Oct-Nov 00 Part A Bulletin - Medicare

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HOSPITAL SERVICES Proper Billing of Units for Intrathecal Baclofen under the Outpatient Prospective Payment System For proper payment under outpatient prospective payment system (OPPS), hospitals must bill for intrathecal baclofen, an orphan drug entitled to pass-through payment under OPPS, using HCPCS code J0476 with the following units: • 0.05 mg/ml (screening kit): bill 7 units • 10 mg/20 ml, 20 ml ampule (refill kit): bill 20 units • 10 mg/5ml, two 5 ml ampules (refill kit): bill 42 units • 10mg/5ml, four 5 ml ampules (refill kit): bill 74 units Effective October 1, 2000, unique codes will be available for each of the package/dosage combinations. A separate notification containing these codes will be issued at a later date. � HH SS IIIIINPATIENT NPATIENT NPATIENT NPATIENT NPATIENT HOSPITAL HH OSPITAL OSPITAL OSPITAL OSPITAL SERVICES SS ERVICES ERVICES ERVICES ERVICES Interim Process for Certain “Inpatient Only” Code Changes The final rule for the outpatient prospective payment system (OPPS), which was published in the Federal Register on April 7, 2000, indicated certain procedures that will not be paid by Medicare if performed on an outpatient basis. A hospital will receive Medicare payment for these procedures only when they are furnished on an inpatient basis only. The HCPCS codes that are on the “inpatient only” list were published in Addendum E of the final rule. However, certain codes from the list were erroneously included as “inpatient only” procedures and as a result are being removed from the list. The following is a list of HCPCS codes that will be removed from the inpatient only list. These codes will be assigned and paid under the appropriate ambulatory payment classification (APC). HCPCS Code Description APC 74300 X-ray bile ducts/pancreas 0263 75945 Intravascular us 0267 75946 Intravascular us add on 0267 75960 Transcatheter intro, stent 0279 75961 Retrieval, broken catheter 0279 75962 Repair arterial blockage 0280 75964 Repair artery blockage, each 0279 75966 Repair arterial blockage 0280 75968 Repair artery blockage, each 0279 75970 Vascular biopsy 0279 75978 Repair venous blockage 0279 75992 Atherectomy 0279 75995 Atherectomy 0279 92977 Dissolve clot, heart vessel 0120 95920 Intraop nerve test add on 0216 95961 Electrode stimulation, brain 0216 95962 Electrode stim, brain add on 0216 Although these changes are effective for services furnished on or after August 1, 2000, the Outpatient Code Editor (OCE) will not be able to properly pay these services as outpatient services until the October OCE update. Therefore, hospital outpatient claims containing any of the above codes will result in rejection of the claim. The October update to the OCE will be revised to properly process these codes for hospital outpatient claims submitted to the fiscal intermediary on or after October 1, 2000, even if the date of service on the claim occurs during the period August 1, 2000 through September 30, 2000. If a hospital has submitted a claim containing any of the above codes prior to October 1, 2000, and the claim has been rejected, the intermediary will reprocess those claims with any of the above codes that were rejected as “inpatient only” no later than November 30, 2000. If a hospital has submitted a claim for all services furnished to a beneficiary (with the exception of the codes listed above), on or after October 1, 2000, the hospital must submit an adjustment claim containing all the services provided, including any of the above codes previously not billed. � 12 The Florida Medicare A Bulletin October/November 2000
NN FF October/November 2000 The Florida Medicare A Bulletin SKILLED NURSING FACILITIES SS SSSSSKILLED KILLED KILLED KILLED KILLED NURSING NN URSING URSING URSING URSING FACILITY FF ACILITY ACILITY ACILITY ACILITY SERVICES SS ERVICES ERVICES ERVICES ERVICES Skilled Nursing Facility Adjustment Billing: Adjustments to HIPPS Codes Resulting From MDS Corrections Background There is a new policy that allows corrections to MDS assessments. The instructions that explain the types of error that may be corrected and the procedures to be followed are available at http://www.hcfa.gov/medicaid/mds20/ whatsnew.htm. The web site does not include any instruction regarding billing changes that are required as a result of an MDS correction. Effective for services provided on and after June 1, 2000, providers must submit adjustment bills whenever a correction of an MDS results in a change in a billed HIPPS code. The adjustment bill is retroactive to the first day payment was made based on the original (but incorrect) MDS assessment or June 1, 2000, whichever is earlier. Unlike the Significant Correction of a Prior Full Assessment that has been available to facilities for some time, an MDS correction is not a new assessment and can never be used as a replacement for any required MDS. Facts about the Adjustment