(Medicare Claims Processing Manual)

Apheresis/pheresis services are billed on a per visit basis and not on a per unit basis.  OPPS providers should report the charge for an Evaluation and Management (E&M) visit only if there is a separately identifiable E&M service performed which extends beyond the evaluation and management portion of a typical apheresis/pheresis service.  If the OPPS provider is billing an E&M visit code in addition to the apheresis/pheresis service, it may be appropriate to use the HCPCS modifier - 25.  231.10 - Billing for Autologous Stem Cell Transplants  (Rev. 3556, Issued: 07- 01-2016; Effective: 01- 27-16; Implementation: 10 -03-16)  The hospital bills and shows all charges for autologous stem cell harvesting, processing, and transplant procedures based on the status of the patient (i.e., inpatient or outpatient) when the services are furnished.  It shows charges for the actual transplant, described by the appropriate ICD procedure or CPT codes in Revenue Center 0362 (Operating Room Services; Organ Transplant, Other than Kidney) or another appropriate cost  center.   The CPT codes describing autologous stem cell harvesting procedures may be billed and are separately payable under the Outpatient Prospective Payment System (OPPS) when provided in the hospital outpatient setting of care.  Autologous harvesting procedures are distinct from the acquisition services described in Pub. 100- 04, Chapter 3, 90.3.1 and 231.11 of this chapter for allogeneic stem cell transplants, which include services provided when stem cells are obtained from a donor and not from the patient undergoing the stem cell  transplant.   The CPT codes describing autologous stem cell processing procedures also may be billed and are separately payable under the OPPS when provided to hospital  outpatients.  231.11 - Billing for Allogeneic Stem Cell Transplants  (Rev. 11150; Issued: 12- 10-21; Effective: 01 -01-22; Implementation: 01 -03-22)  1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants   Acquisition charges for allogeneic stem cell transplants include, but are not limited to, charges for the costs of the following services:   1. National Marrow Donor Program fees, if applicable, for stem cells from an unrelated  donor;   2. Tissue typing of donor and recipient;   3. Donor  evaluation;   4. Physician pre -procedure donor evaluation services;   5. Costs associated with harvesting procedure (e.g., general routine and special care services, procedure/operating room and other ancillary services, apheresis services,  etc.);   6. Post-operative/post -procedure evaluation of donor;  and  7. Preparation and processing of stem  cells.   Payment for these acquisition services is included in the OPPS C -APC  payment for  the allogeneic stem cell transplant when the transplant occurs in the hospital outpatient setting.  The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant.  Recurring update notificat ions describing changes to and billing instructions for various payment policies implemented in the OPPS are issued  annually.   Acquisition charges for stem cell transplants apply only to allogeneic transplants, for which stem cells are obtained from a donor (other than the recipient himself or herself).  Acquisition charges do not apply to autologous transplants (transplanted stem  cells are obtained from the recipient himself or herself), because autologous transplants involve services provided to the beneficiary only (and not to a donor), for which the hospital may bill and receive payment (see Pub. 100- 04, chapter 3, 90.3.1 and 231.10 of this  chapter for information regarding billing for autologous stem cell  transplants).   2. Billing for Acquisition  Services   The hospital bills and shows acquisition charges for allogeneic stem cell transplants based on the status of the patient (i.e., inpatient or outpatient) when the transplant is furnished.  See Pub. 100- 04, chapter 3, 90.3.1 for instructions regarding billi ng for acquisition services for allogeneic stem cell transplants that are performed in the  inpatient setting.   Effective January 1, 2017, when the allogeneic stem cell transplant occurs in the outpatient setting, the hospital identifies stem cell acquisition charges for allogeneic bone marrow/stem cell transplants separately in FL 42 of Form CMS -1450 (or electronic  equivalent) by using revenue code 0815 (Other Organ Acquisition).  Revenue code 0815 charges should include all services required to acquire stem cells from a donor, as defined above, and should be reported on the same claim as the transplant procedure in order to be appropriately packaged for payment  purposes.  Revenue code 0815 charges for allogeneic stem cell acquisition costs are reported on Worksheet D Part V, column 2, line 77, cost center 0077 of the hospital Medicare cost report (Form CMS -2552- 10).  The transplant hospital keeps an itemized statement that identifies the services furnished, the charges, the person receiving the service (donor/recipient), and whether this is a potential transplant donor or recipient.  These charges will be reflected in the transplant hospital's stem cell/bone marrow acquisition cost center.  