(Medicare Claims Processing Manual)

Medicare does not allow payment for routine or related dialysis treatments, which are covered and paid under the ESRD PPS, when furnished to ESRD patients in the outpatient department of a hospital. However, in certain medical situations in which the ESRD outpatient cannot obtain her or his regularly scheduled dialysis treatment at a certified ESRD facility, the OPPS rule for 2003 allows payment for non- routine dialysis treatments (which are not covered under the ESRD benefit) furnished to ESRD outpatients in the outpatient department of a hospital.  Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances:    Dialysis performed following or in connection with a dialysis -related procedure such as vascular access procedure or blood transfusions;    Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or    Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.   In these situations, non- ESRD certified hospital outpatient facilities are to bill Medicare using the Healthcare Common Procedure Coding System (HCPCS) code G0257 (Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility).    HCPCS code G0257 may only be reported on type of bill 13X (hospital outpatient service) or type of bill 85X (critical access hospital) because HCPCS code G0257 only reports services for hospital outpatients with ESRD and only these bill types are used to report services to hospital outpatients.  Effective for services on and after October 1, 2012, claims containing HCPCS code G0257 will be returned to the provider for correction if G0257 is reported with a type of bill other than 13X or 85X (such as a 12x inpatient claim).   HCPCS code 90935 (Hemodialysis procedure with single physician evaluation) may be reported and paid only if one of the following two conditions is met:   1) The patient is a hospital inpatient with or without ESRD and has no coverage under Part A, but has Part B coverage.  The charge for hemodialysis is a charge for the use of a prosthetic device.  See Benefits Policy Manual 100- 02 Chapter 15 section 120.  A.  The service must be reported on a type of bill 12X or type of bill 85X.  See the Benefits Policy Manual 100- 02 Chapter 6 section 10 ( Medical and Other Health Services Furnished to Inpatients of Participating Hospitals)  for the criteria that must be met fo r services to be paid when a hospital inpatient has Part B coverage but does not have coverage under Part A; or   2) A hospital outpatient does not have ESRD and is receiving hemodialysis in the hospital outpatient department.  The service is reported on a type of bill 13X or type of bill 85X.    CPT code 90945 (Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous replacement therapies)), with single physician evaluation, may be reported by a hospital paid under the OPPS or CAH method I or method II on type of bill 12X, 13X or 85X.   200.3 - Billing Codes for Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS)  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  200.3.1 - Billing Instructions for IMRT Planning and Delivery  (Rev. 3685, Issued: 12- 22-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT  code 77301 (IMRT planning). These codes should not be reported in addition to CPT  code 77301 when provided prior to or as part of the development of the IMRT  plan.  In addition, CPT codes 77280- 77290 (simulation- aided field settings) should not be reported for verification of the treatment field during a course of IMRT.     200.3.2 - Billing for Multi- Source Photon (Cobalt 60 -Based) Stereotactic Radiosurgery (SRS) Planning and Delivery (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  Effective for services furnished on or after January 1, 2014, hospitals must report  SRS planning and delivery services using only the CPT codes that accurately describe  the service furnished.  For the delivery services, hospitals must report CPT code  77371, 77372, or  77373.  CPT  Code  Long  Descriptor  77371 Radiation treatment delivery, stereotactic radiosurgery (srs),  complete course of treatment of cranial lesion(s) consisting of 1 session;  multi-  source cobalt 60  based  77372 Radiation treatment delivery, stereotactic radiosurgery (srs),  complete course of treatment of cranial lesion(s) consisting of 1 session;  linear accelerator  based  77373 Stereotactic body radiation therapy, treatment delivery, per fraction to  1 or more lesions, including image guidance, entire course not to exceed 5 fractions   As instructed in the CY 2014 OPPS/ASC final rule, CPT code 77371 is to be used  only for single session cranial SRS cases performed with a Cobalt -60 device, and CPT  code 77372 is to be used only for single session cranial SRS cases performed with a  linac - based device.  The term cranial means that the pathological lesion(s) that are the  target  of the radiation is located in the patients cranium or head.  The term single  session means that the entire intracranial lesion(s) that comprise the patients diagnosis  are treated in their entirety during a single treatment session on a single day.  CPT  code 77372 is never to be used for the first fraction or any other fraction of a fractionated SRS treatment.  CPT code 77372 is to be used only for single session cranial linac -based  SRS treatment.  Fractionated SRS treatment is any SRS delivery service requiring more than  a single session of SRS treatment for a cranial lesion, up to a total of no more than five fractions, and one to five sessions (but no more than five) for non -cranial lesions.   