evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The codes for the optional ACP services furnished as part of an AWV are 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 professional; first 30 minutes, face -to-face with the patient, family member(s) and/or surrogate;) and an add- on code 99498 (each additional 30 minutes (List separately in addition to code for primary procedure)). When ACP services a re provided as a part of an AWV, practitioners would report CPT code 99497 (and add- on CPT code 99498 when applicable) for the ACP services in addition to either of the AWV codes (G0438 or G0439).   The deductible and coinsurance for ACP will only be waived when billed on the same day and on the same claim as an AWV (code G0438 or G0439), and must also be furnished by the same provider. Waiver of the deductible and coinsurance for ACP is limited to on ce per year. Payment for an AWV is limited to once per year. If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance will be applied to the ACP.   Also see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 280.5.1 for more information.   230 - Billing and Payment for Drugs and Drug Administration  (Rev. 573, Issued: 06- 03-05, Effective: 01 -01-05, Implementation: 06 -01-05)  This section provides billing guidance and payment instructions for hospitals when providing drugs and drug administration services in the hospital outpatient department.   230.1 - Coding and Payment for Drugs and Biologicals, and Radiopharmaceuticals (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  This section provides hospitals with coding instructions and payment information for drugs paid under OPPS.  For additional information on coding and payment for drugs and biologicals under the OPPS, see the Medicare Claims Processing Manual, Chapter 17 Drugs and Biologicals.
(Medicare Claims Processing Manual)
This section provides hospitals with coding instructions and payment information for drugs paid under OPPS.  For additional information on coding and payment for drugs and biologicals under the OPPS, see the Medicare Claims Processing Manual, Chapter 17 Drugs and Biologicals.   230.2 - Coding and Payment for Drug Administration  (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)  A. Overview   Drug administration services furnished under the Hospital Outpatient Prospective Payment System (OPPS) during CY 2005 were reported using CPT codes 90780, 90781, and 96400- 96459.   Effective January 1, 2006, some of these CPT codes were replaced with more detailed CPT codes incorporating specific procedural concepts, as defined and described by the CPT manual, such as initial, concurrent, and sequential.  Hospitals are instructed to use the full set of CPT codes, including those codes referencing concepts of initial, concurrent, and sequential, to bill for drug administration services furnished in the hospital outpatient department beginning January 1, 2007.  In addition, hospitals are instructed to continue billing the HCPCS codes that most accurately describe the service(s) provided.   Hospitals are reminded to bill a separate Evaluation and Management code (with modifier 25) only if a significant, separately identifiable E/M service is performed in the same encounter with OPPS drug administration services.   B. Billing for Infusions and Injections
(Medicare Claims Processing Manual)
B. Billing for Infusions and Injections   Beginning in CY 2007, hospitals were instructed to use the full set of drug administration CPT codes (90760- 90779; 96401- 96549), (96413 -96523 beginning in CY 2008) (96360-96549 beginning in CY 2009) when billing for drug administration services provided in the hospital outpatient department.  In addition, hospitals are to continue to bill HCPCS code C8957 (Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump) when appropriate.  Hospitals are expected to report all drug administration CPT codes in a manner consistent with their descriptors, CPT instructions, and correct coding principles.  Hospitals should note the conceptual changes between CY 2006 drug administration codes effective under the OPPS and the CPT codes in effect beginning January 1, 2007, in order to ensure accurate billing under the OPPS.  Hospitals should report all HCPCS codes that describe the drug administration services provided, regardless of whether or not those services are separately paid or their payment is packaged.   Medicares general policy regarding physician supervision within hospital outpatient departments meets the physician supervision requirements for use of CPT codes 90760-90779, 96401- 96549, (96413- 96523 beginning in CY 2008).  (Reference:  Pub.100- 02, Medicare Benefit Policy Manual, Chapter 6, 20.4.)   Drug administration services are to be reported with a line item date of service on the day they are provided.  In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounte r where observation services span more than 1 calendar day.  C. Payments For Drug Administration Services   For CY 2007, OPPS drug administration APCs were restructured, resulting in a six- level hierarchy where active HCPCS codes have been assigned according to their clinical coherence and resource use.  Contrary to the CY 2006 payment structure that bundled payment for several instances of a type of service (non -chemotherapy, chemotherapy by infusion, non- infusion chemotherapy) into a per -encounter APC payment, structure introduced in CY 2007 provides a separate APC payment for each reported unit of a separately  payable HCPCS code.
