OPPS Manager

August 2008 Edition Contents Contents

OPPS Manager Website ...... 1 Covered and Noncovered Charges ...... 35 Introduction ...... 3 Operational Strategies ...... 35 A Reference for the Future ...... 3 Billing Systems ...... 36 Acronyms and Terms Used in the OPPS Manager ...... 4 Operational Strategies ...... 36 Abarelix for Treatment of Prostate Cancer ...... 17 Blood and Blood Products ...... 36 Operational Strategies ...... 17 Purchased Blood ...... 36 Administrative or Judicial Review ...... 17 Blood Deductible ...... 38 2005 Changes ...... 39 Advance Beneficiary Notice ...... 18 Overpayment for Certain Blood Products ...... 39 Requirements for ABNs ...... 18 2007 Update ...... 40 How the ABN Is Delivered ...... 18 2008 Update ...... 40 Operational Strategies ...... 20 Blood Transfusions ...... 40 Alcohol and Substance Abuse Assessment and Operational Strategies ...... 40 Intervention ...... 20 Bone Marrow and Stem Cell Processing Services ...... 41 Operational Strategies ...... 20 Operational Strategies ...... 41 Allergy Testing ...... 20 Bone Mass Measurement ...... 41 Operational Strategies ...... 20 Coverage Criteria ...... 41 All-Inclusive Rate Hospitals ...... 21 Billing and Coding Rules ...... 42 Reimbursement Issues ...... 42 Angioplasty for Hemodialysis Access Sites ...... 21 Operational Strategies ...... 42 Operational Strategies ...... 21 APC Code Assignments ...... 22 Brachytherapy ...... 42 Criteria for APC Code Assignments ...... 22 Cesium-131 and Ytterbium-169 ...... 43 Updates and Changes to APC Assignments ...... 22 Electronic Brachytherapy Services ...... 43 Low-Dose Rate Prostate Brachytherapy Composite APC .... 43 APC Relative Weights ...... 23 2007 Update ...... 44 Appeals Process ...... 24 Operational Strategies ...... 45 Redeterminations ...... 24 Blood Brain Barrier Osmotic Disruption for Reconsideration ...... 24 Treatment of Brain Tumors ...... 45 Administrative Law Judge Hearings ...... 24 Operational Strategies ...... 45 Appeals Council Review ...... 24 Breast Biopsy, Percutaneous Image-Guided ...... 46 Judicial Review in U. S. District Court ...... 25 Coverage ...... 46 Arthroscopic Procedures of the Knee ...... 25 Billing ...... 46 Operational Strategies ...... 25 Contractor Payment ...... 46 Balanced Budget Act (BBA) of 1997 ...... 25 Operational Strategies ...... 46 Balanced Budget Refinement Act (BBRA) of 1999 ...... 26 Cancer Centers ...... 46 Beneficiary Information on OPPS ...... 26 Cardiac Rehabilitation Services ...... 47 Operational Strategies ...... 47 Benefits Improvement and Protection Act (BIPA) 2000 .. 27 Cardioverter-Defibrillator Insertion ...... 47 Billing Errors on the UB-04 ...... 27 Beneficiaries in a Medicare Advantage (MA) Plan ...... 47 Medicare vs. Other Payers ...... 27 Operational Strategies ...... 48 Packaging ...... 28 Most Common Errors Found on the UB-04 ...... 32 Charge Compression ...... 48 Operational Strategies ...... 33 Chargemaster ...... 49 Billing Instructions for the UB-04 ...... 33 Operational Strategies ...... 49 HCPCS Codes Required ...... 33 Clinical Trials ...... 50 Revenue Code Assignments ...... 33 Medical Records Documentation Requirements Date of Service ...... 33 for Clinical Trials ...... 50 Units of Service ...... 34 2005 Changes ...... 50 Billing of Outpatient Surgical Procedures ...... 34 Off-label Use Clinical Trials ...... 50 Preoperative Services ...... 34 Operational Strategies ...... 50 Related Services ...... 34 Repetitive Services ...... 34

