OBJECTIVE

Services Included within the scope of the hospital outpatient pps

Services Excluded from the scope of services paid under the hospital outpatient pps

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM BILL TYPES

LINE ITEM DATES OF SERVICE

REPORTING OF SERVICE UNITS

DISCONTINUATION OF BILL TYPE 83X FOR SERVICES PAID UNDER OUTPATIENT PPS

HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS)

HCPCS/Revenue Code Chart

Reporting of HCPCS Codes

Coding for Clinic and Emergency Visits

Radiation Therapy

Implanted DME and Prosthetic Devices and Diagnostic Devices and Implanted Diagnostic Devices

MODIFIERS

Special Guidelines for Using Modifiers with Radiology Services

Modifier for Bilateral Procedures

50 Bilateral Procedure

Payment Implications

Modifiers for Discontinued Services

52 Reduced Services

Special guidelines for Modifier 52

Payment Implications

Additional Instructions for Coding Discontinued Surgical Services

Modifier for Distinct Procedures

Modifiers for Repeat Procedures

Additional Guidelines for Coding Repeat Procedures

Modifier for Evaluation and Management Services

Modifier for Staged or Related Procedures

Modifier for a Return Trip to the Operating Room

Modifier for an Unrelated Procedure during a Postoperative Period

HCPCS Level II Modifiers

Guidelines for Level II Modifiers

Level II Modifiers

Condition Code G0 (zero)

OBSERVATION AND EMERGENCY ROOM

Emergency Room

HOSPITAL INPATIENT SERVICES COVERED UNDER PART B

Inpatient Part B Services – (Bill type 12x)

Changes to Billing Procedures for Inpatient Part B and Outpatient Hospital Services

BILLING CHANGES FOR CMHC AND PARTIAL HOSPITALIZATION SERVICES

Billing Requirements

Reporting of Service Units

Line Item Date of Service Reporting

Professional Services provided to

Partial Hospitalization Patients:

Payment

Provider Reporting Requirements

Professional Component

Corneal Tissue Acquisition Costs

CONDITION CODES 20 AND 21

Repetitive Services

PROCEDURES FOR SUBMITTING LATE CHARGES VS. ADJUSTMENTS

Payment under Outpatient Prospective Payment System (OPPS) for Certain Services Provided in Various Settings

Site

MISCELLANEOUS ISSUES

Designated Drugs or Biologicals

Designated Devices

Process for Identifying Items Potentially Eligible for Payment as New Technologies or Pass-Throughs

Process for Obtaining HCPCS Codes

Outliers

PROGRAM MANUALS ON THE INTERNET

OBJECTIVE

This chapter provides participants with an overview of the claims processing system and billing changes under the outpatient prospective payment system

Services Included within the scope of the hospital outpatient pps

The following services are included in the scope of hospital outpatient PPS:

• Certain services for patients who have exhausted their Part A benefits
• Partial hospitalization services for CMCHs
• Services designated by the Secretary: surgical procedures, radiology (including radiation therapy), clinic visits, partial hospitalization for the mentally ill, surgical pathology and cancer chemotherapy
• Specific hospital outpatient services furnished to a beneficiary who is admitted to a Medicare-participating SNF, but who is not considered to be a SNF resident for purposes of SNF consolidated billing, with respect to those services that are beyond the scope of SNF comprehensive care plans
• Certain preventive services furnished to healthy persons, e.g., colorectal screening
• Hospital outpatient PPS for certain medical and other health services when they are furnished by other providers, such as CORFS, and HHAs, or to hospice patients for the treatment of a non-terminal illness.
• Implants

Services Excluded from the scope of services paid under the hospital outpatient pps

The following services are excluded from the scope of services paid under outpatient PPS:

• Services already paid under fee schedules or other payment systems including, but not limited to:
• Screening mammographies
• ESRD paid under the ESRD composite rate
• Professional services of physicians and non-physicians paid under the Medicare physician fee schedule
• Laboratory services paid under the clinical diagnostic laboratory fee schedule
• Non-implantable DME, orthotics, prosthetics and prosthetic devices, prosthetic implants, and take-home surgical dressings paid under the DMEPOS fee schedule
• Hospital outpatient services furnished to SNF inpatients as part of his or her resident assessment or comprehensive care plan
• Services and procedures that require inpatient care
• Ambulance services, physical and occupational therapy, and speech/language services
• Drugs and supplies that are used within a dialysis session where payment is not included in the composite rate
• Take-home surgical dressings paid under the DMEPOS fee schedule

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM BILL TYPES

The bill type is a code indicating the specific type of bill (inpatient, outpatient, adjustments, cancels, late charges). This is a three-position field and is mandatory for all outpatient bills paid under the Outpatient Prospective Payment System (OPPS).

