Reporting place of service (POS) codes
Physicians are required to report the place of service (POS) on all health insurance claims they submit to Medicare Part B contractors. The POS code is used to identify where the procedure is furnished. Physicians are paid for services according to the Medicare physician fee schedule (MPFS). This schedule is based on a payment system that includes three major categories, which drive the reimbursement for physician services:
• Practice expense (reflects overhead costs involved in providing service(s))
• Physician work
• Malpractice insurance
To account for the increased practice expense physicians incur by performing services in their offices, Medicare reimburses physicians a higher amount for services performed in their offices (POS code 11) than in an outpatient hospital (POS 22-23) or an ambulatory surgical center (ASC) (POS 24). Therefore, it is important to know the POS also plays a factor in the reimbursement.
Note: Check with individual payers (e.g., Medicare, Medicaid, other private insurance) for reimbursement policies regarding POS codes.
Important facts when filing a claim to Medicare
• The POS is a required field, entered in the 2400 Place of Service Code loop (segment SV105) of the 837P electronic claim or Item 24B on the CMS-1500 paper claim
• The name, address and zip code of where the service(s) were actually performed is required for all POS codes, and is entered in Item 32 on the CMS 1500 claim form or in the corresponding loop on its electronic equivalent
• Must specify the correct location where the service(s) is performed and billed on the claim, since both the POS and the locality address are components of the MPFS
• If the POS is missing, invalid or inconsistent with procedure code on claim form it will be returned as unprocessable (RUC)
• For example, POS 21 (inpatient hospital) is not compatible with procedure code 99211 (Establish patient office or other outpatient visit)
Helpful hints for POS codes for professional claims
• Implement internal control systems to prevent incorrect billing of POS codes
• Keep informed on Medicare coverage and billing requirements
• For example, billing physician's office (POS 11) for a minor surgical procedure that is actually performed in a hospital outpatient department (POS 22) and collecting a higher payment is inappropriate billing and may be viewed as program abuse
Site of Service Payment Differential
Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The CMS furnishes both rates in the MPFSDB update.
The rate, facility or nonfacility, that a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. For the professional component (PC) of diagnostic tests, the facility and nonfacility payment rates are the same – irrespective of the POS code on the claim. See chapter 13, section 150 of this manual for POS instructions for the PC and technical component of diagnostic tests.
The list of settings where a physician’s services are paid at the facility rate include:
*Inpatient Hospital (POS code 21);
*Outpatient Hospital (POS code 22);
*Emergency Room-Hospital (POS code 23);
*Medicare-participating ambulatory surgical center (ASC) for a HCPCS code included on the ASC approved list of procedures (POS code 24);
*Medicare-participating ASC for a procedure not on the ASC list of approved procedures with dates of service on or after January 1, 2008. (POS code 24);
*Skilled Nursing Facility (SNF) for a Part A resident (POS code 31);
*Hospice – for inpatient care (POS code 34);
*Ambulance – Land (POS code 41);
*Ambulance – Air or Water (POS code 42);
*Inpatient Psychiatric Facility (POS code 51);
*Psychiatric Facility -- Partial Hospitalization (POS code 52);
*Community Mental Health Center (POS code 53);
*Psychiatric Residential Treatment Center (POS code 56); and
*Comprehensive Inpatient Rehabilitation Facility (POS code 61).
Physicians’ services are paid at nonfacility rates for procedures furnished in the following settings:
*Pharmacy (POS code 01);
*School (POS code 03);
*Homeless Shelter (POS code 04);
*Prison/Correctional Facility (POS code 09);
*Office (POS code 11);
*Home or Private Residence of Patient (POS code 12);
*Assisted Living Facility (POS code 13);
*Group Home (POS code 14);
*Mobile Unit (POS code 15);
*Temporary Lodging (POS code 16);
*Walk-in Retail Health Clinic (POS code 17);
*Urgent Care Facility (POS code 20);
*Birthing Center (POS code 25);
*Nursing Facility and SNFs to Part B residents (POS code 32);
*Custodial Care Facility (POS code 33);
*Independent Clinic (POS code 49);
*Federally Qualified Health Center (POS code 50);
*Intermediate Health Care Facility/Mentally Retarded (POS code 54);
*Residential Substance Abuse Treatment Facility (POS code 55);
*Non-Residential Substance Abuse Treatment Facility (POS code 57);
*Mass Immunization Center (POS code 60);
*Comprehensive Outpatient Rehabilitation Facility (POS code 62);
*End-Stage Renal Disease Treatment Facility (POS code 65);
*State or Local Health Clinic (POS code 71);
*Rural Health Clinic (POS code 72);
*Independent Laboratory (POS code 81);and
*Other Place of Service (POS code 99).
Showing posts with label Medicare payment for CPT. Show all posts
Showing posts with label Medicare payment for CPT. Show all posts
Will Medicare pay G0101 AND Q0091
Payment for G0101 and Q0091 in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) that Bill Under the All-Inclusive Rate (AIR) System.
Provider Types Affected
This MLN Matters Article is intended for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) who are authorized to bill under the All Inclusive Rate (AIR) system and submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 8927 adds Healthcare Common Procedure Coding System (HCPCS) code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and code Q0091 (screening Papanicolaou smear) to the list of preventive services paid based on the All-Inclusive Rate (AIR) for RHCs and FQHCs. Make sure your billing staffs are aware of this changes.
Background
The Centers for Medicare and Medicaid Services (CMS) has determined that HCPCS codes G0101 and Q0091 are billable visits when furnished by a RHC or FQHC practitioner to a RHC or FQHC patient.
CR8927 instructs MACs to allow HCPCS codes G0101 and Q0091 to be billed as a stand-alone encounter/visit. These services will be paid the AIR on RHC and FQHC claims for 71X and 77X Tyoes of Bills (TOBs), effective for dates of service on or after January 1, 2014. Please note that deductible and coinsurance are NOT to be applied to G0101 or Q0091. If other billable visits are furnished on the same day as G0101 or Q0091, only one visit will be paid.
G0101 or Q0091 are payable annually for women at high risk for developing cervical or vaginal cancer, and women of childbearing age who have had an abnormal Pap test within the past 3 years. It is payable every 2 years for women at normal risk. For FQHCs billing under the PPS, G0101 and Q0091 are qualifying visit when billed with FQHC payment HCPCS codes G0466 or G0467.
Your MAC will not search for claims that have been denied with HCPCS code G0101 or Q0091 prior to the implementation of CR8927, but will adjust any claims that you bring to their attention.
Provider Types Affected
This MLN Matters Article is intended for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) who are authorized to bill under the All Inclusive Rate (AIR) system and submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.
Provider Action Needed
Change Request (CR) 8927 adds Healthcare Common Procedure Coding System (HCPCS) code G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and code Q0091 (screening Papanicolaou smear) to the list of preventive services paid based on the All-Inclusive Rate (AIR) for RHCs and FQHCs. Make sure your billing staffs are aware of this changes.
Background
The Centers for Medicare and Medicaid Services (CMS) has determined that HCPCS codes G0101 and Q0091 are billable visits when furnished by a RHC or FQHC practitioner to a RHC or FQHC patient.
CR8927 instructs MACs to allow HCPCS codes G0101 and Q0091 to be billed as a stand-alone encounter/visit. These services will be paid the AIR on RHC and FQHC claims for 71X and 77X Tyoes of Bills (TOBs), effective for dates of service on or after January 1, 2014. Please note that deductible and coinsurance are NOT to be applied to G0101 or Q0091. If other billable visits are furnished on the same day as G0101 or Q0091, only one visit will be paid.
G0101 or Q0091 are payable annually for women at high risk for developing cervical or vaginal cancer, and women of childbearing age who have had an abnormal Pap test within the past 3 years. It is payable every 2 years for women at normal risk. For FQHCs billing under the PPS, G0101 and Q0091 are qualifying visit when billed with FQHC payment HCPCS codes G0466 or G0467.
Your MAC will not search for claims that have been denied with HCPCS code G0101 or Q0091 prior to the implementation of CR8927, but will adjust any claims that you bring to their attention.
Medicare overpayment denial - what should provider do ?
Medicare E/M claims for new patients
As previously announced with MM8165, Medicare implemented a common working file system edit to identify claims where more than one new patient visit was billed for the same patient within three years. Medicare guidelines only allow one new patient visit by the same provider or different providers in the same group with the same specialty, within a three year period.
In addition to this new edit, the common working file has established an additional edit which identifies claims where an established patient visit was billed in advance of a new patient visit within a three year period. This edit fails when the rendering provider on the claim with the established patient visit is the same as the rendering provider on the claim with the initial patient visit. As a result of these new edits, you may begin to see services deny on the original claim submission or you may receive an overpayment request.
If you receive this denial on a new patient visit (not an overpayment request) and you determine that the procedure code should have been filed as an established visit, you can simply call the interactive voice response (IVR) system and request a reopening.
Additional IVR reopening information can be found by clicking here. If you do not want to use the IVR for this, you have the option of submitting a new claim or writing in for a reopening.
Note: Submitting a new claim for the revised established E/M visit will not result in a duplicate denial since the original visit code was not paid.CMS has mandated that contractors request overpayments on any claims that were previously paid when either:
An established patient visit was billed prior to an initial visit within a three year period by the same rendering provider; orMore than one new patient visit was billed within a three-year period by the same provider or different providers in the same group with the same specialty.
These new system edits were turned on October 1. A large number of paid claims have been identified as overpayments due to the above guidelines. As a result, First Coast Service Options Inc. (First Coast) has initiated recoupment of improper payments related to these claims. The impacted providers will be receiving an overpayment letter soon. To assist providers with questions that they may have relative to these new guidelines, we are providing the following Q&As:
Q: Can I appeal my overpayment?
A: You certainly have the right to appeal any overpayment. However, the overpayment finding will likely be affirmed since Medicare guidelines do not allow more than one new patient visit within three years. Medicare also does not allow payment for a new patient visit billed after an established patient visit by the same rendering provider.
Q: Can I submit a request to change my new patient visit (that generated the overpayment) to an established patient visit?