For allogeneic stem cell acquisition services in cases that do not result in transplant, due to death of the intended recipient or other causes, hospitals include the costs associated with the acqu isition services on the Medicare cost  report.   In the case of an allogeneic transplant in the hospital outpatient setting, the hospital reports the transplant itself with the appropriate CPT code, and a charge under revenue center code 0362 or another appropriate cost center. Selection of the cost center is up to the hospital.  231.12 - Correct Coding Initiative (CCI) Edits  (Rev. 1882, Issued:  12- 21-09; Effective Date:  01 -01-10; Implementation Date:  01-04-10)  The OPPS providers should be aware that certain CCI edits may apply when billing for blood and blood product services.  The OPPS providers should consult the most current list of CCI edits to determine whether they apply to the services or HCPCS blood product codes being reported.  A file with the most current list of CCI edits applicable to Medicare Part B services paid by A/B MACs (A) under the OPPS is available at:  http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp   240 - Inpatient Part B Hospital Services  (Rev. 3106, Issued: 11- 06-14, Effective: 10 -01-13, Implementation: 02- 10-15)   Medicare pays for hospital (including CAH) inpatient Part B services in the circumstances provided in Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6,  10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals).  Hospitals must bill Part B inpatient services on a 12x Type of Bill.  This Part B inpatient claim is subject to the statutory time limit for filing Part B claims described in chapter 1, 70 of this manual.    Inpatient Part B services include inpatient ancillary services that do not require an outpatient status and are not strictly provided in an outpatient setting.  Services that require an outpatient status and are provided only in an outpatient setting are not payable inpatient Part B services, including Clinic Visits, Emergency Department Visits, and Observation Services (this is not a complete listing).   Inpatient routine services in a hospital generally are those services included by the provider in a daily service charge --sometimes referred to as the "Room and Board" charge. They include the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made to Medicare Part A.  Many nursing services provided by the floor nurse (such as IV infusions and injections, blood administration, and nebulizer treatments, etc.) may or may not have a separate charge established depending upon the classification of an item or service as routine or ancillary among providers of the same class in the same S tate.  Some providers customary charging practice has established separate charges for these services following the PRM -1 instructions, however, in order for a providers customary charging practice to be recognized it must be consistently followed for all patients a nd this must not result in an inequitable apportionment of cost to the program.  If the PRM -1 instructions have not been followed, a provider cannot bill these services as separate charges.  Additionally, it is important that the charges for service render ed and documentation meet the definition of the HCPCS in order to separately bill.  240.1 - Editing Of Hospital Part B Inpatient Services: Reasonable and Necessary Part A Hospital Inpatient Denials  (Rev.:11685, Issued:11- 09-22, Effective: 07 -01-22, Implementation: 12- 12-22)  When inpatient services are denied as not medically necessary or a provider submitted medical necessity denial utilizing occurrence span code M1, and the services are furnished by a participating hospital, Medicare pays under Part B for physician service s and the non-physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, 10.1, Reasonable and Necessary Part A Hospital Inpatient Claim Denials.  A hospital may also be paid for Part B inpatient services if it determines under Medicare's utilization review requirements that a beneficiary should have received hospital outpatient rather than hospital inpatient services, and the beneficiary has already been discharged from the hospital (commonly referred to as hospital self- audit). If the hospital already submitted a claim to Medicare for payment under Part A, the hospital would be required to adjust its Part A claim (to make the provider liable) prior to submitting a claim for payment of Part B inpatient services. Whether or not the hospital had submitted a claim to Part A for payment, we require the hospital to submit a Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services. The hospital could then submit an inpatient claim for payment under Part B for all services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as a hospital inpatient, except where those services specifically require an outpatient status.  A hospital part B inpatient services claim billed when a reasonable and necessary part A hospital inpatient was denied must be billed with:   A condition code W2 attesting that this is a rebilling and no appeal is in process,   A/B REBILLING in the treatment authorization field, and   The original, denied inpatient claim (CCN/DCN/ICN) number.