© 2008 Ingenix i CPT only © 2007 American Medical Association. All Rights Reserved. Abarelix for Treatment of Prostate Cancer Abarelix for Treatment of Prostate Cancer Abarelix has been approved for use as a palliative treatment for Operational Strategies patients with advanced symptomatic prostate cancer under the Ensure that the chargemaster has the correct HCPCS codes and following conditions: revenue code for abarelix. „ Gonadotropin-releasing hormone (GnRH) agonist therapy is not appropriate. References „ The patient has declined surgical castration. Medicare Claims Processing Manual, Pub. 100-04 (trans. 532, „ The patient has one of the following conditions: April 25, 2005; trans. 612, July 22, 2005) — risk of neurological compromise due to metastases Medicare National Coverage Determinations Manual Pub. — ureteral or bladder outlet obstruction due to local 100-03 (trans. 34, April 25, 2005) encroachment or metastatic disease — severe bone pain from skeletal metastases persisting on narcotic analgesia Report J0128 with revenue code 636 and the appropriate chemotherapy administration injection code. Assign an ICD-9- CM code for prostate cancer.

Administrative or Judicial Review

While facilities may challenge the payment amounts they receive „ The establishment of a separate conversion factor for cancer from Medicare and other issues specific to their operations, hospitals federal law prohibits legal challenges to the validity or The Balanced Budget Refinement Act of 1999 further amended appropriateness of the outpatient prospective payment system the list of adjustments subject to the limitation on judicial review (OPPS) and its components. By prohibiting administrative or to include the following items: judicial review, CMS attempted to stop the kinds of legal challenges to the diagnosis-related group payment system that „ The factors used to determine outlier payments, that is, the were raised during the first years of the inpatient prospective fixed multiple, or a fixed dollar cutoff amount; the marginal payment system. cost of care, or applicable total payment percentage The Balanced Budget Act of 1997 prohibits administrative or „ The factors used to determine additional payments for certain judicial review of the following: medical devices, drugs, and biologicals such as the determination of insignificant cost „ The development of the PPS classification system „ The duration of the additional payments „ The ambulatory payment classification groups „ The portion of the OPPS payment amount associated with „ Relative payment weights particular devices, drugs, or biologicals, and any pro rata „ Wage adjustment factors reduction „ Volume control methods „ Calculation of base amounts References „ Periodic control methods Balanced Budget Act of 1997, section 4523 „ Periodic adjustments Federal Register, April 7, 2000

© 2008 Ingenix 17 CPT only © 2007 American Medical Association. All Rights Reserved. OPPS Manager Late Charges

Late charges are charges posted to the patient account after the D1 Changes in charges final bill has been produced. Hospitals usually hold bills for three D2 Changes in revenue codes/HCPCS to five days after the patient has been discharged to allow time for D3 Second or subsequent interim PPS bill charges to be posted to tha account and for the completion of D4 Change in GROUPER input (diagnosis or procedure) diagnosis and procedure coding. This time period is usually D5 Cancel only to correct a HICN or provider identification referred to as billing suspense days. number Providers billing under the outpatient prospective payment D6 Cancel only to repay a duplicate payment or OIG over system (OPPS) may not submit a late charge bill for bill types payment and DRG window 012X, 013X, 014X, 034X, 075X, 076X, or any claim containing D7 Change to make Medicare the secondary payer condition code 07 and certain HCPCS codes. This change was D8 Change to make Medicare the primary payer effective for dates of service on and after July 1, 2000. They must D9 Any other change submit an adjustment bill for any service required to be billed E0 Change in patient status with HCPCS codes, units, and line item dates of service by reporting a “7” in the third position of the bill type. Operational Strategies The submission of an adjustment bill, instead of a late charge bill, „ Ensure billing staff is aware of the proper way to submit an will ensure proper duplicate detection, bundling, correct adjustment bill when late charges are applied to a Medicare application of coverage policies and proper editing by OCE, and OPPS claim. payment under OPPS. The document control number (DCN) of the claim that is being adjusted should be reported in field 37 of „ Periodically, audit several accounts to ensure that adjustment the UB-04. One of the following claim change condition codes bills have been properly submitted. must be included on each adjustment. Adjustment claims should be coded to reflect the way the claim should process. References D0 Change in service dates Medicare Program Memorandum A-00-23, April 2000

Line-Item Dates of Service

Providers covered under OPPS are required to report all services Claims will be returned to providers if submitted with a HCPCS utilizing HCPCS coding in order to ensure proper payment. Line and no corresponding line item date of service, or with a line item item dates of service must be reported on all outpatient bills for date of service outside the “statement covers” period. each line where a HCPCS code is required, including claims where the “from” and “through” dates are the same.