A: Yes, you can submit a reopening request in writing to change your new patient visit to an established patient visit code if this is the service you actually performed. In your reopening request, you must tell us the specific established visit code you want us to change on your claim. You want to be mindful that there will still likely be an overpayment since established patient visits typically allow less than new patient visits. You also want to note that if you choose to bill another new patient visit code within a three-year period, another overpayment will occur.
Q: I initially billed a claim with an established patient visit in error before I billed my claim for the initial visit. As a result I received an overpayment letter. Can I make corrections to both claims?
A: Yes, you can correct both claims. On your first claim which continued the established patient visit, you can simply call the IVR and request a reopening. You are only allowed to request a reopening if the claim was processed within the previous 12 month period. If it has been longer than 12 months, a reopening should not be submitted.
To correct your second claim, you would need to submit a written request and indicate the correct procedure that should have originally been billed on your claim. It is likely that a small overpayment will still be due since established patient visit codes allow less than new patient visit codes.
As previously announced with MM8165, Medicare implemented a common working file system edit to identify claims where more than one new patient visit was billed for the same patient within three years. Medicare guidelines only allow one new patient visit by the same provider or different providers in the same group with the same specialty, within a three year period.
In addition to this new edit, the common working file has established an additional edit which identifies claims where an established patient visit was billed in advance of a new patient visit within a three year period. This edit fails when the rendering provider on the claim with the established patient visit is the same as the rendering provider on the claim with the initial patient visit. As a result of these new edits, you may begin to see services deny on the original claim submission or you may receive an overpayment request.
If you receive this denial on a new patient visit (not an overpayment request) and you determine that the procedure code should have been filed as an established visit, you can simply call the interactive voice response (IVR) system and request a reopening.
Additional IVR reopening information can be found by clicking here. If you do not want to use the IVR for this, you have the option of submitting a new claim or writing in for a reopening.
Note: Submitting a new claim for the revised established E/M visit will not result in a duplicate denial since the original visit code was not paid.CMS has mandated that contractors request overpayments on any claims that were previously paid when either:
An established patient visit was billed prior to an initial visit within a three year period by the same rendering provider; orMore than one new patient visit was billed within a three-year period by the same provider or different providers in the same group with the same specialty.
These new system edits were turned on October 1. A large number of paid claims have been identified as overpayments due to the above guidelines. As a result, First Coast Service Options Inc. (First Coast) has initiated recoupment of improper payments related to these claims. The impacted providers will be receiving an overpayment letter soon. To assist providers with questions that they may have relative to these new guidelines, we are providing the following Q&As:
Q: Can I appeal my overpayment?
A: You certainly have the right to appeal any overpayment. However, the overpayment finding will likely be affirmed since Medicare guidelines do not allow more than one new patient visit within three years. Medicare also does not allow payment for a new patient visit billed after an established patient visit by the same rendering provider.
Q: Can I submit a request to change my new patient visit (that generated the overpayment) to an established patient visit?
A: Yes, you can submit a reopening request in writing to change your new patient visit to an established patient visit code if this is the service you actually performed. In your reopening request, you must tell us the specific established visit code you want us to change on your claim. You want to be mindful that there will still likely be an overpayment since established patient visits typically allow less than new patient visits. You also want to note that if you choose to bill another new patient visit code within a three-year period, another overpayment will occur.
Q: I initially billed a claim with an established patient visit in error before I billed my claim for the initial visit. As a result I received an overpayment letter. Can I make corrections to both claims?
A: Yes, you can correct both claims. On your first claim which continued the established patient visit, you can simply call the IVR and request a reopening. You are only allowed to request a reopening if the claim was processed within the previous 12 month period. If it has been longer than 12 months, a reopening should not be submitted.
To correct your second claim, you would need to submit a written request and indicate the correct procedure that should have originally been billed on your claim. It is likely that a small overpayment will still be due since established patient visit codes allow less than new patient visit codes.
PAYMENT FOR CPT 96101, 96118
Payment and Billing Guidelines for Psychological and Neuropsychological Tests
The technician and computer CPT codes for psychological and neuropsychological tests include practice expense, malpractice expense and professional work relative value units. Accordingly, CPT psychological test code 96101 should not be paid when billed for the same tests or services performed under psychological test codes 96102 or 96103. CPT neuropsychological test code 96118 should not be paid when billed for the same tests or services performed under neuropsychological test codes 96119 or 96120. However, CPT codes 96101 and 96118 can be paid separately on the rare occasion when billed on the same date of service for different and separate tests from 96102, 96103, 96119 and 96120.
Under the physician fee schedule, there is no payment for services performed by students or trainees. Accordingly, Medicare does not pay for services represented by CPT codes 96102 and 96119 when performed by a student or a trainee. However, the presence of a student or a trainee while the test is being administered does not prevent a physician, CP, IPP, NP, CNS or PA from performing and being paid for the psychological test under 96102 or the neuropsychological test under 96119.
The technician and computer CPT codes for psychological and neuropsychological tests include practice expense, malpractice expense and professional work relative value units. Accordingly, CPT psychological test code 96101 should not be paid when billed for the same tests or services performed under psychological test codes 96102 or 96103. CPT neuropsychological test code 96118 should not be paid when billed for the same tests or services performed under neuropsychological test codes 96119 or 96120. However, CPT codes 96101 and 96118 can be paid separately on the rare occasion when billed on the same date of service for different and separate tests from 96102, 96103, 96119 and 96120.
Under the physician fee schedule, there is no payment for services performed by students or trainees. Accordingly, Medicare does not pay for services represented by CPT codes 96102 and 96119 when performed by a student or a trainee. However, the presence of a student or a trainee while the test is being administered does not prevent a physician, CP, IPP, NP, CNS or PA from performing and being paid for the psychological test under 96102 or the neuropsychological test under 96119.
payment for CLIA waived CPT codes
CLIA Waived Tests for Manufacturers
Clinical Laboratory Improvement Amendment of 1988 (CLIA). The CLIA-waived status allows a broad base of physicians to perform a test at the point-of-care setting.
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This list omits certain waived tests that are typically not performed in physician office settings.
Indications for usage of CPT code 83880
Congestive Heart Failure (CHF) is a complex clinical syndrome characterized by dysfunction of the left, right, or both ventricles, which results in the impairment of the heart’s ability to circulate blood at the rate sufficient to maintain the metabolic needs of the peripheral tissues and various organs. B-type natriuretic peptide (BNP) is synthesized, stored, and released primarily by the ventricular myocardium in response to volume expansion and pressure overload, which are hemodynamic parameters in CHF. Used in conjunction with other clinical information, serum BNP concentrations parallel dyspnea in heart failure suggesting its usefulness as a neurohormonal index of progressive heart failure. Serum BNP, for the purposes of coverage, is considered a ‘point-of-service test (performed and immediately used in the disposition of patient care).
Serum BNP, when used in conjunction with other clinical information, will be considered reasonable and necessary for the following:
Establishing the diagnosis of CHF in acutely ill patients presenting with dyspnea.
Predicting the long term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute coronary event. Since this situation is an inpatient service, it is not addressed in this LCD.
Limitations
Serum BNP will be considered noncovered in the following:
Monitoring the efficiency of treatment for CHF
Tailoring the therapy for heart failure
Since BNP is a point of service test, the primary outpatient site of service expected to perform a serum BNP is the emergency room or a physician’s office.
Medicare payment for bilateral surgery procedure performed
Bilateral Surgery
50 Modifier Bilateral Procedure. Modifier 50 represents that the procedure was performed bilaterally. To report bilateral services, bill the procedure with the 50 modifier and a unit of one in the days/units field or electronic equivalent.
Example: 29870-50 $1,000 Units = 1
The billed charge should reflect a bilateral procedure amount if the procedure was performed bilaterally.
Note: Please refer to your current MPFSDB to determine whether a 50 modifier may be added on the procedure code being used.
Example: The following example demonstrates pricing of bilateral services billed.
Code Allowed Bilaterally on MPFSDB (50 Modifier)Unilateral Allowed Amount $ Final Allowance$
29870-50 Yes 365.31 x 150% = 547.96 (bilateral) 547.96 x 80%
Example: The following example demonstrates multiple surgery pricing logic as it is applies to bilateral surgeries.
Code Indicator 50 Modifier Unilateral Allowed Amount $ Ranking Final Allowance $
29870-50 2 Yes 365.31 x 150% = 547.96 (bilateral) 100% 547.96 x 80%
29345-50 2 Yes 115.04 x 150% = 172.56 (bilateral) 50% 86.28 x 80%
50 Modifier Bilateral Procedure. Modifier 50 represents that the procedure was performed bilaterally. To report bilateral services, bill the procedure with the 50 modifier and a unit of one in the days/units field or electronic equivalent.
Example: 29870-50 $1,000 Units = 1
The billed charge should reflect a bilateral procedure amount if the procedure was performed bilaterally.
Note: Please refer to your current MPFSDB to determine whether a 50 modifier may be added on the procedure code being used.
Example: The following example demonstrates pricing of bilateral services billed.
Code Allowed Bilaterally on MPFSDB (50 Modifier)Unilateral Allowed Amount $ Final Allowance$
29870-50 Yes 365.31 x 150% = 547.96 (bilateral) 547.96 x 80%
Example: The following example demonstrates multiple surgery pricing logic as it is applies to bilateral surgeries.
Code Indicator 50 Modifier Unilateral Allowed Amount $ Ranking Final Allowance $
29870-50 2 Yes 365.31 x 150% = 547.96 (bilateral) 100% 547.96 x 80%
29345-50 2 Yes 115.04 x 150% = 172.56 (bilateral) 50% 86.28 x 80%
Medicare endoscopic payment pricing method - Multiple procedure
Endoscopic Pricing Method
The endoscopic pricing method is denoted by an indicator of (3) under the “Mult Proc” column on the MPFSDB.
Calculate the allowance and limiting charge (non-assigned claims only) at:
One hundred percent for the procedure with the highest fee schedule amount.
Subsequent procedures equal subsequent procedure allowance minus basic endoscopic allowance.
The pricing formula for multiple endoscopic procedures varies depending on which procedures are billed.
