(Medicare Claims Processing Manual)

Beginning January 1, 2007, critical care services will be paid at two levels, depending on the presence or absence of trauma activation.  Providers will receive one payment rate for critical care without trauma activation and will receive additional paymen t when critical care is associated with trauma activation.   To determine whether trauma activation occurs, follow the National Uniform Billing Committee (NUBC) guidelines in the Claims Processing Manual, Pub 100- 04, Chapter 25, 75.4 related to the reporting of the trauma revenue codes in the 68x series.  The revenue code series 68x can be used only by trauma centers/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons.  Different subcategory revenue codes are reported by designated Level 1- 4 hospital trauma centers. Only patients for whom there has been prehospital notification based on triage information from prehospital caregivers, who meet either local, state or American College of Surgeons field triage criteria , or are delivered by inter -hospital transfers, and are given the appropriate team response can be billed a trauma activation charge.   When critical care services are provided without trauma activation, the hospital may bill CPT code 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30 -74 minutes (and 99292, if appropriate).  If tra uma activation occurs under the circumstances described by the NUBC guidelines that would permit reporting a charge under 68x, the hospital may also bill one unit of code G0390, which describes trauma activation associated with hospital critical care servi ces.  Revenue code 68x must be reported on the same date of service.  The OCE will edit to ensure that G0390 appears with revenue code 68x on the same date of service and that only one unit of G0390 is billed.  CMS believes that trauma activation is a one -time occurrence in association with critical care services, and therefore, CMS will only pay for one unit of G0390 per day.  The CPT code 99291 is defined by CPT as the first 30- 74 minutes of critical care.  This 30 minute minimum has always applied under the OPPS.  The CPT code 99292, Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes, remains a packaged service under the OPPS, so that hospitals do not have the ongoing administrative burden of reporting precisely the time for each critical service provided.  As the CPT guidelines indicate, hospitals that provi de less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines.   Under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face -to-face critical care of a critically ill or critically injured patient.  If the physician and hospital staff or mu ltiple hospital staff members are simultaneously engaged in this active face- to-face care, the time involved can only be counted once.   Beginning in CY 2007 hospitals may continue to report a charge with RC 68x without any HCPCS code when trauma team activation occurs.  In order to receive additional payment when critical care services are associated with trauma activation, the hospital mu st report G0390 on the same date of service as RC 68x, in addition to CPT code 99291 (or 99292, if appropriate.)    Beginning in CY 2007 hospitals should continue to report 99291 (and 99292 as appropriate) for critical care services furnished without trauma team activation.  CPT 99291 maps to APC 0617 (Critical Care).  (CPT 99292 is packaged and not paid separately, but  should be reported if provided.)   Critical care services are paid in some cases separately and in other cases as part of a composite APC payment.  See Section 10.2.1 of this chapter for further details.  Future updates will be issued in a Recurring Update Notification.   170 - Hospital and CMHC Reporting Requirements for Services Performed on the Same Day  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   When reporting a HCPCS code for a separately payable, non- repetitive hospital OPPS service, report charges for all services and supplies associated with that service that were furnished on the same date (services subject to the 3- day payment window are an exception to this OPPS policy).    When a hospital provides electroconvulsive therapy (ECT) on the same day as partial hospitalization or intensive outpatient  services, both the ECT and partial hospitalization or intensive outpatient  services should be reported on the same hospital claim. In this instance, the claim should contain condition code 41 for partial hospitalization services or condition code 92 for intensive outpatient services . As noted above, report charges for all services and supplies associated with the ECT service that were furnished on the same date(s) on the same claim.    When a hospital provides non- partial hospitalization mental health services to a partial hospitalization patient, all partial hospitalization services and non -partial hospitalization mental health services should be reported on the same hospital claim with condition code 41.    Likewise, when a hospital provides non- intensive outpatient program mental health services to an intensive outpatient program patient, all intensive outpatient services and non- intensive outpatient mental health services should be reported on the same hospital claim with condition code 92.    NOTE: For a list of revenue codes that are considered repetitive services, see Chapter 1, 50.2.2.    EXAMPLE 1  If a patient receives a laboratory service on May 1st and has an emergency room (ER) visit on the same day, one bill may be submitted since the laboratory service is paid under the clinical diagnostic laboratory fee schedule and not subject to OPPS. In thi s situation, the laboratory service was not related to the ER visit or done in conjunction with the ER visit.    EXAMPLE 2  If the patient receives physical therapy on July 7th, 29th, and 30th, and receives services in the ER on July 28th, the provider shall submit separate claims since the isolated individual service (ER visit) did not occur on the same day as the repetitive service (physical therapy).    