The three-digit alphanumeric code gives three specific pieces of information. The first digit identifies the type of facility. The second classifies the type of care. The third indicates the sequence of this bill in this particular episode of care: it is referred to as the frequency code.

Data elements in the HCFA uniform billing specifications are consistent with the Form HCFA-1450. The type of bill is located in field 4 of the 1450. In the electronic specifications, the bill type is located in record type 40, position 25.

The bill types that will be affected by Outpatient Prospective Payment System are:

LINE ITEM DATES OF SERVICE

Under the hospital OPPS, hospitals and CMHCS are required to report all services utilizing HCPCS coding in order to assure proper payment. This requirement applies to:

• Acute care hospitals
• Hospital outpatient departments
• Community mental health centers
• Comprehensive outpatient rehabilitation facilities
• Home Health Agencies
• Hospice patients for the treatment of a non-terminal illness

Under OPPS, line item dates of service are to be reported on all outpatient bills for each line where a HCPCS code is required, including claims where the "from" and "through" dates are the same.

Claims will be returned to providers if submitted

• With a HCPCS and no corresponding line item date of service, or
• With a line item date of service outside the ‘statement covers’ period
• Line item dates of service and no HCPCS code

REPORTING OF SERVICE UNITS

The definition of service units is revised for hospital outpatient services and CMHCS where HCPCS code reporting is required.

A unit is now redefined as the "number of times the service or procedure being reported was performed according to the HCPCS code definition."

The pattern remains the same for treatment times in excess of two hours. Hospitals should not bill for services performed for less than 8 minutes. The expectation is that a provider’s time for each unit will average 15 minutes in length.

The beginning and ending time of the treatment should be recorded in the patient’s medical record along with the note describing the treatment. (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 97112 and 23 minutes of 97110 were furnished, then the total treatment time was 47 minutes; therefore, only three units can be billed for the treatment. The correct coding is two units of 97112 and one unit of 97110; thus assigning more units to the service that took more time.

DISCONTINUATION OF BILL TYPE 83X FOR SERVICES PAID UNDER OUTPATIENT PPS

Effective for dates of service July 1, 2000 and after, bill type 83x (ambulatory surgery center or ASC) will no longer be used for hospital ambulatory surgical claims. Hospitals must use 13x for ambulatory surgical claims submitted for outpatient prospective payment system (OPPS) payment. Claims submitted with bill type 13x will no longer be changed to 831 by the claims processing system.

The requirement to submit all charges for ASC services on the same claim has not changed. However, if preoperative lab services are included on the claim, the "from" date of the claim must include the date of the pre-op lab services.

• In the field "statement covers period from date" ( 1450 form locator 6), enter the earliest date services were rendered.
• Preoperative laboratory services must always have a line item date of service within the "from" and "thru" dates on the claim.
• Include all related services on one claim. An adjustment must be submitted if all services were not included on the original claim. Late charge bills (XX5) are no longer acceptable.
• Indian Health Services providers continue to bill surgeries utilizing bill type 83x.

• Critical Access providers continue to bill surgeries utilizing bill type 85X. bill type.

HCFA COMMON PROCEDURE CODING SYSTEM (HCPCS)

In preparation for implementation of the hospital OPPS, hospitals and CMHCs are required to report services using HCPCS coding in order to receive proper outpatient payment. There are three levels of HCPCS codes:

• Level I codes contain the American Medical Association’s Current Procedural Terminology (CPT) coding system. This level consists of all numeric codes.
• Level II codes (national codes) contain the codes for physician and non-physician services which are not included in CPT 4 codes, (e.g., ambulance , DME, orthotics and prosthetics). These are alphanumeric codes maintained jointly by HCFA, Blue Cross and Blue Shield Association and the Health Insurance Association of America (HIAA).
• Level III (local codes) contain the codes that Medicare fiscal intermediaries and carriers develop as needed.

There are certain HCPCS codes that are not used by Medicare. If hospitals report them on a claim with other services that are covered, the intermediary will deny the line item as non-covered.

The following chart represents all HCPCS coding to be reported and paid under the OPPS system.

*Revenue codes have not been identified for these procedures, as they can be performed in a number of revenue centers within a hospital, such as emergency room (450), operating room (360), or clinic (510). Providers are to report these HCPCS codes under the revenue center where they were performed.

Under OPPS, when basing payment on CPT codes, the range of cost reflects hospitals’ billing patterns in increasing levels of intensity. Increasing increments are due largely to hospitals’ use of ‘chargemaster’ systems, which generate bills using predetermined charges for codes.

Hospitals should not use the lowest level code (e.g., CPT code 99201) to bill for all clinic visits. This would distort the data causing inflation in both the volume and cost of low-level clinic visits.