Bill Process • Providers may start submitting adjustment bills on November 6, 2000. • Providers must use condition code D4 (Change in Grouper Code) for adjustment bills that result from corrections to an MDS. This code indicates that the reason for the adjustment is a HIPPS code change resulting from the correction of MDS data. • Adjustment bills based on corrected MDS assessments are eligible for payment under this procedure effective June 1, 2000. This policy only refers to Medicare skilled services that were provided in the SNF on June 1, 2000 or later. HIPPS codes for dates of service (FL 45) prior to June 1, 2000 may not be adjusted based on a correction to the relevant MDS. • After the initial period of this new adjustment bill policy, the beginning date of service, the “from” date, will have little significance. The “through” date will be used to calculate the period during which D4 type adjustment bills may be submitted based on corrected MDS assessments. The “through” date indicates the last day of the billing period for which the HIPPS code is billed. Providers are required to submit adjustment bills based on corrected MDS assessments within 120 days of the “through” date on the bill. • Once the fiscal intermediary has medically reviewed a bill, no adjustment bill may be submitted. The MDS may be corrected, but no adjustment bill may be sent. • The requirement that providers may not knowingly over bill the Medicare program remains in effect. SNFs that identify patterns of errors that result in overpayments must report them to the FI, and these overpayments must be recouped. A pattern of errors includes but is not limited to software errors in transmitting MDS files, misunderstandings of MDS instructions that result in consistent miscoding of one or more MDS files, misunderstandings of MDS instructions that result in consistent miscoding of one or more MDS items used in determining the RUG-III group, etc. • The procedure you should use to report this type of overpayment is by submitting adjustment bills to reflect corrections to the MDS data that results in changes to the RUG-III code (i.e. the first three digits of the HIPPS code). Examples 1. A Medicare 5-day assessment was completed timely and used to establish the RUG-III rate for days 1-14 of the Part A stay. The bill was paid before the provider found the error, on day 16. The facility corrected the 5-day assessment and submitted an adjustment bill for days 1 through 14 of the Part A stay. 2. On day 39 of the Part A stay, the facility identified an error in a 30-day Medicare MDS. Five days of service had already been billed and paid based on the HIPPS code generated from that 30-day Medicare assessment. The facility submitted an MDS correction that resulted in a change in the RUG-III group (and of course, the HIPPS code). Then, the correct RUG-III classification was used to generate the adjustment bill for the remaining covered days in the applicable payment period. � 13
Page 1 and 2: Bulletin A Newsletter for Florida M
Page 3 and 4: A A A A PP PP A PHYSICIAN HYSICIAN
Page 5 and 6: About The Medicare A Bulletin Octob
Page 7 and 8: CC GGGGGENERAL ENERAL ENERAL ENERAL
Page 9 and 10: Medicare Beneficiaries Participatin
Page 11: HH OOOOOUTPATIENT UTPATIENT UTPATIE
Page 15 and 16: Annual Update to the PPS Pricer ...
Page 17 and 18: PP MMMMMEDICAL EDICAL EDICAL EDICAL
Page 19 and 20: 44388: Colonoscopy (continued) •
Page 21 and 22: 44388: Colonoscopy (continued) Star
Page 23 and 24: 78472: Cardiac Blood Pool Imaging (
Page 25 and 26: 80100: Qualitative Drug Screen LOCA
Page 27 and 28: 80100: Qualitative Drug Screen (con
Page 29 and 30: 83540: Iron (continued) ICD-9-CM Co
Page 31 and 32: 84484: Troponin (continued) HCPCS S
Page 33 and 34: LOCAL AND FOCUSED MEDICAL REVIEW PO
Page 35 and 36: 93875: Noninvasive Extracranial Art
Page 39 and 40: 95115: Allergen Immunotherapy Polic
Page 41 and 42: 95934: H-Reflex Study Policy Number
Page 43 and 44: G0102: Prostate Cancer Screening LO
Page 45 and 46: J0001: Self-Administered Drugs Poli
Page 47 and 48: J1440: G-CSF (Filgrastim, Neupogen
Page 49 and 50: J1440: G-CSF (Filgrastim, Neupogen
Page 51 and 52: Q0136: Non-ESRD Epoetin (Procrit) (
Page 55 and 56: 2001 ICD-9-CM Coding Changes (conti
Page 57 and 58: OUTPATIENT PROSPECTIVE PAYMENT SYST
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October/November 2000 The Florida M
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OUTPATIENT PROSPECTIVE PAYMENT SYST
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urinary incontinence, Male Straight
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A Abortion Services, Medicare Cover
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INDEX TO MEDICARE A BULLETIN R (con
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IMPORTANT ADDRESSES , TELEPHONE NUM
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Oct-Nov 00 Part A Bulletin - Medicare

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