(Medicare Claims Processing Manual)

A hospital may attest to specific non -diagnostic services as being unrelated to the hospital Part A claim (that is, the preadmission non -diagnostic services are clinically distinct or independent from the reason for the beneficiarys admission) by adding a  condition code 51 (definition 51 -  Attestation of Unrelated Outpatient Non -diagnostic Services) to the separately billed outpatient non- diagnostic services claim.  Providers may submit outpatient claims with condition code 51 starting April 1, 2011, for  outpatient claims that have a date of service on or after June 25, 2010.  Outpatient claims with a date of service on or after June 25, 2010, that did not contain condition code 51 received prior to April 1, 2011, will need to be adjusted by the provider if they were rejected by FISS or CWF.   20 - Reporting Hospital Outpatient Services Using Healthcare Common Procedure Coding System (HCPCS)  (Rev. 1, 10- 03-03) A3-3626.4, HO -442.6  20.1 - General  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Reporting of HCPCS codes is required of acute care hospitals including those paid under alternate payment systems, e.g., Maryland, long- term care hospitals.  HCPCS codes are also required of rehabilitation hospitals, psychiatric hospitals, hospital -based RHCs, hospital -based FQHCs, and CAHs reimbursed under Method II (HCPCS required to be billed for fee reimbursed services).  This also includes all -inclusive rate hospitals.  HCPCS includes the American Medical Associations Current Procedural Terminology, 4th Edition, (CPT -4) for physician services and CMS developed codes for certain nonphysician services.  All of the CPT -4 is contained within HCPCS, and is identified as Lev el I CPT codes consist of five numeric characters.  The CMS developed codes are known as Level II.  Level II codes are five- character codes that begin with an alpha character that is followed by either numeric or alpha characters.   Hospital -based and independent ESRD facilities must use HCPCS to bill for blood and blood products, and to bill for drugs and clinical laboratory services paid outside the composite rate.  In addition, the hospital is required to report modifiers as applic able and as described in 20.6.   The CAHs are required to report HCPCS only for Part B services not paid to them on a reasonable cost basis, e.g., screening mammographies and bone mass measurements.   The HCPCS codes are required for all outpatient hospital services unless specifically excepted in manual instructions.  This means that codes are required on surgery, radiology, other diagnostic procedures, clinical diagnostic laboratory, durable medical equipment, orthotic -prosthetic devices, take- home surgical dressings, therapies, preventative services, immunosuppressive drugs, other covered drugs, and most other services.   When medical and surgical supplies (other than prosthetic and orthotic devices as described in the Medicare Claims Processing Manual, Chapter 20, 10.1) described by HCPCS codes with status indicators other than H or N are provided incident to a physic ian's service by a hospital outpatient department, the HCPCS codes for these items should not be reported because these items represent supplies.  Claims containing charges for medical and surgical supplies used in providing hospital outpatient services ar e submitted to the Medicare contractor providing OPPS payment for the services in which they are used.  The hospital should include charges associated with these medical and surgical supplies on claims so their costs are incorporated in ratesetting, and pa yment for the supplies is packaged into payment for the associated procedures under the OPPS in accordance with 42 CFR 419.2(b)(4).   For example, if the hospital staff in the emergency department initiate the intravenous administration of a drug through an infusion pump described by HCPCS code E0781 (Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient), complete the drug infusion, and discontinue use of the infusion pump before the patient leaves the hospital outpatient department, HCPCS code E0781 should not be reported because the infusion pump was used as a supply and would be paid through OPPS payment for the drug administration service.  The hospital should include the charge associated with the infusion pump on the claim.   In another example, if hospital outpatient staff perform a surgical procedure on a patient in which temporary bladder catheterization is necessary and use a catheter described by HCPCS code A4338 (Indwelling catheter; Foley type, two- way latex with coating  (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each), the hospital should not report A4338 because the catheter was used as a supply and would be paid through OPPS payment for the surgical procedure.  The hospital should include the charge associated with the urinary catheter on the claim.   When hospital outpatient staff provide a prosthetic or orthotic device, and the HCPCS code that describes that device includes the fitting, adjustment, or other services necessary for the patients use of the item, the hospital should not bill a visit or procedure HCPCS code to report the charges associated with the fitting, adjustment, or other related services.  Instead, the HCPCS code for the device already includes the fitting, adjustment or other similar services.  For example, if the hospital outpatie nt staff provides the orthotic device described by HCPCS code L1830 (KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment), the hospital should only bill HCPCS code L1830 and should not bill a visit or procedure HCPCS code t o describe the fitting and adjustment.   Claims with required HCPCS coding missing will be returned to the hospital for correction.  Future updates will be issued in a Recurring Update Notification.   20.2 - Applicability of OPPS to Specific HCPCS Codes  (Rev. 1536, Issued:  06- 19-08; Effective:  07 -01-08; Implementation: 07 -07-08)  The CPT codes generally are created to describe and report physician services, but are also used by other providers/suppliers to describe and report services that they provide.  