Same Endoscopic Family
When two or more endoscopies are billed that are both in the same endoscopic family, Medicare prices the highest allowed procedure at 100 percent of the fee amount. The other procedures are priced by subtracting the fee amount of the basic endoscopy from their fee amounts.
Example: The following example demonstrates endoscopic pricing in the same endoscopic family.
Codes Definition Indicator Fee Amount $ Allowance $
45305© Proctosigmoidoscopy w/bx 3 130.39 – 68.08 = 62.31 x 80%
45307© Proctosigmoidoscopy fb 3 138.62 138.62 x 80%
Base Endoscopy
45300© Proctosigmoidoscopy dx 2 68.08
Different Endoscopic Family
When two or more endoscopies that are both in the same endoscopic family are billed along with another procedure that is either non-endoscopic or endoscopic from a different family, price the two endoscopies that are in the same family as indicated in Example 1. The allowance of the two procedures should be added together and then compared to the third procedure.
Example: The following example demonstrates endoscopic pricing from different endoscopic families.
Codes Definition Indicator Fee Amount $ Allowance $
*45305© Proctosigmoidoscopy w/bx 3 130.39 – 68.08 = 62.31 31.16 x 80%
62.31 x 50% = 31.16
*45307© Proctosigmoidoscopy fb 3 138.62 138.62 x 50% = 69.31 69.31 x 80%
52325© Cystoscopy, stone removal 3 304.06 @ full physician allowance 304.06 x 80%
The endoscopic pricing method is denoted by an indicator of (3) under the “Mult Proc” column on the MPFSDB.
Calculate the allowance and limiting charge (non-assigned claims only) at:
One hundred percent for the procedure with the highest fee schedule amount.
Subsequent procedures equal subsequent procedure allowance minus basic endoscopic allowance.
The pricing formula for multiple endoscopic procedures varies depending on which procedures are billed.
Same Endoscopic Family
When two or more endoscopies are billed that are both in the same endoscopic family, Medicare prices the highest allowed procedure at 100 percent of the fee amount. The other procedures are priced by subtracting the fee amount of the basic endoscopy from their fee amounts.
Example: The following example demonstrates endoscopic pricing in the same endoscopic family.
Codes Definition Indicator Fee Amount $ Allowance $
45305© Proctosigmoidoscopy w/bx 3 130.39 – 68.08 = 62.31 x 80%
45307© Proctosigmoidoscopy fb 3 138.62 138.62 x 80%
Base Endoscopy
45300© Proctosigmoidoscopy dx 2 68.08
Different Endoscopic Family
When two or more endoscopies that are both in the same endoscopic family are billed along with another procedure that is either non-endoscopic or endoscopic from a different family, price the two endoscopies that are in the same family as indicated in Example 1. The allowance of the two procedures should be added together and then compared to the third procedure.
Example: The following example demonstrates endoscopic pricing from different endoscopic families.
Codes Definition Indicator Fee Amount $ Allowance $
*45305© Proctosigmoidoscopy w/bx 3 130.39 – 68.08 = 62.31 31.16 x 80%
62.31 x 50% = 31.16
*45307© Proctosigmoidoscopy fb 3 138.62 138.62 x 50% = 69.31 69.31 x 80%
52325© Cystoscopy, stone removal 3 304.06 @ full physician allowance 304.06 x 80%
Medicare payment for multiple surgical procedure - standard pricing method
MULTIPLE SURGERY PRICING
Pricing Methods
According to Medicare guidelines, surgical procedures may be priced by two different pricing methods:
* Standard.
* Endoscopic.
Standard Pricing Method
The standard pricing method is denoted by an indicator of (2) under the “Mult Proc” column on the Medicare Physician Fee Schedule Database (MPFSDB). The allowance is calculated at:
* One hundred percent for the procedure with the highest fee schedule amount.
* Fifty percent for the second through fifth highest fee schedule amounts.
Each standard priced procedure after the fifth procedure requires submission of an operative report.
Standard Pricing Example
The following example demonstrates the standard pricing method:
Code Database Indicator Billed Amount $ Medicare Allowed Amount $ Ranking Allowance $
35301 2 2,000 1,043.48 100% 1,043.48 x 80%
35201 2 1,000 922.90 50% 461.45 x 80%
35261 2 1,050 1,010.60 50% 505.30 x 80%
Claims for Multiple Surgeries
A.General
Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day.
Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable. See Chapter 23 for a description of mandatory edits to prevent separate payment for those procedures. Major surgical procedures are determined based on the MFSDB approved amount and not on the submitted amount from the providers. The major surgery, as based on the MFSDB, may or may not be the one with the larger submitted amount.
Also, see subsection D below for a description of the standard payment policy on multiple surgeries. However, these standard payment rules are not appropriate for certain procedures. Field 21 of the MFSDB indicates whether the standard payment policy rules apply to a multiple surgery, or whether special payment rules apply. Site of service payment adjustments (codes with an indicator of “1” in Field 27 of the MFSDB) should be applied before multiple surgery payment adjustments.
B.Billing Instructions
The following procedures apply when billing for multiple surgeries by the same physician on the same day.
*Report the more major surgical procedure without the multiple procedures modifier “-51.”
*Report additional surgical procedures performed by the surgeon on the same day with modifier “-51.”
There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (e.g., in some multiple trauma cases). When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate. In such cases, the physician does not use modifier “-51” unless one of the surgeons individually performs multiple surgeries.
C.Carrier Claims Processing System Requirements
Carriers must be able to:
1.Identify multiple surgeries by both of the following methods:
*The presence on the claim form or electronic submission of the “-51” modifier; and
*The billing of more than one separately payable surgical procedure by the same physician performed on the same patient on the same day, whether on different lines or with a number greater than 1 in the units column on the claim form or inappropriately billed with modifier “-78” (i.e., after the global period has expired);
2.Access Field 34 of the MFSDB to determine the Medicare fee schedule payment amount for each surgery;
3.Access Field 21 for each procedure of the MFSDB to determine if the payment rules for multiple surgeries apply to any of the multiple surgeries billed on the same day;
4.If Field 21 for any of the multiple procedures contains an indicator of “0,” the multiple surgery rules do not apply to that procedure. Base payment on the lower of the billed amount or the fee schedule amount (Field 34 or 35) for each code unless other payment adjustment rules apply;
5.For dates of service prior to January 1, 1995, if Field 21 contains an indicator of “1,” the standard rules for pricing multiple surgeries apply (see items 6-8 below);
6.Rank the surgeries subject to the standard multiple surgery rules (indicator “1”) in descending order by the Medicare fee schedule amount;
7.Base payment for each ranked procedure on the lower of the billed amount, or:
*100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure;
*50 percent of the fee schedule amount for the second highest valued procedure; and
*25 percent of the fee schedule amount for the third through the fifth highest valued procedures;
8.If more than five procedures are billed, pay for the first five according to the rules listed in 5, 6, and 7 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, “by report.” Payment determined on a “by report” basis for these codes should never be lower than 25 percent of the full payment amount;
9.For dates of service on or after January 1, 1995, new standard rules for pricing multiple surgeries apply. If Field 21 contains an indicator of “2,” these new standard rules apply (see items 10-12 below);
10.Rank the surgeries subject to the multiple surgery rules (indicator “2”) in descending order by the Medicare fee schedule amount;
11.Base payment for each ranked procedure (indicator “2”) on the lower of the billed amount:
*100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure; and
*50 percent of the fee schedule amount for the second through the fifth highest valued procedures; or
12.If more than five procedures with an indicator of “2” are billed, pay for the first five according to the rules listed in 9, 10, and 11 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, “by report.” Payment determined on a “by report” basis for these codes should never be lower than 50 percent of the full payment amount. Pay by the unit for services that are already reduced (e.g., 17003). Pay for 17340 only once per session, regardless of how many lesions were destroyed;
NOTE: For dates of service prior to January 1, 1995, the multiple surgery indicator of “2” indicated that special dermatology rules applied. The payment rules for these codes have not changed. The rules were expanded, however, to all codes that previously had a multiple surgery indicator of “1.” For dates of service prior to January 1, 1995, if a dermatological procedure with an indicator of “2” was billed with the “-51” modifier with other procedures that are not dermatological procedures (procedures with an indicator of “1” in Field 21), the standard multiple surgery rules applied. Pay no less than 50 percent for the dermatological procedures with an indicator of “2.” See §§40.6.C.6-8 for required actions.
13.If Field 21 contains an indicator of “3,” and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the
base endoscopy. Access Field 31A of the MFSDB to determine the base endoscopy.
EXAMPLE
In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in.
Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).
Carriers assume the following fee schedule amounts for these codes: 45378 - $255.40
45380 - $285.98
45385 - $374.56
Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.
NOTE: If an endoscopic procedure with an indicator of “3” is billed with the “-51” modifier with other procedures that are not endoscopies (procedures with an indicator of “1” in Field 21), the standard multiple surgery rules apply. See §§40.6.C.6-8 for required actions.
14.Apply the following rules where endoscopies are performed on the same day as unrelated endoscopies or other surgical procedures:
*Two unrelated endoscopies (e.g., 46606 and 43217): Apply the usual multiple surgery rules;
*Two sets of unrelated endoscopies (e.g., 43202 and 43217; 46606 and 46608): Apply the special endoscopy rules to each series and then apply the multiple surgery rules. Consider the total payment for each set of endoscopies as one service;
*Two related endoscopies and a third, unrelated procedure: Apply the special endoscopic rules to the related endoscopies, and, then apply the multiple surgery rules. Consider the total payment for the related endoscopies as one service and the unrelated endoscopy as another service.
15.If two or more multiple surgeries are of equal value, rank them in descending dollar order billed and base payment on the percentages listed above (i.e., 100 percent for the first billed procedure, 50 percent for the second, etc.);
16.If any of the multiple surgeries are bilateral surgeries, consider the bilateral procedure at 150 percent as one payment amount, rank this with the remaining procedures, and apply the appropriate multiple surgery reductions. See §40.7 for bilateral surgery payment instructions.);
17.Round all adjusted payment amounts to the nearest cent;
18.If some of the surgeries are subject to special rules while others are subject to the standard rules, automate pricing to the extent possible. If necessary, price manually;
19.In cases of multiple interventional radiological procedures, both the radiology code and the primary surgical code are paid at 100 percent of the fee schedule amount. The subsequent surgical procedures are paid at the standard multiple surgical percentages (50 percent, 50 percent, 50 percent and 50 percent);
20.Apply the requirements in §§40 on global surgeries to multiple surgeries;
21.Retain the “-51” modifier in history for any multiple surgeries paid at less than the full global amount; and
22.Follow the instructions on adjudicating surgery claims submitted with the “-22” modifier. Review documentation to determine if full payment should be made for those distinctly different, unrelated surgeries performed by different physicians on the same day.
