(Medicare Claims Processing Manual)

200.8 - Billing for Nuclear Medicine Procedures  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Beginning January 1, 2008, the I/OCE began editing for the presence of a radiolabeled product when a separately payable nuclear medicine procedure is present on a claim.  Hospitals should include radiolabeled product HCPCS codes on the same claim as a nuclear medicine procedure beginning on January 1, 2008.  Hospitals are required to submit the HCPCS code for the radiolabeled product on the same claim as the HCPCS code for the nuclear medicine procedure.  Hospitals are also instructed to submit the claim so that the services on the claim each reflect the date the particular service was provided.  Therefore, if the nuclear medicine procedure is provided on a different date of service from the radiolabeled product, the claim will contain more than one date of service.  More information regarding these edits is available on the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/ .  Hospitals are instructed to use HCPCS code C9898 (Radiolabeled product provided during a hospital inpatient stay) on outpatient claims for nuclear medicine procedures to indicate that a radiolabeled product that provides the radioactivity necessary for the  reported diagnostic nuclear medicine procedure was provided during a hospital inpatient stay.  This HCPCS code is assigned status indicator N because no separate payment is made for the code under the OPPS.  The effective date of the code is January 1, 2008, the date the nuclear medicine procedure- to-radiolabeled product edits were initially implemented.  Because the Medicare claims processing system requires that there be a charge for each HCPCS code reported on the claim, hospitals should always report  a token charge of less than $1.01 for HCPCS code C9898.  The date of service reported on the claim for HCPCS code C9898 should be the same as the date of service for the nuclear medicine procedure HCPCS code, which should always accompany the reporting of HCPCS code C9898.  HCPCS code C9898 should never be reported on a claim without a diagnostic nuclear medicine procedure that is subject to the nuclear medicine procedure -to-radiolabeled product edits.  More information regarding these edits is available on the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS   Future updates to this section will be communicated in a Recurring Update Notification.   200.9 - Billing for Sometimes Therapy Services that May be Paid as Non-Therapy Services for Hospital Outpatients  (Rev. 3156, Issued: 12 -22-14, Effective: 01 -01-15, Implementation: 01- 05-15)  Section 1834(k) of the Act, as added by Section 4541 of the BBA, allows payment at 80 percent of the lesser of the actual charge for the services or the applicable fee schedule amount for all outpatient therapy services; that is, physical therapy services, speech -language pathology services, and occupational therapy services.  As provided under Section 1834(k)(5) of the Act, a therapy code list was created based on a uniform coding system (that is, the HCPCS) to identify and track these outpatient therapy s ervices paid under the Medicare Physician Fee Schedule (MPFS).   The list of therapy codes, along with their respective designation, can be found on the CMS Website, specifically at http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage .  Two of the designations that are used for therapy services are: always therapy and sometimes therapy.  An always therapy service must be performed by a qualified therapist under a certified therapy plan of care, and a sometimes therapy service m ay be performed by physician or a non- physician practitioner outside of a certified therapy plan of care.   Under the OPPS, separate payment is provided for certain services designated as sometimes therapy services if these services are furnished to hospital outpatients as a non-therapy service, that is, without a certified therapy plan of care. Specifically, to be paid under the OPPS for a non- therapy service, hospitals SHOULD NOT append the therapy modifier GP (physical therapy), GO (occupational therapy), or GN (speech language pathology), or report a therapy revenue code 042x, 043x, or 044x in association with the sometimes therapy codes listed in the table below.   To receive payment under the MPFS, when sometimes therapy services are performed by a qualified therapist under a certified therapy plan of care, providers should append the appropriate therapy modifier GP, GO, or GN, and report the charges under an appropriate therapy revenue code, specifically 042x, 043x, or 044x. This instruction does not apply to claims for sometimes therapy codes furnished as non- therapy services in the hospital outpatient department and paid under the OPPS.   Effective January 1, 2015, two HCPCS codes designated as Sometimes Therapy services, G0456 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a mechanically -powered device, not durable medical equipment, including provision of cartridge and dressing(s), topic al application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area less than or equal to 50 square centimeters) and G0457 (Negative pressure wound therapy, (e.g. vacuum assisted drainage collection) using a me chanically -powered device, not durable medical equipment, including provision of cartridge and dressing(s), topical application(s), wound assessment, and instructions for ongoing care, per session; total wounds(s) surface area greater than 50 square centim eters) would be terminated and replaced with two new CPT codes 97607 (Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection syste m, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area less than or equal to 50 square centimeters) and 97608 (Negative pressure wound therapy, (eg, vacuum assisted drainage collection), ut ilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area greater than 50 square cen timeters).   