EXAMPLE 3  If a patient has an ER visit (OPPS service) on May 15th and also receives a physical therapy visit (repetitive, non- OPPS service) on the same day (as well as other physical therapy visits provided May 1st through May 31st) the services shall be billed on separate claims. The provider would bill the ER service on one claim and the therapy services on the monthly repetitive claim. Please note, as stated above, the procedures for billing repetitive services remains in effect under OPPS. Therefore, in this exam ple, it would not be appropriate to submit one therapy claim for services provided May 1st through May 15th, a second claim for the ER visit provided on May 15th, and a third claim for therapy visits provided on May 16th through May 31st. Providers shall not split repetitive services in mid -month when another outpatient service occurs.   EXAMPLE 4    If a patient receives chemotherapy, or radiation therapy, clinical laboratory services, a CT scan , and an outpatient consultation on the same date of service, the hospital may report all services on the same claim or may submit multiple claims. Chemotherapy, while commonly administered in multiple encounters across a span of time, is not a repetitive s ervice as defined in Chapter 1, Section 50.2.2. The clinical laboratory services may be reported either on the single consolidated claim or on a separate clai m that reports the services furnished on the same date as the laboratory services.    EXAMPLE 5  If a partial hospitalization patient receives remote non -partial hospitalization mental health services, the hospital should report all partial hospitalization services and non-partial hospitalization remote mental health services on the same claim.  For e ach date of service with partial hospitalization services (see section 260.1 of this chapter) , at least one of which is a partial hospitalization primary service , all partial hospitalization services will be packaged under the appropriate  hospital -based pa rtial hospitalization APC , 5863 or  5864.  When APC 5863 or  5864 is assigned, all remote non-partial hospitalization mental health services on the same date of service will be packaged under APC 8010 with no additional payment.  For any dates of service with no partial hospitalization primary  service, each remote non- partial hospitalization mental health service will be paid at the corresponding APC payment rate or packaged under the daily mental health composite APC 8010.    180 - Accurate Reporting of Surgical and Medical Procedures and Services  (Rev. 1109, Issued: 11- 09-06, Effective: 10 -01-05, Implementation: 04- 02-07)  180.1 - General Rules  (Rev. 1325; Issued:  08- 29-07; Effective:  01 -01-08; Implementation:  01 -07-08)  Hospitals subject to OPPS are required, beginning with claims with dates of service on or after August 1, 2000, to report in Form Locator 6 Statement Covers Period From Date the earliest date that services were rendered.  As a result, preoperative laboratory services will always have a line item date of service within the from and through dates on the claim.   Indian Health Service hospitals continue to bill for surgeries utilizing bill type 83X.  For other hospitals outpatient surgery subject to the ASC payment limit with dates of service prior to August 1, 2000, is reported on bill type 83X, and surgeries perf ormed August 1, 2000 and later are reported with bill type 13X.  NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims on TOB 83X for ASCs.  All IHS ASC providers must submit their claims to the designated A/B MAC (B).   180.2 - Selecting and Reporting Procedure Codes  (Rev. 1, 10- 03-03) A-01-50, A3- 3626.4.B.3   Using medical records as basic sources, hospitals report HCPCS surgical procedure codes for outpatient surgery in FL 44 adjacent to the revenue code for the operating room or other room used for the surgery.  The bill includes the hospitals charges for the surgery as well as all other services provided on the day the procedure was performed.  When multiple surgical procedures are performed at the same session, it is not necessary to bill separate charges for each procedure.  It is acceptable to bill a single charge under the revenue code that describes where the procedure was performed (e.g., o perating room, treatment room, etc.) on the same line as one of the surgical procedure CPT/HCPCS codes and bill the other procedures using the appropriate CPT/HCPCS code and the same revenue code, but with 0 charges in the charge field.   In the past, some hospitals billed a single emergency room (ER) visit charge, which included charges for any surgical procedures that were performed in the ER at the time of the ER visit.  Under the OPPS, CMS requires hospitals to bill a separate charge fo r ER visits and surgical procedures effective with claims with dates of service on or after July 1, 2001.  If a surgical procedure is performed in the ER, the charge for the procedure must be billed with the emergency room revenue code.  If an ER visit occ urs on the same day, a charge should be billed for the ER visit and a separate charge should be billed for the surgical procedure(s) performed.  As described above, a single charge may be billed for all surgical procedures if more than one is performed in the ER during the same session.   EXAMPLE:  The following is an example of how a claim should be completed under these reporting requirements:   Date of  Service  Revenue  Code  HCPCS  Modifier  Charges  7/5/2001 0450 99283 25 $150 7/5/2001 0450 12011  $300 7/5/2001 0450 12035   7/5/2001 0250   $70 7/5/2001 0270   $85  The charge for both surgical procedures in this example is reflected in the $300 charge shown on the line with procedure code 12011.   180.3 - Unlisted Service or Procedure  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  An unlisted HCPCS code represents an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code.  The CPT code book lists a number of unlisted service or procedure codes, which can be found at the end of a section or  subsection.  Alternatively, a summary list of the unlisted CPT codes can be found in the Guidelines section for each chapter of the CPT code book.  The long descriptors for these codes start with the term Unlisted and the last 2 digits of the codes ofte n end in 99.