D.Ranking of Same Day Multiple Surgeries When One Surgery Has a “-22”
If the patient returns to the operating room after the initial operative session on the same day as a result of complications from the original surgery, the complications rules apply to each procedure required to treat the complications from the original surgery. The multiple surgery rules would not apply.
However, if the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for multiple procedures that are required as a result of complications from the original surgery, the complications rules would apply. The multiple surgery rules would also not apply.
Multiple surgeries are defined as separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day.
Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable. See Chapter 23 for a description of mandatory edits to prevent separate payment for those procedures.
Pricing Methods
According to Medicare guidelines, surgical procedures may be priced by two different pricing methods:
* Standard.
* Endoscopic.
Standard Pricing Method
The standard pricing method is denoted by an indicator of (2) under the “Mult Proc” column on the Medicare Physician Fee Schedule Database (MPFSDB). The allowance is calculated at:
* One hundred percent for the procedure with the highest fee schedule amount.
* Fifty percent for the second through fifth highest fee schedule amounts.
Each standard priced procedure after the fifth procedure requires submission of an operative report.
Standard Pricing Example
The following example demonstrates the standard pricing method:
Code Database Indicator Billed Amount $ Medicare Allowed Amount $ Ranking Allowance $
35301 2 2,000 1,043.48 100% 1,043.48 x 80%
35201 2 1,000 922.90 50% 461.45 x 80%
35261 2 1,050 1,010.60 50% 505.30 x 80%
Claims for Multiple Surgeries
A.General
Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day.
Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable. See Chapter 23 for a description of mandatory edits to prevent separate payment for those procedures. Major surgical procedures are determined based on the MFSDB approved amount and not on the submitted amount from the providers. The major surgery, as based on the MFSDB, may or may not be the one with the larger submitted amount.
Also, see subsection D below for a description of the standard payment policy on multiple surgeries. However, these standard payment rules are not appropriate for certain procedures. Field 21 of the MFSDB indicates whether the standard payment policy rules apply to a multiple surgery, or whether special payment rules apply. Site of service payment adjustments (codes with an indicator of “1” in Field 27 of the MFSDB) should be applied before multiple surgery payment adjustments.
B.Billing Instructions
The following procedures apply when billing for multiple surgeries by the same physician on the same day.
*Report the more major surgical procedure without the multiple procedures modifier “-51.”
*Report additional surgical procedures performed by the surgeon on the same day with modifier “-51.”
There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (e.g., in some multiple trauma cases). When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate. In such cases, the physician does not use modifier “-51” unless one of the surgeons individually performs multiple surgeries.
C.Carrier Claims Processing System Requirements
Carriers must be able to:
1.Identify multiple surgeries by both of the following methods:
*The presence on the claim form or electronic submission of the “-51” modifier; and
*The billing of more than one separately payable surgical procedure by the same physician performed on the same patient on the same day, whether on different lines or with a number greater than 1 in the units column on the claim form or inappropriately billed with modifier “-78” (i.e., after the global period has expired);
2.Access Field 34 of the MFSDB to determine the Medicare fee schedule payment amount for each surgery;
3.Access Field 21 for each procedure of the MFSDB to determine if the payment rules for multiple surgeries apply to any of the multiple surgeries billed on the same day;
4.If Field 21 for any of the multiple procedures contains an indicator of “0,” the multiple surgery rules do not apply to that procedure. Base payment on the lower of the billed amount or the fee schedule amount (Field 34 or 35) for each code unless other payment adjustment rules apply;
5.For dates of service prior to January 1, 1995, if Field 21 contains an indicator of “1,” the standard rules for pricing multiple surgeries apply (see items 6-8 below);
6.Rank the surgeries subject to the standard multiple surgery rules (indicator “1”) in descending order by the Medicare fee schedule amount;
7.Base payment for each ranked procedure on the lower of the billed amount, or:
*100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure;
*50 percent of the fee schedule amount for the second highest valued procedure; and
*25 percent of the fee schedule amount for the third through the fifth highest valued procedures;
8.If more than five procedures are billed, pay for the first five according to the rules listed in 5, 6, and 7 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, “by report.” Payment determined on a “by report” basis for these codes should never be lower than 25 percent of the full payment amount;
9.For dates of service on or after January 1, 1995, new standard rules for pricing multiple surgeries apply. If Field 21 contains an indicator of “2,” these new standard rules apply (see items 10-12 below);
10.Rank the surgeries subject to the multiple surgery rules (indicator “2”) in descending order by the Medicare fee schedule amount;
11.Base payment for each ranked procedure (indicator “2”) on the lower of the billed amount:
*100 percent of the fee schedule amount (Field 34 or 35) for the highest valued procedure; and
*50 percent of the fee schedule amount for the second through the fifth highest valued procedures; or
12.If more than five procedures with an indicator of “2” are billed, pay for the first five according to the rules listed in 9, 10, and 11 above and suspend the sixth and subsequent procedures for manual review and payment, if appropriate, “by report.” Payment determined on a “by report” basis for these codes should never be lower than 50 percent of the full payment amount. Pay by the unit for services that are already reduced (e.g., 17003). Pay for 17340 only once per session, regardless of how many lesions were destroyed;
NOTE: For dates of service prior to January 1, 1995, the multiple surgery indicator of “2” indicated that special dermatology rules applied. The payment rules for these codes have not changed. The rules were expanded, however, to all codes that previously had a multiple surgery indicator of “1.” For dates of service prior to January 1, 1995, if a dermatological procedure with an indicator of “2” was billed with the “-51” modifier with other procedures that are not dermatological procedures (procedures with an indicator of “1” in Field 21), the standard multiple surgery rules applied. Pay no less than 50 percent for the dermatological procedures with an indicator of “2.” See §§40.6.C.6-8 for required actions.
13.If Field 21 contains an indicator of “3,” and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the
base endoscopy. Access Field 31A of the MFSDB to determine the base endoscopy.
EXAMPLE
In the course of performing a fiber optic colonoscopy (CPT code 45378), a physician performs a biopsy on a lesion (code 45380) and removes a polyp (code 45385) from a different part of the colon. The physician bills for codes 45380 and 45385. The value of codes 45380 and 45385 have the value of the diagnostic colonoscopy (45378) built in.
Rather than paying 100 percent for the highest valued procedure (45385) and 50 percent for the next (45380), pay the full value of the higher valued endoscopy (45385), plus the difference between the next highest endoscopy (45380) and the base endoscopy (45378).
Carriers assume the following fee schedule amounts for these codes: 45378 - $255.40
45380 - $285.98
45385 - $374.56
Pay the full value of 45385 ($374.56), plus the difference between 45380 and 45378 ($30.58), for a total of $405.14.
NOTE: If an endoscopic procedure with an indicator of “3” is billed with the “-51” modifier with other procedures that are not endoscopies (procedures with an indicator of “1” in Field 21), the standard multiple surgery rules apply. See §§40.6.C.6-8 for required actions.
14.Apply the following rules where endoscopies are performed on the same day as unrelated endoscopies or other surgical procedures:
*Two unrelated endoscopies (e.g., 46606 and 43217): Apply the usual multiple surgery rules;
*Two sets of unrelated endoscopies (e.g., 43202 and 43217; 46606 and 46608): Apply the special endoscopy rules to each series and then apply the multiple surgery rules. Consider the total payment for each set of endoscopies as one service;
*Two related endoscopies and a third, unrelated procedure: Apply the special endoscopic rules to the related endoscopies, and, then apply the multiple surgery rules. Consider the total payment for the related endoscopies as one service and the unrelated endoscopy as another service.
15.If two or more multiple surgeries are of equal value, rank them in descending dollar order billed and base payment on the percentages listed above (i.e., 100 percent for the first billed procedure, 50 percent for the second, etc.);
16.If any of the multiple surgeries are bilateral surgeries, consider the bilateral procedure at 150 percent as one payment amount, rank this with the remaining procedures, and apply the appropriate multiple surgery reductions. See §40.7 for bilateral surgery payment instructions.);
17.Round all adjusted payment amounts to the nearest cent;
18.If some of the surgeries are subject to special rules while others are subject to the standard rules, automate pricing to the extent possible. If necessary, price manually;
19.In cases of multiple interventional radiological procedures, both the radiology code and the primary surgical code are paid at 100 percent of the fee schedule amount. The subsequent surgical procedures are paid at the standard multiple surgical percentages (50 percent, 50 percent, 50 percent and 50 percent);
20.Apply the requirements in §§40 on global surgeries to multiple surgeries;
21.Retain the “-51” modifier in history for any multiple surgeries paid at less than the full global amount; and
22.Follow the instructions on adjudicating surgery claims submitted with the “-22” modifier. Review documentation to determine if full payment should be made for those distinctly different, unrelated surgeries performed by different physicians on the same day.
D.Ranking of Same Day Multiple Surgeries When One Surgery Has a “-22”
If the patient returns to the operating room after the initial operative session on the same day as a result of complications from the original surgery, the complications rules apply to each procedure required to treat the complications from the original surgery. The multiple surgery rules would not apply.
However, if the patient is returned to the operating room during the postoperative period of the original surgery, not on the same day of the original surgery, for multiple procedures that are required as a result of complications from the original surgery, the complications rules would apply. The multiple surgery rules would also not apply.
Multiple surgeries are defined as separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day.
Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable. See Chapter 23 for a description of mandatory edits to prevent separate payment for those procedures.
CPT CODE 83036 -Medicare Payment for Clinical Laboratory Services
Before Medicare pays for any test or diagnostic service, two basic criteria must be met:
(1) the service must be covered by Medicare (e.g., certain procedures such as routine screening tests are not covered) and
(2) the service must be medically necessary or indicated.
