -specific.  There are specific blood HCPCS codes for blood products that have been processed in varying ways, and these codes are intended to make payment for t he variable resource costs of blood products that have been processed differently.   Most OPPS providers obtain blood or blood products from community blood banks that charge only for processing and storage, and not for the blood itself.  These hospitals should follow the instructions outlined in this section.  Those OPPS providers that incur a charge for the blood product itself, in addition to the charge for processing and storage, should follow the coding requirements outlined in 231.2.  231.2 - When a P rovider Paid Under the OPPS Purchases Blood or Blood Products from a Community Blood Bank or When a Provider Paid Under the OPPS Assesses a Charge for Blood or Blood Products Collected By Its Own Blood Bank That Reflects More Than Blood Processing and Stor age (Rev. 1702, Issued: 03- 13-09, Effective: 04- 01-09, Implementation: 04- 06-09)  If an OPPS provider pays for the actual blood or blood product itself, in addition to paying for processing and storage costs when blood or blood products are supplied by either a community blood bank or the OPPS providers own blood bank, the OPPS provide r must separate the charge for the unit(s) of blood or blood product(s) from the charge for processing and storage services.  The OPPS provider reports charges for the blood or blood product itself using Revenue Code series 038X (excluding 0380, which is not a valid revenue code for Medicare billing) with the LIDOS, the number of units transfused, and the appropriate blood product HCPCS code and HCPCS modifier BL.  The OPPS provider reports charges for processing and storage services on a separate line using Revenue Code 0390, 0392, or 0399 with the LIDOS, the number of units transfused, and the appropriate blood product HCPCS code and HCPCS modifier BL.   The same LIDOS, the same number of units, the same HCPCS code, and HCPCS modifier BL must be reported on both  lines.  This requirement applies to all OPPS providers that transfuse blood and incur charges for both the blood itself and processing and storage.