Coding and Reimbursement for Hospital Outpatient Services

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Chapter 1 40 Certain Preventive Services Furnished to Healthy Persons The OPPS includes certain preventive services that are furnished to healthy patients. The status indicators for the screening services vary from medical visits (“V”), significant procedures (“S”), and surgical services (“T”). Code SI Abbreviated Code Description G0101 V CA screen; pelvic/breast exam G0104 S CA screen; flexi sigmoidscope G0105 T Colorectal scrn; hi risk ind G0106 S Colon CA screen; barium enema G0117 S Glaucoma scrn hgh risk direc G0118 S Glaucoma scrn hgh risk direc G0120 S Colon ca scrn; barium enema G0121 T Colon ca scrn not hi rsk ind Source documents and contents:The following documents may contain information about the preventive services rendered: operative report/procedure note, physician’s orders, referral form, progress notes. Coding from source documents: The medical record should be reviewed carefully because the CMS has specific documentation requirements to justify the medical necessity of the screening services. Example: Screening colonoscopies are covered for people at high risk for colorectal cancer once every twenty-four months. High-risk individuals are those people who have a close relative who has had colorectal cancer or an adenomatous polyp; a family history of adenomatous polyposis or hereditary nonpolyposis colorectal cancer; a personal history of adenomatous polyps or colorectal cancer; inflammatory bowel disease, including Crohn’s Disease; and/or ulcerative colitis. The following operative report excerpts are excellent examples of documentation that supports the coding and billing of code G0105, Colorectal cancer screening; colonoscopy on individual at high risk: Case #1: “She is a high-risk patient with a family history of colon cancer, and breast cancer in herself.” Case #2: “Preoperative Diagnosis: Personal history of polyps; family history of colon cancer.” Case #3: “Preoperative Diagnosis: Family history of colon cancer in a first-degree relative, screening examination.” Antigens, Vaccines, Splints, and Casts The Balanced Budget Act of 1997 (BBA) authorized the CMS to implement a Medicare PPS for the following services, and, effective August 1, 2000, the CMS implemented the OPPS for these services: • Vaccines, splints, casts, and antigens provided by home health agencies (HHAs) that provide medical and other health services • Vaccines provided by comprehensive outpatient rehabilitation facilities (CORFs) • Splints, casts, and antigens provided to hospice patients for treatment of a nonterminal illness
HHAs, CORFs, and hospices are required to report the following codes (when applicable) to ensure that they are paid under the OPPS: Antigens: 95144-95149, 95165, 95170, 95180 and 95199 Hepatitis B Vaccines: G0010, 90740, 90743, 90744, 90746, 90747 Splints: 29105-29131, 29505, 29515 Casts: 29000-29086, 29305, 29325-29445, 29450, 29700-29750, 29799 Partial Hospitalization for the Mentally Ill A partial hospitalization program (PHP) is a distinct and organized intensive psychiatric outpatient day-treatment program designed to provide patients with profound and disabling mental health conditions with an individualized, coordinated, comprehensive, and multidisciplinary treatment program. Patients eligible for the Medicare partial hospitalization benefit comprise two groups: • Patients who have been discharged from a psychiatric hospital for whom partial hospitalization services are provided in lieu of continued inpatient treatment • Patients who exhibit disabling psychiatric/psychological symptoms as a result of an acute exacerbation of a severe and persistent mental illness for whom the partial hospitalization services are provided in lieu of admission to an inpatient psychiatric hospital The OPPS includes partial hospitalization services provided by a hospital to its outpatients or by a Medicare-certified community mental health center (CMHC). Partial hospitalization APC group 033 contains three HCPCS Level II codes that are assigned to status indicator “P.” APC Rel. Pay Natl. Min. APC HCPCS Description HCPCS Description SI Wt. Rate Coin. Coin. Partial 0033 Hospitalization P 4.9370 281.33 — 56.27 G0129 Partial hosp prog service G0176 PHP activity therapy G0177 PHP train & educ serv The APC group 0033 payment for partial hospitalization services represents the facility’s costs for overhead, support staff, and the services of clinical social workers (CSWs) and occupational therapists (OTs), whose professional services are considered to be partial hospitalization services for which payment is made to the facility. Source documents and contents:The following documents may contain information about the PHP services rendered: intake assessment form, treatment plan, psychiatric progress note, certification statement, recertification statement. As required by the SSA, admission to a partial hospitalization program is limited to patients whose physicians certify that: • The individual would require inpatient psychiatric care in the absence of partial hospitalization services. • An individualized, written plan of care has been established by a physician and is reviewed periodically by a physician. • The patient is or was under the care of a physician. Overview of Coding and Reimbursement under OPPS 41
Page 1 and 2: Coding and Reimbursement for Hospit
Page 3 and 4: Contents About the Author . . . . .
Page 5: Chapter 11 Eye and Auditory System.
Page 8 and 9: viii Editor’s Note Medicare Trans
Page 10 and 11: Preface x Each chapter in part II c
Page 13 and 14: Chapter 1 Overview of Coding and Re
Page 15 and 16: The Balanced Budget Act of 1997 Ove
Page 17 and 18: ambulatory payment classification s
Page 19 and 20: The CMS assigns one and only one SI
Page 21 and 22: Description of the APC Groups Each
Page 23 and 24: The SSA requires the HHS to establi
Page 25 and 26: Labor-Related Portion of Hospital O
Page 27 and 28: and procedures from one APC to anot
Page 29 and 30: Example: The SI “A” appears for
Page 31 and 32: Preadmission Diagnostic Services Ef
Page 33 and 34: Example: Under the OPPS, when a hos
Page 35 and 36: for the implant(s) inserted or repl
Page 37 and 38: Example: Under the OPPS, multiple p
Page 39 and 40: CPT/HCPCS Code SI Code Description
Page 41 and 42: Figure 1.1. Sample clinic visit not
Page 43 and 44: Overview of Coding and Reimbursemen
Page 45 and 46: CPT 99292 to bill for critical care
Page 47 and 48: Surgical Pathology Example: The rep
Page 49: Coding from source documents: The m
Page 53 and 54: The CMS believes that such patients
Page 55 and 56: Overview of Coding and Reimbursemen
Page 57 and 58: Medicare Coverage for Direct Admiss
Page 59 and 60: Exhibit 1.1. Recommendation for sta
Page 61 and 62: Exhibit 1.1. (Continued) Isolation
Page 63 and 64: Exhibit 1.2. (Continued) * Assistan
Page 65: Overview of Coding and Reimbursemen

Coding and Reimbursement for Hospital Outpatient Services

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