Once these two criteria are met, Medicare pays for most clinical laboratory tests based on the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and adjusts payment levels annually on January 1st based on Congressional budget recommendation.
Medicare payment for clinical laboratory tests is always the lesser of the fee schedule amount or the actual amount billed. The provider must accept the Medicare reimbursement as payment in full for a laboratory test. Medicare patients may NOT be billed for any additional amounts. Tests must be billed directly to Medicare by the laboratory or physician performing the test. If an outside laboratory performs a test on a referral from a physician, only the reference laboratory may legally bill Medicare for the procedure.
Procedure (CPT) Codes and Modifiers
The CPT codes for Glycated Hemogobin (A1c) determinations are:
83036 Hemoglobin; glycated (A1c)
83036QW Hemoglobin; glycated (A1c) using CLIA waived method
Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states except:
Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95
Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49
Correct DOS FOR Clinical lab services
The DOS is the date the specimen was collected. If the specimen is collected over a period that spans two calendar dates, the DOS is the date the collection ended. This would include the collection fee, services provided in a physician laboratory, in a clinical laboratory, and/or a reference laboratory.
(1) the service must be covered by Medicare (e.g., certain procedures such as routine screening tests are not covered) and
(2) the service must be medically necessary or indicated.
Once these two criteria are met, Medicare pays for most clinical laboratory tests based on the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and adjusts payment levels annually on January 1st based on Congressional budget recommendation.
Medicare payment for clinical laboratory tests is always the lesser of the fee schedule amount or the actual amount billed. The provider must accept the Medicare reimbursement as payment in full for a laboratory test. Medicare patients may NOT be billed for any additional amounts. Tests must be billed directly to Medicare by the laboratory or physician performing the test. If an outside laboratory performs a test on a referral from a physician, only the reference laboratory may legally bill Medicare for the procedure.
Procedure (CPT) Codes and Modifiers
The CPT codes for Glycated Hemogobin (A1c) determinations are:
83036 Hemoglobin; glycated (A1c)
83036QW Hemoglobin; glycated (A1c) using CLIA waived method
Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states except:
Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95
Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49
Correct DOS FOR Clinical lab services
The DOS is the date the specimen was collected. If the specimen is collected over a period that spans two calendar dates, the DOS is the date the collection ended. This would include the collection fee, services provided in a physician laboratory, in a clinical laboratory, and/or a reference laboratory.
Splints & Casts cpt code payment - Q4004,Q4005, Q4048,Q4049
Splints & Casts Payment limit
| Code | Payment Limit |
| Q4004 | $110.92 |
| Q4005 | $11.81 |
| Q4006 | $26.62 |
| Q4007 | $5.92 |
| Q4008 | $13.31 |
| Q4009 | $7.89 |
| Q4010 | $17.75 |
| Q4011 | $3.94 |
| Q4012 | $8.88 |
| Q4013 | $14.36 |
| Q4014 | $24.21 |
| Q4015 | $7.18 |
| Q4016 | $12.10 |
| Q4017 | $8.30 |
| Q4018 | $13.23 |
| Q4019 | $4.16 |
| Q4020 | $6.62 |
| Q4021 | $6.14 |
| Q4022 | $11.08 |
| Q4023 | $3.09 |
| Q4024 | $5.54 |
| Q4025 | $34.44 |
| Q4026 | $107.54 |
| Q4027 | $17.23 |
| Q4028 | $53.78 |
| Q4029 | $26.34 |
| Q4030 | $69.33 |
| Q4031 | $13.17 |
| Q4032 | $34.66 |
| Q4033 | $24.57 |
| Q4034 | $61.10 |
| Q4035 | $12.28 |
| Q4036 | $30.56 |
| Q4037 | $14.99 |
| Q4038 | $37.55 |
| Q4039 | $7.51 |
| Q4040 | $18.76 |
| Q4041 | $18.22 |
| Q4042 | $31.11 |
| Q4043 | $9.12 |
| Q4044 | $15.56 |
| Q4045 | $10.58 |
| Q4046 | $17.02 |
| Q4047 | $5.28 |
| Q4048 | $8.51 |
| Q4049 | $1.93 |
Getting Payment from Medicare for Clinical Laboratory Services codes
Certain clinical diagnosis procedures listed in the Pathology and Laboratory sections of the Physicians' Current Procedural Terminology (CPT) (1) are not considered a part of the laboratory fee schedule. The procedures listed below are paid from the Physician Fee Schedule at 80% of the amount listed on that fee schedule. The beneficiary is responsible for the remaining 20% once the annual deductible has been met. These procedures are not subject to national limitations:
- Clinical pathology consultations
- Bone marrow smears and biopsy
- Blood bank physician services
- Skin tests
- Anatomical and surgical pathology services
- Duodenal and gastric intubation
- Sputum and sweat collection
Direct billing is also required for all Medicare-reimbursed laboratory tests. Tests must be billed directly to Medicare by the laboratory or physician performing the tests. If an outside laboratory performs a test on a referral from a physician, only the reference laboratory may legally bill Medicare for the procedure.
However, hospitals and reference laboratories that send specimens to other laboratories may bill Medicare for tests performed by the other laboratories if the referring laboratory meets any one of the following three exceptions:
- (a) The referring laboratory is located in or is part of a rural hospital;
- (b) The referring laboratory is wholly owned by the reference laboratory, or the referring laboratory wholly owns the reference laboratory, or both referring laboratory and reference laboratory are wholly owned by a third entity; or
- (c) No more than 30% of the clinical diagnostic tests for which a laboratory receives requests annually are performed by another laboratory other than an ownership-related laboratory.
Medicare maximum payment for J1956,J1980 J2001 J2020 J2175 J2180
Drugs & Biologicals: Maximum Allowed Units (MAUs) - Palmetto GBA Medicare
CPT CODE description
J7030 - Infusion, normal saline solution , 1000 cc
Maximum Allowed Units List - 2
GENERAL INFORMATION
Effective April 1, 2002, CWF edits were implemented to identify HCPCS codes for ambulance services that are either subject to or excluded from Skilled Nursing Facility (SNF) consolidated billing (CB). This coding change added SNF CB edits to CWF to deny payment of some separately billed ambulance services for beneficiaries in a SNF Part A covered stay. Effective July 1, 2003, CWF added an edit to allow claims submitted with specialty type “59” and HCPCS codes J7030 or J7050 (Saline Solution Injection) to process and pay correctly for modifiers other than “NN” when a beneficiary is in a Part A stay, and for claims submitted with an “NN” modifier when the beneficiary is not in a Part A stay. Since the implementation of this update, CMS has identified additional HCPCS codes for drugs and CPT codes for electrocardiogram (EKG) testing that may be separately payable when provided during a SNF ambulance transport that is not subject to SNF CB. HCPCS J-codes (J0000-J9999) not included in previous updates, Q-codes for anti-emetic drugs (Q0163 through Q0181), and CPT codes for EKG testing (93005 and 93041) will be added to the CWF SNF CB bypass for ambulance specialty type “59” carrier claims during the October 2004 SNF CB quarterly update.
Hydration (90760–90761)
Hydration codes are used for reporting intravenous (IV) administration of prepackaged fluid and electrolytes. These codes are not applicable to infusion of drugs or other substances and should not be reported if concurrently administered with chemotherapy or infusions of other drugs. Hydration is typically not a high-risk procedure, and once the IV line is in place, the patient requires little monitoring. Documentation of start and stop times is needed to allow the coder to choose the correct code(s). The codes are based on time, with 90760 for the initial hour and an add-on code of 90761 used for each additional hour.
Supply codes (substance/drug and amount administered) for injections and infusions are documented using a “J” code from HCPCS Level II, such as J7030 for infusion of normal saline solution, 1,000 mL. Some commercial payers do not accept the HCPCS Level II supply codes and will not reimburse for them. In this case, CPT provides a general supply code, 99070, that is submitted along with the name(s) of the product(s) used. To avoid repeating the code for a particular product (e.g., drug), the number of units can be reported in an additional field on the billing form/abstract.
A dehydrated patient is infused with one unit of a 5% dextrose/normal saline solution, which takes approximately 50 minutes: 90760, J7042. Alternatively, supply code 99070 can be used for the product administered if required by the payer (in place of J7042).
CPT provides codes for intravenous push and intra-arterial push. A substance that is pushed is injected directly into an existing IV line that is in use. To use these push codes, the provider must be present for the administration of the substance, or the infusion must take less than 16 minutes to complete. If a push is given subsequent to starting a separate infusion, then the push is coded as subsequent, not as an initial service. If a total infusion lasts less than 16 minutes, the push code is assigned for the service. Push codes cannot be assigned for infusion services that do not meet the time
requirements for add-on codes. For instance, if a patient receives an (initial) infusion for 1 hour 10 minutes, only the initial code of 90765 would be assigned. No add-on or push code can be assigned for the 10 minutes past 1 hour of services.
EXAMPLE Patient presents with severe vomiting and dehydration. IV infusion of normal saline, 1,000 mL for 2 hours. Phenergan IV push given. Report code 90774 for IV push, 90761, 90761 for administration of hydration (normal saline), and the following “J” codes from HCPCS Level II for the products administered: J2550, J7030. (Some payers do not recognize “J” codes, and then the supply code 99070 can be used for the products administered.)