(Medicare Claims Processing Manual)
Hospitals should note that the transition to the full set of CPT drug administration codes provides for conceptual differences when reporting, such as those noted below.   In CY 2006, hospitals were instructed to bill for the first hour (and any additional hours) by each type of infusion service (non- chemotherapy, chemotherapy by infusion, non- infusion chemotherapy).  Beginning in CY 2007, the first hour concept no longer exists. CPT codes in CY 2007 and beyond allow for only one initial service per encounter, for each vascular access site, no matter how many types of infusion services are provided; however, hospitals will receive an APC payment for the initial service and se parate APC payment(s) for additional hours of infusion or other drug administration services provided that are separately payable.    In CY 2006, hospitals providing infusion services of different types (non-chemotherapy, chemotherapy by infusion, non- infusion chemotherapy) received payment for the associated per -encounter infusion APC even if these infusions occurred during the same tim e period.  Beginning in CY 2007, hospitals should report only one initial drug administration service, including infusion services, per encounter for each distinct vascular access site, with other services through the same vascular access site being report ed via the sequential, concurrent or additional hour codes.  Although new CPT guidance has been issued for reporting initial drug administration services, Medicare contractors shall continue to follow the guidance given in this manual.  (NOTE:  This list above provides a brief overview of a limited number of the conceptual changes between CY 2006 OPPS drug administration codes and CY 2007 OPPS drug administration codes -  this list is not comprehensive and does not include all items hospitals wil l need to consider during this transition)   For APC payment rates, refer to the most current quarterly version of Addendum B on the CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/.   D. Infusions Started Outside the Hospital
(Medicare Claims Processing Manual)
D. Infusions Started Outside the Hospital   Hospitals may receive Medicare beneficiaries for outpatient services who are in the process of receiving an infusion at their time of arrival at the hospital (e.g., a patient who arrives via ambulance with an ongoing intravenous infusion initiated by param edics during transport).  Hospitals are reminded to bill for all services provided using the HCPCS code(s) that most accurately describe the service(s) they provided.  This includes hospitals reporting an initial hour of infusion, even if the hospital did not initiate the infusion, and additional HCPCS codes for additional or sequential infusion services if needed.   231 - Billing and Payment for Blood, Blood Products, and Stem Cells and Related Services  Under the Hospital Outpatient Prospective Payment System (OPPS)  (Rev. 1702, Issued: 03- 13-09, Effective: 04 -01-09, Implementation: 04- 06-09)  231.1 - When a Provider Paid Under the OPPS Does Not Purchase the Blood or Blood Products That It Procures from a Community Blood Bank, or When a Provider Paid Under the OPPS Does Not Assess a Charge for Blood or Blood Products Supplied by the Providers Own Blood Bank Other Than Blood Processing and Storage  (Rev. 1702, Issued: 03- 13-09, Effective: 04 -01-09, Implementation: 04- 06-09)
(Medicare Claims Processing Manual)
When an OPPS provider furnishes blood or a blood product collected by its own blood bank for which only processing and storage costs are assessed, or when an OPPS provider procures blood or a blood product from a community blood bank for which it is charged only the processing and storage costs incurred by the community blood bank, the OPPS provider bills the processing and storage charges using Revenue Code 0390 (Blood Processing/Storage), 0392 (Blood Processing/Storage; Processing and Storage),  or 0399 (Blood Processing /Storage; Other Processing and Storage), along with the appropriate blood HCPCS code, the number of units transfused, and the line item date of service (LIDOS).  Processing and storage costs may include blood product collection, safety testing, retyping, pooling, irradiating, leukocyte -reducing, freezing, and thawing blood products, along with the costs of blood delivery, monitoring, and storage.  In general, such categories of processing costs are not patient -specific.  There are specific blood HCPCS codes for blood products that have been processed in varying ways, and these codes are intended to make payment for the variable resource costs of blood products that have been processed differently.   Most OPPS providers obtain blood or blood products from community blood banks that charge only for processing and storage, and not for the blood itself.  These hospitals should follow the instructions outlined in this section.  Those OPPS providers that incur a charge for the blood product itself, in addition to the charge for processing and storage, should follow the coding requirements outlined in 231.2.  231.2 - When a Provider Paid Under the OPPS Purchases Blood or Blood Products from a Community Blood Bank or When a Provider Paid Under the OPPS Assesses a Charge for Blood or Blood Products Collected By Its Own Blood Bank That Reflects More Than Blood Processing and Storage  (Rev. 1702, Issued: 03- 13-09, Effective: 04 -01-09, Implementation: 04- 06-09)
(Medicare Claims Processing Manual)
If an OPPS provider pays for the actual blood or blood product itself, in addition to paying for processing and storage costs when blood or blood products are supplied by either a community blood bank or the OPPS providers own blood bank, the OPPS provide r must separate the charge for the unit(s) of blood or blood product(s) from the charge for processing and storage services.  The OPPS provider reports charges for the blood or blood product itself using Revenue Code series 038X (excluding 0380, which is not a valid revenue code for Medicare billing) with the LIDOS, the number of units transfused, and the appropriate blood product HCPCS code and HCPCS modifier BL.  The OPPS provider reports charges for processing and storage services on a separate line using Revenue Code 0390, 0392, or 0399 with the LIDOS, the number of units transfused, and the appropriate blood product HCPCS code and HCPCS modifier BL.  The same LIDOS, the same number of units, the same HCPCS code, and HCPCS modifier BL must be reported on both  lines.  This requirement applies to all OPPS providers that transfuse blood and incur charges for both the blood itself and processing and storage.
