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TRANSMITTAL 557
On May 6, 2005 CMS printed Transmittal 557, Clarifying Manual Instructions for Coding and Payment for Drug Administration under OPPS. This article will summarize the transmittal:
CMS requests that hospitals voluntarily report the HCPCS codes and charges for drugs that are packaged into payment for the corresponding drug administration service. Effective January 1, 2005 hospitals were required to report the CPT drug administration codes as listed in the CPT-4 coding book. Infusions lasting longer than 9 hours should report additional infusion hours on a separate line of the corresponding add-on code (as appropriate). There is a limit of 8 units per line. In the unusual case where the beneficiary makes two (2) separate visits to the hospital for chemotherapy treatment (i.e., infusions, injections) in the same day, modifier –59 should be added to the codes during the second encounter that were also furnished in the first chemotherapy encounter. Just as with chemotherapy services, when an infusion lasts longer than 9 hours, the additional infusion hours should be reported on a separate line, as appropriate, with a limit of 8 units per line. CPT codes 90780 and 90781 should not be reported when the infusion is a necessary and integral part of a separately payable OPPS procedure. CPT codes 90780 and 90781 should report the duration of the infusion regardless of the number of drugs infused, therefore, hospitals may bill one unit of CPT code 90780 for each encounter, but not for each drug infused. Regardless of whether separate payment is made, hospitals are instructed to report all codes that appropriately describe the services provided and corresponding charges so that CMS may capture hospital historical data for future payment rate setting. Modifier –59 indicates a distinct encounter on the same date of service. Modifier –59 is appended to drug administration CPT codes that meet the following criteria:
- The drug administration occurs during a distinct encounter on the same date of service of previous drug administration codes; and
- The same CPT code has already been billed for services provided during separate and distinct encounter earlier on that same date.
Modifier –59 is NOT to be used when a beneficiary receives infusion therapy at more than one (1) site or when an infusion is stopped and then started again in the same encounter. Hospitals are to report the first hour infusion codes (i.e., 90780, 96410, 96422) after 15 minutes of infusion. Infusions lasting 15 minutes or less should be billed as intravenous (or intra-arterial) pushes and billed accordingly. Hospitals are to bill push codes (96408, 96420, 90783, 90784) for services that meet existing CPT guidelines and meet either of the following criteria:
- a healthcare professional administering the injection is continuously present,
- an infusion that is administered lasts 15 minutes or less.
The effective date of Transmittal 557 is January 1, 2005, implementation date if June 1, 2005.
As you read this transmittal, you will note that the documentation of times is essential!
TRANSMITTAL 34
Transmittal 34 of May 6, 2005 addresses changes to sections 220 and 230, Therapy Services, of the Medicare Benefit Policy. In summary:
Claims should be paid based on a certified plan of care (rather than physician order), but the use of a physician order is prudent to determine that a physician is involved in the patient’s care and available to certify the plan. Claims may be denied if there is no documentation indicating a certified therapy plan for each 30-day interval of treatment unless there is a delayed certification. The evaluation and treatment may occur and are both billable either on the same day or subsequent visits. Therapy may be initiated based on a dictated plan after it has been committed to writing and before it is signed. A dictated plan must be signed by close of business on the day following dictation by the person who established it. Certifications are acceptable without justification for 30 days after they are due. A qualified therapist is a person who is licensed as a therapist by the state in which he or she is practicing and meets other requirements as noted in the transmittal. The cost of supplies used in furnishing covered therapy care is included in the payment for HCPCS codes and is not separately billable.
The effective date of this transmittal is June 6, 2005. Become familiar with the details before implementation!
COMING IN JUNE
The June newsletter will list HCPCS codes where a therapy modifier (GN, GO, GP) is required and also HCPCS codes which should not be billed with a modifier, according to Transmittal 515.
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