(Medicare Claims Processing Manual)

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.   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 each 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 se parate APC payment(s) for additional hours of infusion or other drug administration services provided 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 infusions occurred during the same tim e 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 report ed 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 Hospital   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 by param edics 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 hospital 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 Payment 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 transfused, 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 delivery, 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 the 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 Provider 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 Storage  (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.   Effective for services furnished on or after July 1, 2005, the I/OCE will return to providers any claim that reports a charge for blood or blood products using Revenue Code 038X without a separate line for processing and storage services using Revenue Code  0390, 0392, or 0399.  Moreover, in order to process to payment, both lines must report the same line item date of service, the same number of units, and the same HCPCS code accompanied by modifier BL.  Payment for blood and blood products is based on the Ambulatory Payment Classification (APC) Group to which its HCPCS code is assigned, multiplied by the number of units transfused.  Units of whole blood or packed red cells for which only processing and storage charges are reported are not subject to the blood deductible.  The Medicare blood deductible is applicable only if the OPPS provider purchases whole blood or packed red cells fr om a community blood blank or if the OPPS provider assesses a charge that reflects more than blood processing and storage for whole blood or packed red cells collected by its owns blood bank.  If the beneficiary has not already fulfilled the annual blood deductible or replaced the blood, OPPS payment will be made for processing and storage costs only.  The beneficiary is liable for the blood portion of the payment as the blood deductible.  In order to ensure correct application of the Medicare blood deductible, providers should report charges for whole units of packed red cells using Revenue Code 381 (Packed red cells), and should report charges for whole units of whole blood using Revenue Code  382 (Whole blood).  Revenue Codes 381 and 382 should be used only to report charges for packed red cells and whole blood, respectively.   Please note that most hospitals obtain blood or blood products from community blood banks that charge only for processing and storage, rather than for the blood itself.  The blood coding requirements discussed in this section do not apply to blood and blood products carrying only a processing and storage fee; when billing only for blood processing and storage, OPPS providers should follow the coding requirements outlined in 231.1.  EXAMPLE:  An OPPS provider purchases 2 units of leukocyte -reduced red blood cells from a community blood bank and incurs a charge for the red cells themselves, and a charge for the blood banks processing and storage of the red blood cell unit.  The OPPS provider f urther incurs costs related to additional processing and storage of the red blood cell units after the OPPS provider has received the 2 units.  A Medicare beneficiary is transfused the two units of leukocyte -reduced red blood cells.  The OPPS provider should report the charges for 2 units of P9016 by separately billing the red blood cell charges and the total processing and storage charges incurred.  The charges for the red blood cell units are to be reported on one line with the date the blood was transfused, Revenue Code series 038X (excluding 380), 2 units, HCPCS code P9016, and modifier BL.  The total charges for processing and storage are to be reported on the same claim, on a separate line, showing the date the blood was transfuse d, Revenue Code 390, 0392, or 399, 2 units, HCPCS code P9016, and modifier BL.  Note that HCPCS modifier BL is reported on both lines.  231.3 - Billing for Autologous Blood (Including Salvaged Blood) and Directed Donor Blood  (Rev. 496, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)  In general, when autologous (predeposited or obtained through intra - or postoperative salvage) or directed -donor transfusion is performed, OPPS providers should bill for the transfusion service and the number of units of the appropriate HCPCS code that des cribes the blood product.  Payment for the product is intended to cover the costs associated with providing the autologous or directed donor blood product service (e.g., collection, processing, transportation, and storage).  OPPS providers should bill the transfusion service and the blood product HCPCS code on the date that the transfusion took place and not on the date when the autologous blood was collected.   When an autologous blood product is collected but not transfused, OPPS providers should bill CPT 86890 (autologous blood or component, collection, processing, and storage; predeposited) or 86891(autologous blood or component, collection, processing, and storage; intra - or postoperative salvage) and the number of units collected but not transfused.  CPT 86890 and 86891 are intended to provide payment for the additional resources needed to provide these services, which are not captured when a blood product HCPCS code is not billed.  Because billing 86890 or 86891 is only indicated when autologous blood is collected but not transfused, the OPPS provider should bill 86890 or 86891 on the date when the OPPS provider is certain the blood will not be transfus ed (i.e., date of a procedure or date of outpatient discharge), rather than on the date of the products collection or receipt from the supplier.   When a directed donor blood product is collected but not transfused to the initial targeted recipient or to any other patient, refer to the section 231.7 titled Billing for Unused Blood.   231.4 - Billing for Split Unit of Blood  (Rev. 1487, Issued: 04- 08-08, Effective: 04 -01-08, Implementation: 04- 07-08)