CPT CODE description
J7030 - Infusion, normal saline solution , 1000 cc
Maximum Allowed Units List - 2
KEY
|
HCPCS Code
|
Code Description
|
MAU
|
Release Date
|
Reassesment
Date |
|---|---|---|---|---|---|
J1956 | Injection, levofloxacin, 250 mg | 3 | 11/14/2008 | ||
J1980 | Injection, hyoscyamine sulfate, up to 0.25 mg | 6 | 12/16/2008 | ||
J2001 | Injection, lidocaine HCl for intravenous infusion, 10 mg | 210 | 12/16/2008 | ||
J2010 | Injection, lincomycin HCl, up to 300 mg | 7 | 12/3/2008 | ||
| J2020 | Injection, linezolid, 200 mg | 3 | 7/17/2009 | ||
J2060 | Injection, lorazepam, 2 mg | 4 | 12/16/2008 | ||
J2150 | Injection, mannitol, 25% in 50 ml | 8 | 12/16/2008 | 7/1/2010 | |
J2175 | Injection, meperidine HCl, per 100 mg | 3 | 12/3/2008 | ||
4 | J2180 | Injection, meperidine and promethazine HCl, up to 50 mg | 0 | 11/21/2008 | |
J2185 | Injection, meropenem, 100 mg | 88 | 12/16/2008 | ||
J2210 | Injection, methylergonovine maleate, up to 0.2 mg | 3 | 12/16/2008 | 7/1/2010 | |
J2250 | Injection, midazolam hydrochloride, per 1 mg | 22 | 12/16/2008 | ||
J2270 | Injection, morphine sulfate, up to 10 mg | 3 | 11/14/2008 | 7/1/2010 | |
J2271 | Injection, morphine sulfate, 100 mg | 1 | 11/14/2008 | ||
5 | J2275 | Injection, morphine sulfate (preservative-free sterile solution), per 10 mg | 15 | 12/3/2008 | |
| J2280 | Injection, moxifloxacin, 100 mg | 4 | 7/17/2009 | ||
J2300 | Injection, nalbuphine HCl, per 10 mg | 16 | 11/14/2008 | ||
J2310 | Injection, naloxone hydrochloride, per 1 mg | 10 | 12/16/2008 | ||
J2320 | Injection, nandrolone deconoate, up to 50 mg | 4 | 12/16/2008 | ||
| J2321 | Injection, nandrolone deconoate, up to 100 mg | 2 | 7/17/2009 | ||
| J2322 | Injection, nandrolone decanoate, up to 200 mg | 1 | 4/1/2010 | ||
J2323 | Injection, natalizumab, 1 mg | 300 | 11/14/2008 | ||
J2353 | Injection, octreotide, depot form for intramuscular injection, 1 mg | 30 | 12/16/2008 | Denied | |
3 | J2354 | Injection, octreotide, non-depot form for subcutaneous or intravenous injection, 25 mcg | 0 | 12/16/2008 | |
J2355 | Injection, oprelvekin, 5 mg | 1 | 11/14/2008 | ||
5 | J2357 | Injection, omalizumab, 5 mg | 75 | 12/16/2008 | |
J2360 | Injection, orphenadrine citrate, up to 60 mg | 1 | 12/3/2008 | ||
J2405 | Injection, ondansetron hydrochloride, per 1 mg | 50 | 12/16/2008 | ||
J2410 | Injection, oxymorphone HCl, up to 1 mg | 5 | 12/16/2008 | ||
J2430 | Injection, pamidronate disodium, per 30 mg | 3 | 11/14/2008 | ||
J2440 | Injection, papaverine HCl, up to 60 mg | 2 | 11/14/2008 | ||
| J2460 | Injection, oxytetracycline HCl, up to 50 mg | 5 | 7/17/2009 | ||
J2469 | Injection, palonosetron HCl, 25 mcg | 10 | 11/14/2008 | ||
J2503 | Injection, pegaptanib sodium, 0.3 mg | 2 | 11/14/2008 | ||
J2505 | Injection, pegfilgrastim, 6 mg | 1 | 11/7/2008 | ||
J2510 | Injection, penicillin G procaine, aqueous, up to 600,000 units | 4 | 11/14/2008 | 7/1/2010 | |
J2543 | Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) | 12 | 12/16/2008 | 6/1/2010 | |
J2550 | Injection, promethazine HCl, up to 50 mg | 3 | 12/3/2008 | ||
| J2562 | Injection, plerixafor, 1 mg | 40 | 1/1/2010 | ||
J2597 | Injection, desmopressin acetate, per 1 mcg | 32 | 12/16/2008 | ||
4 | J2650 | Injection, prednisolone acetate, up to 1 ml | 0 | 11/21/2008 | |
3 | J2675 | Injection, progesterone, per 50 mg | 0 | 11/21/2008 | |
J2680 | Injection, fluphenazine decanoate, up to 25 mg | 4 | 11/14/2008 | ||
J2690 | Injection, procainamide HCl, up to 1 gram | 1 | 11/14/2008 | ||
J2720 | Injection, protamine sulfate, per 10 mg | 5 | 11/14/2008 | ||
J2760 | Injection, phentolamine mesylate, up to 5 mg | 1 | 11/14/2008 | ||
J2765 | Injection, metoclopramide HCl, up to 10 mg | 132 | 12/16/2008 | ||
J2778 | Injection, ranibizumab, 0.1 mg | 10 | 12/16/2008 | ||
J2780 | Injection, ranitidine hydrochloride, 25 mg | 4 | 12/16/2008 | ||
8 | J2785 | Injection, regadenoson, 0.1 mg | 4 | 12/16/2008 | |
| J2788 | Injection, RHo D immune globulin, human, minidose, 50 micrograms | 1 | 7/1/2010 | ||
J2790 | Injection, RHo D immune globulin, human, full dose, 300 micrograms (1500 IU) | 1 | 11/14/2008 | ||
| J2791 | Injection, RHo D immune globulin, human, IM or IV, 100 IU | 275 | 7/1/2010 | ||
J2792 | Injection, RHo D immune globulin, intravenous, human, solvent detergent, 100 IU | 300 | 11/14/2008 | 7/1/2010 | |
| 5 | J2793 | Injection, rilonacept, 1 mg | 440 | 1/1/2010 | |
J2794 | Injection, risperidone, long acting, 0.5 mg | 100 | 11/14/2008 | ||
5 | J2795 | Injection, ropivacaine hydrochloride, 1 mg | 300 | 12/16/2008 | |
| 5 | J2796 | Injection, romiplostim, 10 micrograms | 150 | 1/1/2010 | |
J2800 | Injection, methocarbamol, up to 10 ml | 2 | 12/3/2008 | ||
J2805 | Injection, sincalide, 5 micrograms | 1 | 11/14/2008 | ||
5 | J2820 | Injection, sargramostim (GM-CSF), 50 mcg | 15 | 11/14/2008 | 2/17/2009 |
J2910 | Injection, aurothioglucose, up to 50 mg | 1 | 11/14/2008 | ||
4 | J2912 | Injection, sodium chloride, 0.9%, per 2 ml | 0 | 11/14/2008 | |
J2916 | Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg | 10 | 12/16/2008 | ||
J2920 | Injection, methylprednisolone sodium succinate, up to 40 mg | 83 | 12/16/2008 | ||
J2930 | Injection, methylprednisolone sodium succinate, up to 125 mg | 27 | 12/16/2008 | ||
3 | J2941 | Injection, somatropin, 1 mg | 0 | 11/21/2008 | |
J2950 | Injection, promazine HCl, up to 25 mg | 8 | 12/16/2008 | ||
J2997 | Injection, alteplase recombinant, 1 mg | 100 | 12/16/2008 | ||
J3000 | Injection, streptomycin, up to 1 gram | 2 | 12/3/2008 | ||
5 | J3010 | Injection, fentanyl citrate, 0.1 mg | 3 | 12/3/2008 | |
3 | J3030 | Injection, sumatriptan succinate, 6 mg (only for direct physician supervision administration) | 0 | 11/21/2008 | |
J3070 | Injection, pentazocine, 30 mg | 4 | 12/16/2008 | ||
| 1 | J3100 | Injection, tenecteplase, 50 mg | 1 | 7/17/2009 | |
8 | J3101 | Injection, tenecteplase, 1 mg | 50 | 12/16/2008 | |
J3105 | Injection, terbutaline sulfate, up to 1 mg | 1 | 11/14/2008 | ||
J3120 | Injection, testosterone enanthate, up to 100 mg | 4 | 12/3/2008 | ||
J3130 | Injection, testosterone enanthate, up to 200 mg | 2 | 11/14/2008 | ||
4 | J3140 | Injection, testosterone suspension, up to 50 mg | 0 | 11/21/2008 | |
4 | J3150 | Injection, testosterone propionate, up to 100 mg | 0 | 11/21/2008 | |
J3230 | Injection, chlorpromazine HCl, up to 50 mg | 4 | 12/16/2008 | ||
J3240 | Injection, thyrotropin alpha, 0.9 mg, provided in 1.1 mg vial | 1 | 11/14/2008 | ||
J3243 | Injection, tigecycline, 1 mg | 100 | 11/14/2008 | ||
J3250 | Injection, trimethobenzamide HCl, up to 200 mg | 2 | 11/14/2008 | ||
J3260 | Injection, tobramycin sulfate, up to 80 mg | 5 | 12/16/2008 | ||
J3265 | Injection, torsemide, 10 mg/ml | 2 | 11/14/2008 | ||
8 | J3300 | Injection, triamcinolone acetonide, preservative free, 1 mg | 40 | 12/16/2008 | |
J3301 | Injection, triamcinolone acetonide, not otherwise specified, per 10 mg | 16 | 12/16/2008 | ||
4 | J3302 | Injection, triamcinolone diacetate, per 5 mg | 0 | 11/21/2008 | |
J3303 | Injection, triamcinolone hexacetonide, per 5 mg | 12 | 12/16/2008 | 4/10/2009 | |
J3315 | Injection, triptorelin pamoate, 3.75 mg | 6 | 11/14/2008 | 7/1/2010 | |
J3360 | Injection, diazepam, up to 5 mg | 6 | 12/16/2008 | ||
J3370 | Injection, vancomycin HCl, 500 mg | 8 | 12/16/2008 | 9/18/2009 | |
J3396 | Injection, verteporfin, 0.1 mg | 150 | 12/16/2008 | ||
J3410 | Injection, hydroxyzine HCl, up to 25 mg | 12 | 12/16/2008 | ||
J3411 | Injection, thiamine HCl, 100 mg | 1 | 11/21/2008 | ||
J3420 | Injection, vitamin B-12 cyanocobalamin, up to 1000 mcg | 1 | 11/21/2008 | ||
J3430 | Injection, phytonadione (vitamin K), per 1 mg | 100 | 12/16/2008 | ||
J3470 | Injection, hyaluronidase, up to 150 units | 2 | 11/21/2008 | ||
J3471 | Injection hyaluronidase, ovine, preservative free, per 1 usp unit (up to 999 USP units) | 400 | 12/16/2008 | ||
| J3473 | Injection, hyaluronidase, recombinant, 1 USP unit | 300 | 7/17/2009 | ||
J3475 | Injection, magnesium sulfate, per 500 mg | 48 | 12/16/2008 | ||