It is important that hospitals use the appropriate level of intensity of their clinic visits and reporting codes properly based on internal assessment of the charges for those codes rather than failing to distinguish between low- and mid-level visits because the payment is the same.

The billing information that hospitals report during the first years of implementation of OPPS will be vitally important to the revision of weights and other adjustments that affect payment in future years.

Each facility will be accountable for following its own system for assigning the different level of HCPCS codes.

Hospitals can use HCPCS code 99291 in place of, but not in addition to, a code for a medical visit/service in a clinic, emergency department.

The CPT definition of ‘critical care’ is the evaluation and management of a critically injured patient who requires periods of continual attendance of a physician.

Prior to OPPS, hospitals could report CPT code 99201 to indicate a visit of any type. Under OPPS, 31 codes are used to indicate visits with payment differentials for more or less intense service. Hospitals should code the visit using the following HCPCS codes:

92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204,99205,99211,99212,99213,99214,99215,99241,

99242,99243,99244,99245,99271,99272,99273,99274,

99275,99281,99282,99283,99284,99285,G0101 and G0175.

Hospitals should use CPT guidelines when applicable or crosswalk hospital coding structures to CPT codes. For example, a hospital that has 8 levels of emergency and trauma care depending on nursing ratios should walk those 8 levels to the CPT codes for emergency care.

Hospitals can use HCPCS code G0175 in reporting a scheduled medical conference with the patient involving a combination of at least three health care professionals, and one of whom is a physician, but cannot be nurse.

Two new HCPCS codes have been developed to report radiation therapy in place of HCPCS code 61793.

Providers should use these codes beginning with dates of service July 1, 2000.

• G0173 stereotactic radiosurgery, complete course of therapy in one session.
• G0174 stereotactic radiosurgery, requiring more than one session.

Initially, both codes will pay the same however, expect differences in cost to become apparent during the first year or 18 months of OPPS.

Implanted Durable Medical Equipment (DME) and implanted prosthetic devices are now paid under the Outpatient Prospective Payment System and no longer paid on fee schedule. The following are the appropriate HCPCS codes for payment under OPPS. Do not bill your local carrier for dates of service on and after July 1, 2000.

MODIFIERS

A modifier is a two position alpha or numeric code that is added to the end of a HCPCS code to clarify the services being billed.

Modifiers provide a means by which a service can be altered without changing the procedure code. They add more information, such as the anatomical site, to the HCPCS code. In addition, they help to eliminate the appearance of duplicate billing and unbundling.

There are CPT-4 and Level II HCPCS modifiers. They are used to increase accuracy in reimbursement, coding consistency, editing, and to capture payment data. Billing accurately with modifiers is an integral part of the OPPS.

Use the modifiers identified below, when appropriate, for surgical procedures (HCPCS codes 10000–69999), radiology (HCPCS codes 70010–79999), and other diagnostic procedures (HCPCS codes 90700–99199).

• Do not use a modifier to indicate an anatomical site location on body (modifier 50 or Level II modifiers) if the narrative definition of a code indicates multiple occurrences.

• Do not use a modifier to indicate an anatomic site (modifier 50 or Level II modifiers) if the narrative definition of a code indicates the procedure applies to more than two sites.

• Use modifiers 50, 52, 59,, 76, 77, and level II modifiers.
• Do not report a radiology procedure that was canceled.

Modifier 50 is used to report bilateral procedures that are performed at the same session. Report the appropriate HCPCS code and add the modifier 50 to the procedure code to identify that the procedure was performed on a contralateral site. Units should be reported as one.

• surgical procedures (CPT 10000-69990)
• radiology procedure if applicable
• any bilateral procedure performed on both sides at the same session

• procedures identified by their terminology as "bilateral," e.g., 27395 (Lengthening of hamstring tendon, multiple, bilateral)
• procedures identified as "unilateral or bilateral," e.g., 52290 (Cystourethroscopy, with meatotomy, unilateral or bilateral)

• submit two line items to report a bilateral procedure
• submit with modifiers RT and LT when modifier 50 applies

• When modifier 50 is reported, reimbursement is for two procedures: PRICER will apply the rules for calculating payment for multiple procedures. The provider is Reimbursement at 150% of the group rate.
• Radiology is reimbursed at 200%. (Reimbursed is for two procedures)

Modifier 52 is for radiology and other diagnostic procedures. It can also be used for surgery when the use of anesthesia was not an inherent part of performing the procedure.

Example: If a colonoscopy, HCPCS code 45378, flexible, promimal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) was started (conscious sedation had been administered), but is was found that the patient was inadequately prepped for the procedure, so the procedure was discontinued, and no exam of even the sigmoid was possible. This should be billed as 4537852

*Revenue code should be billed where the services were performed.

