|
HAPPY NEW YEAR!!
The Medicare OPPS Final Rule for calendar year 2006 was
published and as we all know there have been many changes to the drug
administration coding. This issue will summarize the Federal Register's
rule and print any additional information noted since the rule was
published.
At this point in time, there seems to be more questions than
answers. Hopefully, CMS will continue to evaluate their drug
administration coding and issues that remain unanswered and publish their
advice, taking into consideration the hospital's dilemmas.
DRUG ADMINISTRATION - 2006
According to the Final OPPS Rule published by CMS, there have been significant changes for reporting drug administration.
Hospitals will be required to bill 1 initial service code for IV drug administration effective January 1, 2006. A modifier is used to indicate an additional episode of care on the same date of service.
CMS will adopt 20 out of the 33 drug administration codes for billing and payment in 2006. These 20 codes are:
| Code |
Description |
Add-On |
SI |
APC |
| 90772 |
Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular |
- - |
X |
0353 |
| 90773 |
Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intra-arterial |
- - |
X |
0359 |
| 90779 |
Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion |
- - |
X |
0352 |
| 96401 |
Chemotherapy administration, subcutaneous or intramuscular; non-hormonal
anti-neoplastic |
- - |
S |
0116 |
| 96402 |
Chemotherapy administration, subcutaneous or intramuscular; hormonal
anti-neoplastic |
- - |
S |
0116 |
| 96405 |
Chemotherapy administration; intralesional, up to and including 7 lesions |
- - |
S |
0116 |
| 96406 |
Chemotherapy administration; intralesional, more than 7 lesions |
- - |
S |
0116 |
| 96416 |
Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of portable or implantable pump |
- - |
S |
0117 |
| 96420 |
Chemotherapy administration, intra-arterial; push technique |
- - |
S |
0116 |
| 96422 |
Chemotherapy administration, intra-arterial; infusion technique, up to one hour |
- - |
S |
0117 |
| 96423 |
Chemotherapy administration, intra-arterial; infusion technique, each additional hour up to 8 hours (list separately in addition to code for primary procedure) |
Y |
N |
- |
| 96425 |
Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump |
- - |
S |
0117 |
| 96440 |
Chemotherapy administration into pleural cavity, requiring and including thoracentesis |
- - |
S |
0116 |
| 96445 |
Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis |
- - |
S |
0116 |
| 96450 |
Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture |
- - |
S |
0116 |
| 96521 |
Refilling and maintenance of portable pump |
- - |
T |
0125 |
| 96522 |
Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic
(eg, intravenous, intra-arterial) |
- - |
T |
0125 |
| 96523 |
Irrigation of implanted venous access device for drug delivery systems |
- - |
N |
- |
| 96542 |
Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents |
- - |
S |
0116 |
| 96549 |
Unlisted chemotherapy procedure |
- - |
S |
0116 |
In addition, hospitals will use 6 new HCPCS C codes for billing and payment. The CPT codes
NOT being used by CMS are codes that require determination of initial, sequential and concurrent infusion or IV pushes. The C codes being used and listed below will permit straightforward billing of types of infusions and IV pushes for the first hour and then each additional hour of infusion and IV pushes, an approach to coding that commenters indicated was consistent with current patterns of delivery and billing drug administration. These new C codes are:
| Code |
Description |
Add-On |
SI |
APC |
| C8950 |
Intravenous infusion for therapy/diagnosis; up to 1 hour |
- - |
S |
0120 |
| C8951 |
Intravenous infusion for therapy/diagnosis; each additional hour (list separately in addition to C8950) |
Y |
N |
- - |
| C8952 |
Therapeutic, prophylactic or diagnostic injection; intravenous push |
- - |
X |
0359 |
| C8953 |
Chemotherapy administration, intravenous; push technique |
- - |
S |
0116 |
| C8954 |
Chemotherapy administration, intravenous; infusion technique, up to one hour |
- - |
S |
0117 |
| C8955 |
Chemotherapy administration, intravenous; infusion technique, each additional hour (list separately in addition to C8954) |
Y |
N |
- - |
More detailed instructions will be released separately from this final rule that indicate drug administration and coding guidelines for hospitals in 2006. This information will be distributed through a CMS transmittal.