Lithotripsy

Under APCs, CPT code 50590 for lithotripsy, extracorporeal Lithotripsy is used to break up stones in other organs such as the shock waves, of kidney stones is reimbursed. Lithotripsy of bladder and bile duct. kidney stones had been the highest paid service in an ambulatory surgery center (ASC) setting. Operational Strategies Prior to the implementation of the outpatient prospective „ Review any contractor guidelines or LMRPs/LCDs for payment system (OPPS), CMS received many comments from the lithotripsy coverage. industry on lithotripsy. Many commenters believed that the procedure should not be classified as a surgical procedure. Another comment suggested that since it is not a surgical References procedure, ASCs should not be allowed to perform lithotripsy. Federal Register, November 13, 2000; November 30, 2001, CMS chose to consider it a surgical procedure and place it into page 59862 APC 0169 when used for kidney stones.

158 © 2008 Ingenix CPT only © 2007 American Medical Association. All Rights Reserved. OPPS Manager Trauma Diagnosis Codes

CMS requires that claims be reviewed to determine if the services ICD-9-CM Code Description may be covered under an automobile, no-fault or liability insurance policy. Claims submitted with a trauma code are 800.00–829.1 Fractures suspended for review if Medicare records confirm that an accident 839.0–839.9 Dislocations and the related services are covered under an insurance policy. If Medicare records do not indicate that an accident occurred has 847.0 Sprains and strains of the neck (whiplash) occurred, a questionnaire is sent to the beneficiary requesting 850.0–854.19 Intracranial injuries without skull fractures information to determine whether the trauma diagnosis is the 860.0–869.1 Internal injuries to thorax, abdomen, and pelvis result of an accident. These codes will produce a Medicare 887.0–887.7 Traumatic amputation of upper appendage secondary payer (MSP) Alert, OCE Edit #4. This edit is currently inactive. However the inactive status does not relieve the hospital 895.0–897.7 Traumatic amputation of lower appendage of the responsibility for identifying the appropriate primary payer. 900.00–904.9 Injuries to blood vessels When submitting a claim, trauma diagnosis codes should be used 925.1–929.9 Crush injuries only to report an injury. If the condition being reported is related 958.4 Traumatic shock to a chronic condition or it is the result of a systemic disease 958.5 Traumatic anuria rather than an injury, report the proper nontrauma diagnosis 959.01–959.9 Injuries, other and unspecified codes. 996.00–996.49 Mechanical complications of devices, implants, The information in the following table is intended to warn and grafts facilities of possible trauma diagnoses. It is not intended to V54.10–V54.14 Aftercare for healing traumatic fractures represent an official list used by the contractor or COBC. The list is not all inclusive. V58.43 Aftercare following surgery for injury or trauma Note that there are also numerous E codes used to communicate an external cause of an injury that may also indicate liability Operational Strategies situations where Medicare would be secondary. For example, „ Ensure that policies and procedures ensure the MSP E810.0 indicates that the patient was the driver of a motor vehicle questionnaire is completed at the emergency department (other than a motorcycle) that collided with a train; code E880.0 registration, completing the information needed after all indicates that the patient accidentally fell on or from an escalator. EMTALA requirements are met. It usually can be made into a Please consult ICD-9-CM coding source for all diagnosis coding. mandatory function to complete the registration. References Medicare Secondary Payer Manual, Pub. 100-05, chap. 1, sec. 10.6; chap 2, sec. 60; chap. 3, sec. 30.2.1; chap. 5, sec. 20.1

Two-times Rule Exemptions

The two-times rule authorizes the Health and Human Services „ Resource homogeneity secretary to make exceptions to this limit on the variation of costs „ Clinical homogeneity within each APC group in unusual cases such as low-volume „ Hospital concentration items and services. No exception may be made in the case of a drug or biological that has been designated as an orphan drug „ Frequency of service (volume) under section 526 of the federal Food, Drug, and Cosmetic Act. „ Opportunity for upcoding and code fragmentation CMS reviews all APCs, including those new APC assignments outlined above. It uses prior year claims data to calculate the References median cost of procedures classified to APCs and determined Medicare Claims Processing Manual, Pub. 100-04, chap. 4, which APCs would not meet the two-times limit. The following sec. 10 criteria are used when deciding whether to make exceptions to the two-times rule for affected APCs:

258 © 2008 Ingenix CPT only © 2007 American Medical Association. All Rights Reserved.