Therefore, the CPT code descriptors do not necessarily reflect the facility co mponent of a service furnished by the hospital.  Some CPT code descriptors include reference to a physician performing a service.  For OPPS purposes, unless indicated otherwise, the usage of the term "physician" does not restrict the reporting of the code or application of related policies to physicians only, but applies to all practitioners, hospitals, providers, or suppliers eligible to bill the relevant CPT codes pursuant to applicable portions of the Social Security Act (SSA) of 1965, the Code of Federa l Regulations (CFR), and Medicare rules.  In cases where there are separate codes for the technical component, professional component, and/or complete procedure, hospitals should report the code that represents the technical component for their facility se rvices.  If there is no separate technical component code for the service, hospitals should report the code that represents the complete procedure.  Tables describing the treatment of HCPCS codes for OPPS are published in the Federal Register annually.   20.3 - Line Item Dates of Service  (Rev. 1, 10- 03-03)  Where HCPCS is required a line item date of service is also required.  (FL 45 on Form CMS -1450).  The A/B MAC (A) will return claims to hospitals where a line item date of service is not entered for each HCPCS code reported or if the line item dates of service reported are outside of the statement -covers period.  20.4 - Reporting of Service Units  (Rev. 1, 10- 03-03)  The definition of service units (FL 46 on the Form CMS -1450) where HCPCS code reporting is required is the number of times the service or procedure being reported was performed.   EXAMPLES:   If the following codes are performed once on a specific date of service, the entry in the service units field is as follows:  HCPCS Code  Service Units  90849 -  Multiple -family group psychotherapy  Units >  1 HCPCS Code  Service Units  92265 -  Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report  Units >  1 95004 -  Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, specify number of tests. Units = no.  of tests performed 95861 -  Needle electromyography two extremities with or without related paraspinal areas  Units >  1  6 Units >  83 min.  to < 98 min. 7 Units >  98 min.  to < 113 min. 8 Units >  113 min.  to < 128 min.  The pattern remains the same for treatment times in excess of two hours.  Hospitals should not bill for services performed for less than eight minutes.  The expectation (based on the work values for these codes) is that a providers time for each unit will  average 15 minutes in length.  If hospitals have a practice of billing less than 15 minutes for a unit, their A/B MAC (A) will highlight these situations for review.   The above schedule of times is intended to provide assistance in rounding time into 15-minute increments.  It does not imply that any minute until the eighth should be excluded from the total count as the timing of active treatment counted includes time.   The beginning and ending time of the treatment should be recorded in the patients medical record along with the note describing the treatment.  (The total length of the treatment to the minute could be recorded instead.)  If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time.  For example, if 24 minutes of code 97112 and 23 minutes of code 97110 were furnished, then the total treatment time was 47 minutes; so only 3 units can be billed for the treatment.  The correct coding is two units of code 97112 and one unit of code 97110, assigning more units to the service that took more time.   20.5 - Clarification of HCPCS Code to Revenue Code Reporting  (Rev. 1487, Issued: 04- 08-08, Effective: 04 -01-08, Implementation: 04- 07-08)  Generally, CMS does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals assignment of cost vary. Where explicit instructions are not provided, providers should report their charges unde r the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.   20.6 - Use of Modifiers  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  Modifiers are two -digit identifiers that are reported with CPT and HCPCS Level II codes to provide additional information about how an item, procedure, or service is provided, and improve the accuracy of coding. These two -digit modifiers can be alphabetic,  numeric, or a combination of both. The use of modifiers is not limited to certain code sets. Specifically, CPT modifiers may be used with HCPCS Level II codes when appropriate. Similarly, HCPCS Level II modifiers may be used with CPT codes to appropriatel y describe how an item, procedure, or service is provided. Providers may use any applicable modifier where appropriate. For Medicare purposes, modifiers are used either as pricing or informational/tracking indicators.  The Integrated Outpatient Code Editor (I/OCE) accepts all valid CPT and HCPCS Level II modifiers on OPPS claims. As of April 1, 2023, there are approximately 410 active and valid modifiers. Definitions for all valid modifiers may be found in the latest CPT  and HCPCS Level II code references. The complete descriptions for all CPT modifiers can be found in the latest CPT code book. Alternatively, the complete descriptions for the HCPCS Level II modifiers can be found in the latest HCPCS Level II code book, as  well as in the latest HCPCS Level II code file that is available on the CMS HCPCS website, specifically, at https://www.cms.gov/medicare/coding/hcpcsreleasecodesets/hcpcs -quarterly -update. Additional guidance on the use of modifiers can also be found on t he Medicare Administrative Contractors (MAC) websites. Note that, under the OPPS, the use of modifiers applies to services/procedures performed on the same calendar day.   The following subsections provide information on the use of certain modifiers under the hospital OPPS. For information on additional modifiers not described below, refer to your MAC website(s) for guidance.  20.6.1 - Where to Report Modifiers on the Hospital Part B Claim  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)