J3480 | Injection, potassium chloride, per 2 mEq | 60 | 12/16/2008 | ||
J3486 | Injection, ziprasidone mesylate, 10 mg | 4 | 11/21/2008 | ||
J3487 | Injection, zoledronic acid, 1 mg | 4 | 12/3/2008 | ||
J3488 | Injection, zoledronic acid, 1 mg | 5 | 11/21/2008 | ||
2 | J3520 | Edetate disodium, per 150 mg | 0 | 11/21/2008 | |
2 | J3535 | Drug administered through a metered dose inhaler | 0 | 11/21/2008 | |
J7030 | Infusion, normal saline solution, 1000 cc | 2 | 12/16/2008 | ||
J7040 | Infusion, normal saline solution, sterile (500 ml = 1 unit) | 4 | 12/3/2008 | ||
J7042 | 5% dextrose/normal saline solution (500 ml = 1 unit) | 4 | 12/3/2008 | ||
J7050 | Infusion, normal saline solution , 250 cc | 8 | 12/16/2008 | ||
J7060 | 5% dextrose/water (500 ml = 1 unit) | 4 | 12/3/2008 | ||
J7070 | Infusion, D5W, 1000 cc | 2 | 11/21/2008 | ||
| J7100 | Infusion, dextran 40, 500 ml | 2 | 7/1/2010 | ||
| J7110 | Infusion, dextran 75, 500 ml | 2 | 7/1/2010 | ||
J7120 | Ringers lactate infusion, up to 1000 cc | 4 | 12/3/2008 | 7/1/2010 | |
2 | J7130 | Hypertonic saline solution, 50 or 100 mEq, 20 cc vial | 0 | 11/21/2008 | |
| 5 | J7185 | Injection, factor VII (antihemophilic factor, recombinant) (Xyntha), per I.U. | 5500 | 1/1/2010 | |
8 | J7186 | Injection, antihemophilic factor VIII/Von Willebrand factor complex (human), per factor VIII IU | 5500 | 12/16/2008 | |
5 | J7192 | Factor VIII (antihemophilic factor, recombinant) per IU | 5500 | 12/16/2008 | |
2 | J7300 | Intrauterine copper contraceptive | 0 | 11/21/2008 | |
2 | J7302 | Levonorgestrel-releasing intrauterine contraceptive system, 52 mg | 0 | 11/21/2008 | |
J7308 | Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form | 2 | 11/21/2008 | ||
J7311 | Fluocinolone acetonide, intravitreal implant (Retisert) | 1 | 11/21/2008 | 4/1/2010 | |
2 | J7317 | Sodium hyaluronate, per 20 to 25 mg dose for intra-articular injection | 0 | 11/21/2008 | |
J7321 | Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose | 2 | 11/21/2008 | ||
9 | J7322 | Hyaluronan or derivative, Synvisc, for intra-articular injection, per dose | 2 | 11/21/2008 | |
J7323 | Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose | 2 | 11/21/2008 | ||
J7324 | Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose | 2 | 11/21/2008 | ||
| J7325 | Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg | 96 | 1/1/2010 | ||
2 | J7502 | Cyclosporine, oral 100 mg | 0 | 12/16/2008 | |
2 | J7506 | Prednisone, oral, per 5 mg | 0 | 12/16/2008 | |
2 | J7510 | Prednisolone, oral, per 5 mg | 0 | 12/16/2008 | |
J7513 | Daclizumab, parenteral, 25 mg | 5 | 11/21/2008 | ||
2 | J7515 | Cyclosporine, oral, 25 mg | 0 | 12/16/2008 | |
7 | J7602 | Albuterol, all formulations including separated isomers, inhalation, solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, per 1 mg (albuterol) or per 0.5 mg (levalbuterol) | 3 | 12/16/2008 | |
7 | J7603 | Albuterol, all formulations including separated isomers, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, per 1 mg (albuterol) or per 0.5 mg (levalbuterol) | 3 | 12/16/2008 | |
8 | J7606 | Formoterol fumarate, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, 20 micrograms | 1 | 12/16/2008 | |
J7607 | Levalbuterol, inhalation solution, compounded product, administered through DME, concentrated form, 0.5 mg | 3 | 12/16/2008 | ||
J7615 | Levalbuterol inhalation solution, compounded product, administered through DME, unit dose, 0.5 mg | 3 | 12/16/2008 | ||
J7620 | Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME | 1 | 12/16/2008 | ||
J7626 | Budesonide, inhalation solution, FDA-approved final product, non-compounded, administered trough DME, unit dose form, up to 0.5 mg | 2 | 12/16/2008 | ||
4 | J7628 | Bitolterol mesylate, inhalation solution, compounded product, administered through DME, concentrated form, per mg | 0 | 11/21/2008 | |
4 | J7636 | Atropine, inhalation solution, compounded product, administered through DME, unit dose form, per mg | 0 | 11/21/2008 | |
J7638 | Dexamethasone, inhalation solution, compounded product, administered through DME, unit dose form, per mg | 10 | 12/16/2008 | ||
3 | J7639 | Dornase alpha, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, per mg | 0 | 12/16/2008 | |
3 | J7641 | Flunisolide, inhalation solution, compounded product, administered through DME, unit dose, per milligram | 0 | 12/16/2008 | |
3 | J7643 | Glycopyrrolate, inhalation solution, compounded product, administered through DME, unit dose, per mg | 0 | 12/16/2008 | |
J7644 | Ipratropium bromide, inhalation solution, FDA-aapproved final product, non-compounded, administered through DME, unit dose form, per mg | 1 | 12/16/2008 | ||
J7645 | Ipratropium bromide, inhalation solution, compounded product, administered through DME, unit dose, per mg | 1 | 12/16/2008 | ||
J7668 | Metaproterenol sulfate, inhalation solution, FDA-approved final product, non-compounded, administesred through DME, concentrated form, per 10mg | 2 | 12/16/2008 | ||
J7681 | Terbutaline sulfate, inhalant solution, compounded product, administered through DME, unit dose form, per mg | 3 | 12/16/2008 | ||
3 | J7685 | Tobramycin, inhalation solution, compounded product, administered through DME, unit dose form, per 300mg | 0 | 12/16/2008 | |
2 | J8501 | Aprepitant, oral, 5 mg | 0 | 11/21/2008 | |
2 | J8521 | Capecitabine, oral, 500 mg | 0 | 12/16/2008 | |
2 | J8530 | Cyclophosphamide, oral, 25 mg | 0 | 12/16/2008 | |
2 | J8600 | Melphalan, oral, 2mg | 0 | 12/16/2008 | |
2 | J8700 | Temozolmide, oral 5 mg | 0 | 11/21/2008 | |
2, 8 | J8705 | Topotecan, oral, 0.25 mg | 0 | 12/16/2008 | |
J9000 | Injection, doxorubicin hydrochoride, 10 mg | 18 | 12/16/2008 | ||
J9001 | Injection, doxorubicin hydrochloride, all lipid formulations, 10 mg | 14 | 11/7/2008 | 7/1/2010 | |
J9010 | Injection, alemtuzumab, 10 mg | 3 | 11/7/2008 | ||
J9015 | Aldesleukin, per single use vial | 6 | 12/16/2008 | ||
J9017 | Injection, arsenic trioxide, 1 mg | 20 | 12/3/2008 | 1/12/2009 | |
J9020 | Injection, asparaginase, 10,000 units | 2 | 11/21/2008 | ||
J9025 | Injection, azacitidine, 1 mg | 300 | 12/3/2008 | ||
J9031 | BCG (intravesical), per instillation | 1 | 11/21/2008 | ||
8 | J9033 | Injection, bendamustine HCl, 1 mg | 300 | 12/16/2008 | |
J9035 | Injection, bevacizumab, 10 mg | 170 | 12/3/2008 | Denied | |
J9040 | Injection, bleomycin sulfate, 15 units | 4 | 11/21/2008 | ||
J9041 | Injection, bortezomib, 0.1 mg | 35 | 11/7/2008 | ||
J9045 | Injection, carboplatin, 50 mg | 20 | 11/21/2008 | Denied | |
J9050 | Injection, carmustine, 100 mg | 5 | 12/3/2008 | ||
J9055 | Injection, cetuximab, 10 mg | 120 | 11/7/2008 | 2/27/2009 | |
J9060 | Cisplatin, powder or solution, per 10 mg | 24 | 12/3/2008 | ||
J9062 | Cisplatin, 50 mg | 5 | 11/21/2008 | ||
J9065 | Injection, cladribine, per 1 mg | 11 | 11/21/2008 | 6/1/2010 | |
J9070 | Cyclophosphamide, 100 mg | 55 | 12/3/2008 | ||
J9080 | Cyclophosphamide, 200 mg | 19 | 12/16/2008 | 7/1/2010 | |
J9090 | Cyclophosphamide, 500 mg | 11 | 12/3/2008 | ||
J9091 | Cyclophosphamide, 1.0 gram | 6 | 12/3/2008 | ||
J9092 | Cyclophosphamide, 2.0 gram | 3 | 11/21/2008 | ||
J9093 | Cyclophosphamide, lyophilized, 100 mg | 24 | 12/3/2008 | 7/1/2010 | |
J9094 | Cyclophosphamide, lyophilized, 200 mg | 19 | 12/16/2008 | 7/1/2010 | |
J9095 | Cyclophosphamide, lyophilized, 500 mg | 6 | 12/3/2008 | 7/1/2010 | |
J9096 | Cyclophosphamide, lyophilized, 1.0 gram | 4 | 12/3/2008 | 7/1/2010 | |
J9097 | Cyclophosphamide, lyophilized, 2.0 gram | 2 | 11/21/2008 | 7/1/2010 | |
J9098 | Injection, cytarabine liposome, 10 mg | 5 | 11/21/2008 | ||
J9100 | Injection, cytarabine, 100 mg | 3 | 11/21/2008 | ||
J9110 | Injection, cytarabine, 500 mg | 10 | 11/21/2008 | 3/12/2009 | |
J9120 | Injection, dactinomycin, 0.5 mg | 4 | 11/21/2008 | ||
J9130 | Dacarbazine, 100 mg | 10 | 12/3/2008 | 6/12/2009 | |
J9140 | Dacarbazine, 200 mg | 5 | 12/3/2008 | 2/27/2009 | |
J9150 | Injection, daunorubicin, 10 mg | 11 | 12/3/2008 | ||
| J9155 | Injection, degarelix, 1 mg | 240 | 1/1/2010 | ||
