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6/23/2009
On January 15, 2009, the Centers for Medicare & Medicaid Services (CMS) finalized National Coverage Determinations (NCDs) for non-coverage of three surgical “never events.” Per the NCDs, Medicare will not cover a particular surgery or invasive procedure if:
- the wrong procedure is performed on a patient,
- the procedure is performed on the wrong body part, or
- the procedure is performed on the wrong patient.
On June 12, 2009, CMS released two transmittals that manualize the determinations, further define related non-covered services, and provide billing instructions.
The effective date of the transmittals is for discharges and services on or after January 15, 2009, but the implementation date, including availability of the new HCPCS modifiers is July 6, 2009 for Part B claims and October 5, 2009 for Part A claims. Contractors will not go back and search for erroneously processed claims prior to the implementation dates but will adjust any claims brought to their attention.
Related Services
Medicare will not cover hospitalizations and other services related to these non-covered procedures as defined in the Medicare Benefit Policy Manual, Chapter 1 , Sections 10 and 120 and Chapter 16, Section 180.
- Related services do not include performance of the correct procedure
- All services provided in the operating room when an error occurs are considered related and therefore not covered
- All providers in the operating room when the error occurs, who could bill individually for their services, are not eligible for payment
- All related services provided during the same hospitalization in which the error occurred are not covered
- Following hospital discharge, any reasonable and necessary services are covered regardless of whether they are or are not related to the surgical error.
Billing Instructions – Inpatient Admission
If covered services were provided during the same hospitalization in which a surgical error occurred, the hospital should submit two separate claims: one claim with covered services and procedures unrelated to the erroneous surgery on a Type of Bill (TOB) 11X (except not 110) and another claim with the non-covered services and procedures related to the error on a TOB 110 (no-pay claim). On the claim for the non-covered services (TOB 110), hospitals should enter one of the following 2-digit surgical error codes in the Remarks field.
- MX: wrong surgery on patient
- MY: surgery on wrong body part
- MZ: surgery on wrong patient
Claims submitted on a TOB 110 with one of the surgical error codes will be denied for payment.
Billing Instructions – Hospital Outpatient
On hospital outpatient claims for services where one of the non-covered surgical events occurred, the hospital should append one of the following applicable HCPCS modifiers to all lines related to the surgical error.
- PA: surgery on wrong body part
- PB: surgery on wrong patient
- PC: wrong surgery on patient
All line-items with one of the above HCPCS modifiers will be denied for payment.
CMS cannot envision a scenario in which HINNs or ABNs could be validly delivered in these NCD cases. Medicare contractors will maintain a list of surgical error occurrences and will review beneficiary history for other claims potentially related to the surgical error. If the contractor determines that related services should not have been covered, they will deny payment for the related services and recover overpayments when appropriate.
Links to the CMS transmittals:
http://www.cms.hhs.gov/transmittals/downloads/R1755CP.pdf
http://www.cms.hhs.gov/transmittals/downloads/R101NCD.pdf
6/1/2009
There have been questions regarding whether it is appropriate to bill CPT codes for IV push injection when given in conjunction with a blood transfusion - particularly since the IV push injection requires a 59 modifier when billed on the same outpatient date of service as the blood transfusion, CPT code 36415, representing a separate and distinct service.
We contacted National Correct Coding Initiative and received confirmation that it is appropriate to bill IV push injections in this scenario for the administration of drugs administered in conjunction with the blood transfusion, including but not limited to Benadryl, Lasix, Solumedrol. the drugs must be ordered by the physician and medically necessary.
It is also appropriate to assign modifier 59 to the IV push injections to verify the codes are not being reported for the actual administration of the blood.
5/7/2009
CMS provides clear guidance on billing for frozen/thawed blood products. Providers should bill the most specific HCPCS code that describes the blood product in addition to the CPT code for the transfusion. If the blood product HCPCS code description includes “frozen” in the description, it would not be appropriate to also bill additional CPT codes for freezing and/or thawing since charges for freezing and thawing should be included in the charge for the product. If there is not a specific HCPCS code for the frozen blood product, then the provider should bill the appropriate HCPCS code for the blood product plus the CPT codes for freezing and/or thawing. Also, if a product is frozen and/or thawed in preparation for a transfusion, but the patient does not receive the transfusion, the provider may bill for the freezing and/or thawing services provided. Please note that for frozen plasma HCPCS codes P9017, P9023, P9059 and P9060; cryoprecipitate HCPCS codes P9012 and P9044; and frozen blood/RBC HCPCS codes P9039, P9054, and P9057 freezing and thawing codes are not separately billable.
This information can be found in Chapter 4 of the Medicare Claims Processing Manual, section 231.6 including a detailed list of all blood/blood product codes with freezing/thawing billing instructions. Link to the Claims Processing Manual Chapter 4:
http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf
The same billing guidelines apply to blood and blood products regarding irradiation of blood (§231.5) and autologous processing (§231.3).
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