However, it is not appropriate to use modifier 52 if a portion of the intended procedure was completed and a code exists which represents the completed portion of the intended procedure.

Example: If a colonoscopy, HCPCS code 45378, was partially completed, that is, the colonoscopy was advanced as far as the splenic flexion, to the extent that the procedure meets the definition of a sigmoidoscopy, HCPCS code 45330, it is appropriate to bill that code. Otherwise, if no codes exists for what has been done, report the intended code with modifier 52.

• Code to the extent of the procedure that was performed and do not use modifier 52
• If no code exists for what has been done, report the intended code with modifier 52

• procedures requiring anesthesia
• an outpatient hospital procedure discontinued

• use modifiers 52 and 73 together

• A terminated procedure with modifier 73 will be discounted at 50%

Modifier 74 is used for surgical procedures for which anesthesia (general,regional or local) has been started.

• procedures requiring anesthesia
• an outpatient hospital/ambulatory surgery center (ASC) or diagnostic procedure discontinued after the administration of anesthesia

When multiple procedures were planned and there was a termination:

• If one of more of the procedures were completed, report the completed procedure(s) as usual. The other(s) planned and not started are not reported.
• If none of the planned procedures were completed, report the first procedure that was planned with modifier 73 or modifier 74. The others are not reported.

59 Distinct Procedural Services

• Indicating that a procedure or service was distinct or independent from other services performed on the same day.
• Representing

different procedure or surgery,

• different site or organ system,
• separate incision, or
• separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician
• different session or patient encounter

• a level II HCPCS modifier can be used to indicate different body areas

Modifier 76 is used to indicate that a procedure or service was repeated in a separate session on the same day by the same physician. This modifier may be reported for services ordered by physicians but performed by technicians. The procedure code is listed once and then listed again with modifier 76 added (two line items). The number of times that the procedure was repeated is reported on separate lines.

For surgical procedures, report the HCPCS code without modifier 76 to indicate the first time the procedure was performed. For each additional time the procedure was performed, the HCPCS code is repeated with modifier 76 added. Do not use the units field to indicate that the procedure was repeated more than once on the same day.

Modifier 77 is used for a procedure performed that had to be repeated by a different physician in a separate session on the same day. The procedure code is listed once and then listed again with modifier 77 added. The number of times the procedure was repeated is reported on separate lines. Do not use the units field to indicate that the procedure was performed more than once on the same day.

For surgical procedures, report the HCPCS code without modifier 77 to indicate the first time the procedure was performed. For each additional time the procedure was performed, the HCPCS code is repeated with modifier 77 added. Do not use the units field to indicate that the procedure was performed more than once on the same day.

• If you are not sure who ordered the second procedure, or whether the same physician ordered both procedures, code based on the physician who performed the procedures.
• The procedure repeated must be the same procedure.

Modifier 25 is billed with an evaluation and management (E & M) code to indicate that on the same day a procedure was performed, the patient’s condition required a significant, separately identifiable E & M service (even though the E & M service may be necessary because of the symptom or condition for which the procedure was provided).

• that is above and beyond the procedure performed
• that is beyond the usual pre-operative and post-operative care associated with the procedure
• when a separate history was taken, a separate physical was performed, and a separate medical decision was made and is documented in the medical record

58. A Staged Or Related Procedure Or Service By The Same Physician During The Postoperative

An example of modifier 58 is one were a needle biopsy is performed in the morning and the plan, which subsequently carried out, is to perform an excisional biopsy later in the day depending on the results of the surgical pathology report. The post operative period refers to same calender day

• planned prospectively at the time of the original procedure (staged)
• more extensive than the original procedure
• for therapy following a diagnostic surgical procedure

Modifier 78 is used to indicate that another procedure was performed during the postoperative period of the initital procedure that was performed earlier in the same day.

• the subsequent procedure relates to the first procedure; and

the subsequent procedure requires the use of an operating room.

Modifier 79 is used to indicate that the performance of a procedure or service by the same physician during the post-operative period was unrelated to the original procedure that was performed earlier in the day.

HCPCS Level II Modifiers

The following HCPCS level II modifiers are added, as appropriate, primarily to codes for procedures performed paired organs etc., on eyelids, fingers, toes, or arteries. These modifiers are used to prevent erroneous denials when duplicate HCPCS codes are billed to report separate procedures performed on different anatomical sites or different sides of the body.

• When a modifier is needed, the most specific modifier should be used first.

• If more than one level II modifier applies, repeat the HCPCS code on another line with the appropriate level II modifier.

• Modifiers LT and RT