CPT code 77373 is to be used for any fraction (including the first fraction) in any series  of fractionated treatments, regardless of the anatomical location of the lesion or  lesions being radiated.  Fractionated cranial SRS is any cranial SRS that exceeds one treatment session and fractionated non- cranial SRS is any non -cranial SRS, regardless of  the number of fractions but never more than five.  Therefore, CPT code 77373 is  the exclusive code (and the use of no other SRS treatment delivery code is permitted) for  any and all fractionated SRS treatment services delivered anywhere in the body, including, but not limited to, the cranium or head.  77372 is not to be used for the first fraction of  a fractionated cranial SRS treatment series and must only be used in cranial SRS  when  there is a single treatment session to treat the patients entire  condition.   In addition, for the planning services, hospitals must report the specific CPT code  that accurately describes the service provided.  The planning services may include but are  not limited to CPT code 77290, 77295, 77300, 77334, or  77370.  CPT  Code  Long Descriptor  77290 Therapeutic radiology simulation- aided field setting; complex  77295 Therapeutic radiology simulation- aided field setting; 3-dimensional  77300 Basic radiation dosimetry calculation, central axis depth dose  calculation, tdf, nsd, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non- ionizing radiation surface and depth dose, as  required during course of treatment, only when prescribed by the  treating physician  77334 Treatment devices, design and construction; complex (irregular  blocks, special shields, compensators, wedges, molds or  casts)  77370 Special medical radiation physics  consultation   Effective for cranial single session stereotactic radiosurgery procedures (CPT code  77371 or 77372) furnished on or after January 1, 2016, costs  for certain adjunctive services (e.g., planning and preparation) are not factored into the  APC payment rate for APC 5627 (Level 7 Radiation Therapy).  Rather, the ten planning and preparation codes, will be paid according to their assigned status indicator when furnished 30 days prior or 30 days post SRS treatment  delivery. A list of the excluded planning and preparation CPT codes is provided in the C Y 2018 OPPS/ASC final rule with comment period.   200.4 - Billing for Amniotic Membrane  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  Hospitals should report HCPCS code V2790 (Amniotic membrane for surgical reconstruction, per procedure) to report amniotic membrane tissue when the tissue is used.  A specific procedure code associated with use of amniotic membrane tissue is CPT code 65780 (Ocular surface reconstruction; amniotic membrane transplantation).  Payment for the amniotic membrane tissue is packaged into payment for CPT code 65780 or other procedures with which the amniotic membrane is used.   200.5 - Reserved  (Rev. 1882, Issued:  12- 21-09; Effective Date:  01 -01-10; Implementation Date:  01-04-10)  200.6 - Billing and Payment for Alcohol and/or Substance Abuse Assessment and Intervention Services  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  For CY 2008, the CPT Editorial Panel has created two new Category I CPT codes for reporting alcohol and/or substance abuse screening and intervention services.  They are CPT code 99408 ( Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes); and CPT code 99409 ( Alcohol and/or substance (other than tobacco) abuse structured screening (e.g., AUDIT, DAST), and brief intervention (SBI) services; greater than 30 minut es).  However, screening services are not covered by Medicare without specific statutory authority, such as has been provided for mammography, diabetes, and colorectal cancer screening.  Therefore, beginning January 1, 2008, the OPPS recognizes two parallel G -codes (HCPCS codes G0396 and G0397) to allow for appropriate reporting and payment of alcohol and substance abuse structured assessment and intervention services that are not provided as screening services, but that are performed in the context of the diagnosis or treatment of illness or injury.  Contractors shall make payment under the OPPS for HCPCS code G0396 (Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST) and brief intervention, 15 to 30 minutes) and HCPCS code G0397, (Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST) and intervention greater than 30 minutes), only when reasonable and necessary (i.e., when the service is provided to evaluate patients with signs/symptoms of illness or injury) as per section  1862(a)(1)(A) of the Act.   HCPCS codes G0396 and G0397 are to be used for structured alcohol and/or substance (other than tobacco) abuse assessment and intervention services that are distinct from other clinic and emergency department visit services performed during the same encount er.  Hospital resources expended performing services described by HCPCS codes G0396 and G0397 may not be counted as resources for determining the level of a visit service and vice versa (i.e., hospitals may not double count the same facility resources in order to reach a higher level clinic or emergency department visit).  However, alcohol and/or substance structured assessment or intervention services lasting less than 15 minutes should not be reported using these HCPCS codes, but the hospital resources expended should be included in determining the level of the visit service reported.