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OPPS Visit Codes
Recently CMS has provided some answers to frequently asked questions regarding
visit codes, specifically Type A and Type B hospital emergency department
visits. This reference may be helpful especially when there are areas
designated as fast track areas within the emergency department.
Read the CMS notice.
Date of Service for ED Visit Spanning Two Days
When the patient’s visit to the Emergency Department (ED) crosses over a
calendar date, the entire ED visit should be listed on the claim with revenue
code 0450 with the date of service being the date the patient entered in ED.
Ancillary services related to that ED visit should be listed on the claim with
the appropriate revenue code for that service and the date of service reported
as the date the test was actually performed (which could be different than the
date the patient entered the ED).
Change Request (CR) 5389 dated November 9, 2006 clarifies this issue. The
implementation date of the CR was April 2, 2007.
Billing Diagnostic Mammograms on an Inpatient
Effective April 1, 2007 hospitals should bill a diagnostic mammogram for an
inpatient using Bill Type 12x when billing to Medicare fiscal intermediaries.
According to Change Request 5377, hospitals should continue to use Bill Type
13x, 22x, 23x or 85x when billing diagnostic mammograms to Medicare patients,
other than inpatients.
Medically Unlikely Edits (MUE)
According to Change Request 5495 the next version (Version 1.1) of the MUEs was
implemented April 2, 2007. An MUE is defined as an edit that tests claim lines
for the same beneficiary, HCPCS/CPT code, date of service and provider against
a determined number of units of service. Claims submitted to a fiscal
intermediary that have units of service billed in excess of the MUE determined
criteria will be returned to the provider (RTP). An appeal process will not be
allowed for RTP’d claims. The error should be corrected and resubmitted to the
fiscal intermediary. Providers can not bill the beneficiary for excess charges
due to units of service greater than what a MUE will allow.
April 2007 Update to the Medicare OPPS
Change Request 5544 lists the changes to the Medicare OPPS effective April 1,
2007 with an implementation date of April 2, 2007.
One item mentioned includes the changes made to certain device edits. If claims
were returned due to failure to pass these device edits before April 1, 2007,
the claim can be resubmitted for payment.
Device to Procedure Edit Changes Being Implemented in the April
2007
OCE; Effective for Services Furnished on or After January 1, 2007
| C1820 |
(Generator, neuron rechg bat sys) is now
allowed with 61885 (Insrt/redo neurostim 1 array) |
| C1898 |
(Lead, pmkr, other than trans) is now allowed with G0300 (Insert reposit lead
dual+gen) |
| C1779 |
(Lead, pmkr, transvenous VDD) is now allowed with G0300 (Insert reposit lead
dual+gen) |
Procedure to Device Edit Changes Being Implemented
in the April 2007 OCE with Effective Dates as Shown
| 93651 |
(Ablate heart dysrhythm focus) is now allowed with C2630 (Cath EP, Cool tip);
effective 01/01/07 |
| 33206 |
(Insertion of heart pacemaker) is now allowed with C2621 (Pmkr, single, non
rate-resp); effective 10/01/05 |
| 33212 |
(Insertion of pulse generator) is now allowed with C2621 (Pmkr, single, non
rate-resp); effective 04/01/05 |
| 61885 |
(Insrt/redo neurostim 1 array) is now allowed with C1820
(Generator, neuron rechg bat sys); effective 01/01/06 |
When billing drugs, biologicals and radiopharmaceuticals, the change request
continues to strongly urge hospitals to report charges and the corresponding
correct HCPCS codes for all of these services whether the items are paid
separately or packaged. It is important when billing for these products that
the units of service for the reported HCPCS code are consistent with the
quantity documented in the care of the patient. Units reported on the claim
should be reported in multiples according to the HCPCS long descriptor as
stated in the HCPCS Level II Book.
A reminder also stated that the fact that a drug, device, procedure or service
is assigned a HCPCS code and payment rate under OPPS does not imply coverage
under the Medicare program. This only indicates how the services may be paid if
covered by the program. The fiscal intermediary must determine that the service
is reasonable and necessary to treat the Medicare beneficiary’s condition and
that it meets all program requirements for coverage before payment will be
made.
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