(Medicare Claims Processing Manual)
Effective for services furnished on or after July 1, 2005, the I/OCE will return to providers any claim that reports a charge for blood or blood products using Revenue Code 038X without a separate line for processing and storage services using Revenue Code  0390, 0392, or 0399.  Moreover, in order to process to payment, both lines must report the same line item date of service, the same number of units, and the same HCPCS code accompanied by modifier BL.  Payment for blood and blood products is based on the Ambulatory Payment Classification (APC) Group to which its HCPCS code is assigned, multiplied by the number of units transfused.  Units of whole blood or packed red cells for which only processing and storage charges are reported are not subject to the blood deductible.  The Medicare blood deductible is applicable only if the OPPS provider purchases whole blood or packed red cells fr om a community blood blank or if the OPPS provider assesses a charge that reflects more than blood processing and storage for whole blood or packed red cells collected by its owns blood bank.  If the beneficiary has not already fulfilled the annual blood deductible or replaced the blood, OPPS payment will be made for processing and storage costs only.  The beneficiary is liable for the blood portion of the payment as the blood deductible.  In order to ensure correct application of the Medicare blood deductible, providers should report charges for whole units of packed red cells using Revenue Code 381 (Packed red cells), and should report charges for whole units of whole blood using Revenue Code 382 (Whole blood).  Revenue Codes 381 and 382 should be used only to report charges for packed red cells and whole blood, respectively.
(Medicare Claims Processing Manual)
Please note that most hospitals obtain blood or blood products from community blood banks that charge only for processing and storage, rather than for the blood itself.  The blood coding requirements discussed in this section do not apply to blood and blood products carrying only a processing and storage fee; when billing only for blood processing and storage, OPPS providers should follow the coding requirements outlined in 231.1.  EXAMPLE:  An OPPS provider purchases 2 units of leukocyte -reduced red blood cells from a community blood bank and incurs a charge for the red cells themselves, and a charge for the blood banks processing and storage of the red blood cell unit.  The OPPS provider f urther incurs costs related to additional processing and storage of the red blood cell units after the OPPS provider has received the 2 units.  A Medicare beneficiary is transfused the two units of leukocyte -reduced red blood cells.  The OPPS provider should report the charges for 2 units of P9016 by separately billing the red blood cell charges and the total processing and storage charges incurred.  The charges for the red blood cell units are to be reported on one line with the date the blood was transfused, Revenue Code series 038X (excluding 380), 2 units, HCPCS code P9016, and modifier BL.  The total charges for processing and storage are to be reported on the same claim, on a separate line, showing the date the blood was transfuse d, Revenue Code 390, 0392, or 399, 2 units, HCPCS code P9016, and modifier BL.  Note that HCPCS modifier BL is reported on both lines.  231.3 - Billing for Autologous Blood (Including Salvaged Blood) and Directed Donor Blood  (Rev. 496, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)
(Medicare Claims Processing Manual)
In general, when autologous (predeposited or obtained through intra - or postoperative salvage) or directed -donor transfusion is performed, OPPS providers should bill for the transfusion service and the number of units of the appropriate HCPCS code that describes the blood product.  Payment for the product is intended to cover the costs associated with providing the autologous or directed donor blood product service (e.g., collection, processing, transportation, and storage).  OPPS providers should bill the transfusion service and the blood product  HCPCS code on the date that the transfusion took place and not on the date when the autologous blood was collected.   When an autologous blood product is collected but not transfused, OPPS providers should bill CPT 86890 (autologous blood or component, collection, processing, and storage; predeposited) or 86891(autologous blood or component, collection, processing, and st orage; intra - or postoperative salvage) and the number of units collected but not transfused.  CPT 86890 and 86891 are intended to provide payment for the additional resources needed to provide these services, which are not captured when a blood product HCPCS code is not billed.  Because billing 86890 or 86891 is only indicated when autologous blood is collected but not transfused, the OPPS provider should bill 86890 or 86891 on the date when the OPPS provider is certain the blood will not be transfused (i.e., date of a procedure or date of outpatient discharge), rather than on the date of the products collection or receipt from the supplier.   When a directed donor blood product is collected but not transfused to the initial targeted recipient or to any other patient, refer to the section 231.7 titled Billing for Unused Blood.   231.4 - Billing for Split Unit of Blood  (Rev. 1487, Issued: 04- 08-08, Effective: 04 -01-08, Implementation: 04- 07-08)