The list of HCPCS codes designated as sometimes therapy services that may be paid as non-therapy services when furnished to hospital outpatients is displayed in the table below.  Services Designated as Sometimes Therapy that May be Paid as Non -Therapy Services for Hospital Outpatients  HCPCS Code  Long Descriptor  92520  Laryngeal function studies (i.e., aerodynamic testing and acoustic testing)  97597  Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (eg., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, pe r session; total wound(s) surface area less than or equal to 20 square centimeters  97598  Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assess ment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters  97602  Removal of devitalized tissue from wound(s), non -selective debridement, without anesthesia (e.g., wet -to-moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session  97605  Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters  97606  Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters  97607  Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area less than or equal to 50 square centimeters  97608  Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non- durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session;  total wounds(s) surface area greater than 50 square centimeters  97610  Low frequency, non -contact, non -thermal ultrasound, including topical application(s), when performed, wound assessment, and instruction(s) for ongoing care, per day   200.10 - Billing for Cost Based Payment for Certified Registered Nurse Anesthetists (CRNA) Services Furnished by Outpatient Prospective Payment System (OPPS) Hospitals (Rev. 3065, Issued: 09- 12-14, Effective: 04 -01-03, Implementation: 12- 15-14)  Payment of outpatient services of CRNAs furnished by small rural hospitals subject to OPPS that qualify for cost based payment under 42 CFR 412.113(c) are made through biweekly interim payments that are calculated based on retrospective adjustments from a settled cost report.   In order for interim payments to be made to these hospitals based on submitted claims, a number of changes were required in the reporting and acceptance of revenue code 0964 Anesthetists (CRNA).  Those changes are as follows:   (1) Hospitals that qualify for cost based CRNA services must report these services under revenue code 0964;   (2) Shared System Maintainer is required to accept revenue code 0964 on type of bill 013X for these hospitals; and   (3) Reporting and acceptance of revenue code 0964 from other OPPS hospitals (without a CRNA pass -through exemption) may not be allowed.   NOTE:   Value code 05 Professional Component Included In Charges and Also Billed Separately to A/B MACs (B), should not be reported with revenue code 0964.  The Integrated Outpatient Code Editor (IOCE) will assign a service indicator of F to revenue code 0964. This allows for cost -based payment for revenue code 0964.  The facility is paid a cost- based interim payment (charges multiplied by the hospitals outpatient interim rate) for the revenue code 0964 charge on the claim, and assume when calculating the interim payment that coinsurance is billed (by the hospital to the beneficiary) in the amount of 20 percent of the submitted charges.  In addition, an adjustment to the hospitals biweekly interim payment amount for cost paid services should exclude any amounts attributable to outpatient hospital CRNA services from all  future biweekly interim payments.  Hospitals shall not bill Healthcare Common Procedure Coding System (HCPCS) when billing for CRNA services.  Beneficiaries are billed for coinsurance for cost based CRNA services billed under revenue code 0964.  Coinsurance is based on 20 percent of the submitted covered charges.  The Part B deductible is applicable.   200.11  Billing Advance Care Planning (ACP) as an Optional Element of an Annual Wellness Visit (AWV)   (Rev. 3739, Issued: 03- 17-17, Effective: 01 -01-16, Implementation: 06- 19-17)   Effective January 1, 2016 payment for the service described by CPT code 99497 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face -to-face with the patient, family member(s), and/or surrogate) is conditionally packaged under the OPPS and is consequently assigned to a conditionally packaged payment status indicator of Q1. When this service is furnished with another s ervice paid under the OPPS, payment is packaged; when it is the only service furnished, payment is made separately. CPT code 99498 (Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)) is an add- on code and therefore payment for the service described by this  code is unconditionally packaged (assigned status indicator N) in the OPPS in accordance with 42 CFR 419.2(b)(18).   In addition, for services furnished on or after January 1, 2016, Advance Care Planning (ACP) is treated as a preventive service when furnished with an AWV. The Medicare coinsurance and Part B deductible are waived for ACP when furnished as an optional elem ent of an AWV.