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Clarification for Coding and Payment for Drug Administration
Transmittal 902, Change Request 4388 of April 7, 2006 was recently released and
clarified some issues regarding drug administration for OPPS.
Highlights of the article include:
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Hospitals are to bill for additional IV pushes of different substances or
drugs using multiple units of the HCPCS code for IV push drugs. Additional IV
pushes of the same substance/drug are not separately reported with
multiple units of an IV push code.
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Certain items/services regarding an infusion are considered part of the
procedure and are not separately billable. They are:
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Use of local anesthesia;
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IV start;
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Access to indwelling IV;
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Flush at the conclusion of the infusion;
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Standard tubing, syringes and supplies;
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Preparation of chemotherapy agents
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Continue to report the charges for these items/supplies without a CPT/HCPCS
code and an appropriate packaged revenue code;
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Include the charge for the items/supplies in the charge for the procedure in
which the items/services are supplied.
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the drug administration occurs during a distinct encounter on the same date of
service as the previous drug administration service; and
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the same HCPCS code has already been billed for services provided during a
separate encounter earlier in that same day; or
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a distinct and separate drug administration service is provided on the same day
as a procedure when there is a NCCI edit for the drug administration service
and procedure code pair. In this case the 59 modifier is clinically
appropriate.
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In the case where infusions of the same type are provided through 2 vascular
access sites of the same type in the same encounter, hospitals may report 2
units of the appropriate first hour infusion code without modifier 59.
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When a hospital receives Medicare patients who are in the process of receiving
an infusion at the time of arrival to the hospital, hospitals should bill for
the first hour of infusion that the patient receives while at the hospital even
if the hospital did not initiate the infusion. The additional hours of infusion
should also be listed on the claim.
The implementation date is May 8, 2006.
Q & A for OPPS Drug Administration
In February, an article was published on the CMS website regarding OPPS drug
administration. One question/answer addresses billing multiple units of an IVP.
According to the article, This means that hospitals are to bill multiple units
of C8952 (therapeutic, prophylactic or diagnostic injection, intravenous push) only
when different substances or drugs are provided via intravenous push in the
same encounter.
View the entire article.
April 2006 OPPS OCE (Outpatient Code Editor)
Effective April 3, 2006 CMS reinstated the CCI (Correct Coding Initiative) for
OPPS drug administration codes. CCI edits for hospitals are implemented 1
calendar quarter behind the carrier (edits for physician billing) edits.
Therefore, version 12.0 of the CCI edits will be applied to outpatient claims
except for the edits for anesthesiology, E & M codes and mental health
codes.
In particular, the drug administration CCI edits will be implemented in April.
These edits had been temporarily suspended in January to allow hospitals
sufficient time to incorporate the 2006 coding changes. In that the edits for
drug administration support correct coding, these edits will be implemented.
CCI edits identify code pairs where the second code is not payable with the
first code unless an edit permits the use of a modifier. The CCI edits may not
allow payment of the second code (could be a drug administration code) when
reported with the first code in the edit pair.
It is important that modifiers are used appropriately to ensure that services
are properly coded that deserve separate payment.
Units of drugs administered to patients must be accurately reported on the claim
in terms of dosage specified in the full HCPCS Level II code descriptor. The
drug should not be billed based on the way the drug is packaged, stored,
stacked or ordered.
Two drugs were newly approved to be eligible for pass-through status effective
April 1, 2006. They are:
| HCPCS |
APC |
Description |
| C9227 |
9227 |
Injection, micafungin sodium, per 1 mg |
| C9228 |
9228 |
Injection, tigecycline, per 1 mg |
OPPS Hospital ED Services Exceeding 24 Hours
Effective April 3, 2006 when emergency room services exceed 24 hours the claim
should be billed in the following manner:
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Revenue code 450 (Emergency Room),
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Date of service should be the date the service was provided in the emergency
room,
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If the patient was in the emergency room after midnight, only 1 service date
should be entered-the date the patient entered the emergency room,
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Units of service should be reported as one (1).
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