HCPCS codes have also been created for the refilling and maintenance of a portable or implantable pump and for the initiation of prolonged infusion requiring the use of a portable or implantable pump.
Non Chemotherapy Prolonged Infusion Codes That Require a Pump
| Code |
Description |
Add-On |
SI |
APC |
| C8956 |
Refilling and maintenance of portable or implantable pump or reservoir for drug delivery for therapy/diagnosis, systemic (e.g., Intravenous, intra-arterial) |
- |
T |
0125 |
| C8957 |
Intravenous infusion for therapy/diagnosis; initiation of
prolonged infusion (more than 8 hours), requiring use of portable or
implantable pump |
- |
S |
0120 |
The table below notes the status indicator, APC and payment for vaccine administration in 2005 and 2006. It is important to note that some of the status indictors have changed and there will be payment to hospitals in 2006 for some HCPCS codes that were not paid in 2005.
| HCPCS |
Description |
CY 2005 |
CY 2006 |
| SI |
APC
|
SI |
APC |
Payment |
| G0008 |
Influenza vaccine administration |
L |
Reasonable cost |
X |
0350 |
$23.31 |
| G0009 |
Pneumococcal vaccine administration |
L |
Reasonable cost |
X |
0350 |
$23.31 |
| G0010 |
Hepatitis B vaccine administration |
K |
0355 |
B |
- - |
- - |
| 90465 |
Immunization admin, under 8 yrs old, with counseling; first injection |
N |
- - |
B |
- - |
- - |
| 90466 |
Immunization admin, under 8 yrs old, with counseling; each additional injection |
N |
- - |
B |
- - |
- - |
| 90467 |
Immunization admin, under 8 yrs old, with counseling; first intranasal or oral |
N |
- - |
B |
- - |
- - |
| 90468 |
Immunization admin, under 8 yrs old, with counseling; each additional intranasal or oral |
N |
- - |
B |
- - |
- - |
| 90471 |
Immunization admin, one vaccine injection |
N |
- - |
X |
0353 |
$23.31 |
| 90472 |
Immunization admin, each additional vaccine injection |
N |
- - |
X |
0353 |
$23.31 |
| 90473 |
Immunization admin, one vaccine by intranasal or oral |
E |
- - |
S |
1491 |
$5.00 |
| 90474 |
Immunization admin, each additional vaccine by intranasal or oral |
E |
- - |
S |
1491 |
$5.00 |
Since the Final Rule was published in the Federal Register, CMS published Transmittal 785 on December 16, 2005, titled January 2006 Update of the Hospital Outpatient Prospective Payment System (OPPS) Manual Instructions: Changes to Coding and Payment for Drug Administration.
It is important to read the transmittal in its entirety. A few highlights are:
-
Infusions lasting 15 minutes or less should be billed as intravenous (or intra-arterial) pushes and should be coded accordingly.
-
Concurrent infusions through the same vascular access site of the same type are not separately reportable under the
OPPS.
-
Hospitals should report C8950 or C8954 for the first hour of intravenous infusion that the patient receives while at the hospital, even if the hospital did not initiate the infusion, and HCPCS codes for additional hours of infusion if needed.
-
Where a beneficiary makes 2 separate visits to the hospital for non-chemotherapy infusions in the same day, hospitals are to report modifier -59 for non-chemotherapy infusion codes during the second encounter that were also furnished in the first encounter.
-
In an example in the transmittal, when 12 hours of anti-neoplastic drugs are administered, CMS reports the 12 hours as C8950, 1 unit; C8951, 11 units.
The December 23, 2005 Federal Register published changes to the Hospital OPPS. It should be noted that a correction shows C8956 (refilling and maintenance of a portable or implantable pump) as a deleted code in 2006.
In addition in 2006, C codes have been eliminated for 2005 brand name drug codes. Payments for those 2006 code changes may have resulted in cost based reimbursement, packaged payment or a reduced payment from the 2006 payment rate.
FUTURE ISSUE
The next issue will address Medicare Observation.
|
