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