J9160 | Injection, denileukin diftitox, 300 micrograms | 7 | 11/21/2008 | ||
9 | J9170 | Injection, docetaxel, 20 mg | 12 | 11/21/2008 | |
| J9171 | Injection, docetaxel, 1 mg | 240 | 1/1/2010 | 1/8/2010 | |
J9178 | Injection, epirubicin HCl, 2 mg | 150 | 12/16/2008 | ||
J9181 | Injection, etoposide, 10 mg | 30 | 12/3/2008 | 6/23/2009 | |
J9182 | Etoposide, 100 mg | 3 | 11/21/2008 | ||
J9185 | Injection, fludarabine phosphate, 50 mg | 2 | 11/21/2008 | ||
J9190 | Injection, fluorouracil, 500 mg | 21 | 11/21/2008 | 1/12/2009 | |
J9200 | Floxuridine, 500 mg | 4 | 12/16/2008 | ||
J9201 | Injection, gemcitabine hydrochloride, 200 mg | 14 | 11/7/2008 | ||
J9202 | Goserelin acetate implant, per 3.6 mg | 3 | 11/7/2008 | ||
J9206 | Injection, irinotecan, 20 mg | 42 | 11/7/2008 | ||
8 | J9207 | Injection, ixabepilone, 1 mg | 105 | 12/16/2008 | |
J9208 | Injection, ifosfamide, 1 gram | 6 | 12/3/2008 | 2/27/2009 | |
J9209 | Injection, mesna, 200 mg | 30 | 12/3/2008 | 2/27/2009 | |
J9211 | Injection, idarubicin hydrochloride, 5 mg | 8 | 12/16/2008 | ||
J9213 | Injection, interferon, alfa-2A, recombinant, 3 million units | 3 | 11/21/2008 | ||
J9214 | Injection, interferon, alfa-2B, recombinant, 1 million units | 100 | 11/21/2008 | ||
3 | J9216 | Injection, interferon, gamma 1-B, 3 million units | 0 | 11/21/2008 | |
J9217 | Leuprolide acetate (for depot suspension), 7.5 mg | 6 | 12/16/2008 | 4/24/2009 | |
| J9218 | Leuprolide acetate, per 1 mg | 1 | 7/1/2010 | ||
J9219 | Leuprolide acetate implant, 65 mg | 1 | 12/16/2008 | ||
J9225 | Histrelin implant, 50 mg | 1 | 12/16/2008 | ||
J9226 | Histrelin implant, 50 mg | 1 | 12/16/2008 | ||
J9230 | Mechlorethamine HCl, (nitrogen mustard), 10 mg | 5 | 12/16/2008 | ||
J9245 | Injection, melphalan HCl, 50 mg | 1 | 11/21/2008 | ||
J9250 | Methotrexate sodium, 5 mg | 7200 | 12/16/2008 | ||
J9260 | Methotrexate sodium, 50 mg | 720 | 12/16/2008 | ||
J9263 | Injection, oxaliplatin, 0.5 mg | 624 | 12/16/2008 | 2/27/2009 | |
J9264 | Injection, paclitaxel protein-bound particles, 1 mg | 624 | 12/16/2008 | ||
J9265 | Paclitaxel, 30 mg | 18 | 12/16/2008 | 2/27/2009 | |
J9268 | Injection, pentostatin, per 10 mg | 1 | 11/21/2008 | ||
J9280 | Mitomycin, 5 mg | 10 | 12/16/2008 | ||
J9290 | Mitomycin, 20 mg | 3 | 11/21/2008 | ||
J9291 | Mitomycin, 40 mg | 2 | 11/21/2008 | ||
J9293 | Injection, mitoxantrone hydrochloride, per 5 mg | 10 | 12/16/2008 | ||
J9300 | Injection, gemtuzumab ozogamicin, 5 mg | 5 | 12/3/2008 | ||
J9303 | Injection, panitumumab, 10 mg | 70 | 12/16/2008 | 4/20/2010 | |
J9305 | Injection, pemetrexed, 10 mg | 120 | 12/3/2008 | ||
J9310 | Injection, rituximab, 100 mg | 11 | 11/7/2008 | ||
J9320 | Injection, streptozocin, 1 gram | 4 | 12/16/2008 | ||
| J9328 | Injection, temozolomide, 1 mg | 500 | 1/1/2010 | ||
8 | J9330 | Injection, temsirolimus, 1 mg | 25 | 12/16/2008 | |
J9340 | Injection, thiotepa, 15 mg | 6 | 12/3/2008 | ||
J9350 | Injection, topotecan, 4 mg | 10 | 12/3/2008 | 1/12/2009 | |
J9355 | Injection, trastuzumab, 10 mg | 88 | 11/7/2008 | Denied | |
J9360 | Vinblastine sulfate, 1 mg | 45 | 12/16/2008 | ||
J9370 | Vincristine sulfate, 1 mg | 4 | 12/16/2008 | ||
J9375 | Vincristine sulfate, 2 mg | 2 | 12/3/2008 | ||
| J9380 | Vincristine sulfate, 5 mg | 1 | 4/1/2010 | ||
J9390 | Injection, vinorelbine tartrate, per 10 mg | 8 | 12/3/2008 | ||
J9395 | Injection, fulvestrant, 25 mg | 20 | 11/21/2008 | 6/1/2010 | |
| Q0138 | Injection ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use) | 510 | 1/1/2010 | ||
| Q0139 | Injection ferumoxytol, for treatment of iron deficiency anemia, 1 mg (for ESRD use) | 510 | 1/1/2010 | ||
| 9 | Q2024 | Injection, bevacizumab, 0.25 mg | 510 | 10/1/2009 | |
6 | Q4083 | Hyalgan-supartz, per dose | 2 | 11/21/2008 | |
6 | Q4084 | Synvisc, per dose | 2 | 11/21/2008 | |
6 | Q4085 | Euflexxa, per dose | 2 | 11/21/2008 | |
6 | Q4086 | Orthovisc, per dose | 2 | 11/21/2008 |
GENERAL INFORMATION
Effective April 1, 2002, CWF edits were implemented to identify HCPCS codes for ambulance services that are either subject to or excluded from Skilled Nursing Facility (SNF) consolidated billing (CB). This coding change added SNF CB edits to CWF to deny payment of some separately billed ambulance services for beneficiaries in a SNF Part A covered stay. Effective July 1, 2003, CWF added an edit to allow claims submitted with specialty type “59” and HCPCS codes J7030 or J7050 (Saline Solution Injection) to process and pay correctly for modifiers other than “NN” when a beneficiary is in a Part A stay, and for claims submitted with an “NN” modifier when the beneficiary is not in a Part A stay. Since the implementation of this update, CMS has identified additional HCPCS codes for drugs and CPT codes for electrocardiogram (EKG) testing that may be separately payable when provided during a SNF ambulance transport that is not subject to SNF CB. HCPCS J-codes (J0000-J9999) not included in previous updates, Q-codes for anti-emetic drugs (Q0163 through Q0181), and CPT codes for EKG testing (93005 and 93041) will be added to the CWF SNF CB bypass for ambulance specialty type “59” carrier claims during the October 2004 SNF CB quarterly update.
Hydration (90760–90761)
Hydration codes are used for reporting intravenous (IV) administration of prepackaged fluid and electrolytes. These codes are not applicable to infusion of drugs or other substances and should not be reported if concurrently administered with chemotherapy or infusions of other drugs. Hydration is typically not a high-risk procedure, and once the IV line is in place, the patient requires little monitoring. Documentation of start and stop times is needed to allow the coder to choose the correct code(s). The codes are based on time, with 90760 for the initial hour and an add-on code of 90761 used for each additional hour.
Supply codes (substance/drug and amount administered) for injections and infusions are documented using a “J” code from HCPCS Level II, such as J7030 for infusion of normal saline solution, 1,000 mL. Some commercial payers do not accept the HCPCS Level II supply codes and will not reimburse for them. In this case, CPT provides a general supply code, 99070, that is submitted along with the name(s) of the product(s) used. To avoid repeating the code for a particular product (e.g., drug), the number of units can be reported in an additional field on the billing form/abstract.
A dehydrated patient is infused with one unit of a 5% dextrose/normal saline solution, which takes approximately 50 minutes: 90760, J7042. Alternatively, supply code 99070 can be used for the product administered if required by the payer (in place of J7042).
CPT provides codes for intravenous push and intra-arterial push. A substance that is pushed is injected directly into an existing IV line that is in use. To use these push codes, the provider must be present for the administration of the substance, or the infusion must take less than 16 minutes to complete. If a push is given subsequent to starting a separate infusion, then the push is coded as subsequent, not as an initial service. If a total infusion lasts less than 16 minutes, the push code is assigned for the service. Push codes cannot be assigned for infusion services that do not meet the time
requirements for add-on codes. For instance, if a patient receives an (initial) infusion for 1 hour 10 minutes, only the initial code of 90765 would be assigned. No add-on or push code can be assigned for the 10 minutes past 1 hour of services.
EXAMPLE Patient presents with severe vomiting and dehydration. IV infusion of normal saline, 1,000 mL for 2 hours. Phenergan IV push given. Report code 90774 for IV push, 90761, 90761 for administration of hydration (normal saline), and the following “J” codes from HCPCS Level II for the products administered: J2550, J7030. (Some payers do not recognize “J” codes, and then the supply code 99070 can be used for the products administered.)
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