(Medicare Claims Processing Manual)
231.4 - Billing for Split Unit of Blood  (Rev. 1487, Issued: 04- 08-08, Effective: 04 -01-08, Implementation: 04- 07-08)  HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split and some portion of the unit is transfused to one patient and the other portions are transfused to other patients or to the same patient at other times.   When a patient receives a transfusion of a split unit of blood or blood product, OPPS providers should bill P9011 for the blood product transfused, as well as CPT 86985 (Splitting, blood products) for each splitting procedure performed to prepare the blood product for a specific patient.   Providers should bill split units of packed red cells and whole blood using Revenue Code 389 (Other blood), and should not use Revenue Codes 381 (Packed red cells) or 382 (Whole blood).  Providers should bill split units of other blood products using the applicable revenue codes for the blood product type, such as 383 (Plasma) or 384 (Platelets), rather than 389.  Reporting revenue codes according to these specifications will ensure the Medicare beneficiary's blood deductible is applied correctly.  EXAMPLE:   OPPS provider splits off a 100cc aliquot from a 250 cc unit of leukocyte -reduced red blood cells for a transfusion to Patient X.  The hospital then splits off an 80cc aliquot of the remaining unit for a transfusion to Patient Y. At a later time, the rema ining 70cc from the unit is transfused to Patient Z.  In billing for the services for Patient X and Patient Y, the OPPS provider should report the charges by billing P9011 and 86985 in addition to the CPT code for the transfusion service, because a specific splitting service was required to prepare a split un it for transfusion to each of those patients. However, the OPPS provider should report only P9011 and the CPT code for the transfusion service for Patient Z because no additional splitting was necessary to prepare the split unit for transfusion to Patient Z.  The OPPS provider should bill Revenue Code 0389 for each split unit of the leukocyte -reduced red blood cells that was transfused.
(Medicare Claims Processing Manual)
231.5 - Billing for Irradiation of Blood Products  (Rev. 496, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)  In situations where a beneficiary receives a medically reasonable and necessary transfusion of an irradiated blood product, an OPPS provider may bill the specific HCPCS code which describes the irradiated product, if a specific code exists, in addition to the CPT code for the transfusion.  If a specific HCPCS code for the irradiated blood product does not exist, then the OPPS provider should bill the appropriate HCPCS code for the blood product, along with CPT code 86945 (irradiation of blood product, each unit).  EXAMPLE:   If an OPPS provider transfuses the product described by P9040 (red blood cells, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill an additional CPT code for irradiation of the blood product since charges for irradiation should be included in the charge for P9040.   231.6 - Billing for Frozen and Thawed Blood and Blood Products  (Rev. 1487, Issued: 04- 08-08, Effective: 04 -01-08, Implementation: 04- 07-08)  In situations where a beneficiary receives a transfusion of frozen blood or a blood product which has been frozen and thawed for the patient prior to the transfusion, an OPPS provider may bill the specific HCPCS code which describes the frozen and thawed product, if a specific code exists, in addition to the CPT code for the transfusion..  If a specific HCPCS code for the frozen and thawed blood or blood product does not exist, then the OPPS provider should bill the appropriate HCPCS code for the blood product, along with CPT codes for freezing and/or thawing services that are not reflected in the blood product HCPCS code.  EXAMPLE:  If an OPPS provider transfuses the product described by P9057 (red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill additional CPT codes for freezing and/or thawing since charges for freezing and thawing should be included in the charge for P9057.
(Medicare Claims Processing Manual)
If a blood product has been frozen and/or thawed in preparation for a transfusion, but the patient does not receive the transfusion of the blood product, the OPPS provider may bill the patient for the CPT code that describes the freezing and/or thawing ser vices specifically provided for the patient.  Similar to billing for autologous blood collection when blood is not transfused, the OPPS provider should bill the freezing and/or thawing services on the date when the OPPS provider is certain the blood produc t will not be transfused (e.g., date of a procedure or date of outpatient discharge), rather than on the date of the freezing and/or thawing services.   The following chart of blood and blood products indicates whether providers should bill separately for freezing and thawing using the available CPT codes.