(Medicare Claims Processing Manual)

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 outpatient 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 to 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 Recu rring 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 component 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, hos pitals, 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 Federal 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 services.  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 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 treatme nt.  (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 unit s 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 under 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. 1487, Issued: 04- 08-08, Effective: 04-01-08, Implementation: 04-07-08)  The Integrated Outpatient Code Editor (I/OCE) accepts all valid CPT and HCPCS modifiers on OPPS claims.  Definitions for the following modifiers may be found in the CPT and HCPCS guides:  Level I (CPT) Modifiers   -25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79, -91  Level II (HCPCS) Modifiers   -CA, -E1, -E2, -E3, -E4, - FA, - FB, - FC, -F1, -F2, -F3, -F4, -F5, -F6, -F7, -F8, -F9, - GA,  -GG, - GH, - GY, -GZ, -LC, -LD, - LT, - QL, - QM, - RC, - RT, - TA, -T1, -T2, -T3, -T4, -T5, - T6, -T7, -T8, - T9  As indicated in 20.6.2, modifier -50, while it may be used with diagnostic and radiology procedures as well as with surgical procedures, should be used to report bilateral procedures that are performed at the same operative session as a single line item.  Modifiers RT and LT are not used when modifier -50 applies.  A bilateral procedure is reported on one line using modifier -50.  Modifier - 50 applies to any bilateral procedure performed on both sides at the same session.  NOTE:  Use of modifiers applies to services/procedures performed on the same cal endar day.   Other valid modifiers that are used under other payment methods are still valid and should continue to be reported, e.g., those that are used to report outpatient rehabilitation and ambulance services.  Modifiers may be applied to surgical, radiology, and other diagnostic procedures.  Providers must use any applicable modifier where appropriate.  Providers do not use a modifier if the narrative definition of a code indicates multiple occurrences.  EXAMPLES:   The code definition indicates two to four lesions.  The code indicates multiple extremities.   Providers do not use a modifier if the narrative definition of a code indicates that the procedure applies to different body parts.   EXAMPLES:   Code 11600 (Excision malignant lesion, trunks, arms, or legs; lesion diameter 0.5 cm. or less)   Code 11640 (Excision malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5 cm. or less)  Modifiers - GN, - GO, and -GP must be used to identify the therapist performing speech language therapy, occupa tional therapy, and physical therapy respectively.   Modifier -50 (bilateral) applies to diagnostic, radiological, and surgical procedures.  Modifier -52 applies to radiological procedures.   Modifiers - 73, and - 74 apply only to certain diagnostic and surgic al procedures that require anesthesia.   Following are some general guidelines for using modifiers.  They are in the form of questions to be considered.  If the answer to any of the following questions is yes, it is appropriate to use the applicable modifie r.  1. Will the modifier add more information regarding the anatomic site of the procedure?   EXAMPLE:  Cataract surgery on the right or left eye.   2. Will the modifier help to eliminate the appearance of duplicate billing?   EXAMPLES:  Use modifier 77 to re port the same procedure performed more than once on the same date of service but at different encounters.   Use modifier 25 to report significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.   Use modifier 58 to report staged or related procedure or service by the same physician during the postoperative period.   Use modifier 78 to report a return to the operating room for a related procedure during the postoperative period.  Use modifier 79 to report an unrelated procedure or service by the same physician during the postoperative period.  3. Would a modifier help to eliminate the appearance of unbundling?   EXAMPLE:  CPT codes 90765 (Intravenous infusion, for therapy, p rophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour) and 36000 (Introduction of needle or intra catheter, vein):  If procedure 36000 was performed for a reason other than as part of the IV infusion, modifier - 59 would be appropriate .  20.6.1 - Where to Report Modifiers on the Hospital Part B Claim  (Rev. 3019, Issued: 08- 07-14, Effective: 01- 01-12, ICD -10: Upon Implementation of ICD - 10, Implementation: 09 -08-14, ICD -10: Upon Implementation of ICD - 10)   Modifiers are reported on the hardcopy Form CMS -1450 with the HCPCS code.  See Chapter 25 of this manual for related instructions.  There is space for four modifiers on the hardcopy.   See the ASC X12 837 Institutional Claim implementation guide for instructions for reporting HCPCS modifiers when using the ASC X12 837 institutional claim format.    The dash that is often seen preceding a modifier should never be reported.   When it is appropriate to use a modifier, the most specific modifier should be used first.  That is, when modifiers  E1 through E4, FA through F9, LC, LD, RC, and TA through T9 apply, they should be used before modifiers LT, RT, or - 59.  20.6.2 - Use of Modifiers -50, -LT, and -RT (Rev. 1, 10- 03-03)   Modifier - 50 is used to report bilateral procedures that are performed at the same operative session as a single line item.  Do not use modifiers RT and LT when modifier - 50 applies.  Do not submit two line items to report a bilateral procedure using modifier - 50.  Modifier - 50 applies to any bilateral procedure performed on both sides at the same operative session.   The bilateral modifier -50 is restricted to operative sessions only.   Modifier - 50 may not be used:    To report surgical procedures identified by their terminology as bilateral, or   To report surgical procedures identified by their terminology as unilateral or bilateral.   The unit entry to use when modifier - 50 is reported is one.  20.6.3 - Modifiers -LT and -RT  (Rev. 1, 10- 03-03)  Modifiers - LT or -RT apply to codes, which identify procedures, which can be perf ormed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries.  Modifiers - LT and -RT should be used whenever a procedure is performed on only one side.  Hospitals use the appropriate - RT or - LT modifier to identify which of the paired or gans was operated upon.   These modifiers are required whenever they are appropriate.