The document provides guidance on coding and billing for outpatient infusions and injections. Key points include using CPT codes 96360-96549 to report infusion therapy and injections, specifying the type of therapy using revenue codes, following a hierarchy when administering multiple therapies, and documenting start and stop times to determine whether an infusion or injection code should be used. Additional services like IV starts are not separately reported.

1. HFMA Western NY Chapter
January 26, 2011 – Day 2
2011 OPPS UPDATES, CODING CHANGES
AND CHARGE MASTER APPROACHES

2. CY2011 HCPCS/CPT AND OPPS UPDATES
Outline for remainder of work shop:
Laboratory (inc. Blood Bank)
D Radiology (inc. Nuclear Medicine)
Pain Management
A Interventional Radiology
Y Cardiac Catheterization
Electrophysiology
1 Medical and Surgical Supplies
Outpatient Facility E/M Services; Clinic and Emergency Services
D Outpatient Observation Services
Infusions and Injections
A Pharmaceuticals
Y Diagnostic Cardiology
Respiratory/Pulmonary
2 Cardiac and Pulmonary Rehabilitation
Radiation Oncology
2

3. CY2011 HCPCS/CPT AND OPPS UPDATES
Hospital Facility Chargemaster Reference Guide
Includes additional detail for topics discussed today
HCPCS/CPT Code to UB04 crosswalk
Modifier definitions
Greater narrative detail
The companion guide provides for quick access
to important payment tables and references
UB04 claim form
UB04 revenue code descriptions
CMS Medically Unlikely Edits (MUEs)
CY2011 CPT Code Changes
CMS OPPS status indicator definitions
CMS OPPS comment indicator definitions
CY2011 CMS OPPS Final Rule Addendum B
3

4. CLINIC AND EMERGENCY SERVICES
Separate HCPCS/CPT codes have yet to be established to describe E/M services
provided within a facility.
Hospitals are permitted to utilize “physician” E/M to capture charges for
services provided.
Physicians – expertise
Hospitals – overhead
To determine the appropriate level of service for a patient’s visit, it is
necessary to first determine whether the patient is new or already established.
New vs. Established
Pertains to whether or not the patient already has a medical record
number
If patient had use of that medical record number within the past 3 years,
the patient is considered an established patient to the hospital
The same patient could be “new” to a physician or department, but
“established” to the hospital
4

5. CLINIC AND EMERGENCY SERVICES
CMS Standards for E/M Guidelines for Facilities
1. The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should
be designed to reasonably relate the intensity of hospital resources
2. The coding guidelines should be based on hospital facility resources, not physician
3. The coding guidelines should be clear to facilitate accurate payments and be usable for compliance
purposes and audits
4. The coding guidelines should meet the HIPAA requirements
5. The coding guidelines should only require documentation that is clinically necessary for patient care
6. The coding guidelines should not facilitate upcoding or gaming
7. The coding guidelines should be written or recorded, well-documented, and provide the basis for
selection of a specific code.
8. The coding guidelines should be applied consistently across patients in the clinic or emergency
department to which they apply.
9. The coding guidelines should not change with great frequency.
10. The coding guidelines should be readily available for fiscal intermediary (or if applicable MAC) review.
11. The coding guidelines should result in coding decisions that could be verified by other hospital staff, as
well as outside sources.
2008, Federal Register Vol. 72, p. 66805
5

6. EMERGENCY SERVICES
CY2009 New York State ED Facility Levels
40.00%
35.00%
30.00%
25.00%
% Distribution
20.00%
15.00%
10.00%
5.00%
0.00%
1 2 3 4 5 6
New York 3.69% 13.12% 35.69% 34.59% 12.91% 1.00%
National 3.40% 12.52% 33.22% 33.00% 17.87% 2.00%

7. CLINIC AND EMERGENCY SERVICES
A visit should be charged only when the patient is being seen for such services
as to:
be diagnosed;
obtain a referral;
obtain or renew prescriptions;
discuss plans for therapy;
have a dressing changed;
check vital signs, and/or
obtain services where the reason for the visit is not for the sole purposes
of having a diagnostic test/procedure, injection, surgical procedure or
other service that is further defined by a CPT/HCPCS Code.
7

8. CLINIC AND EMERGENCY SERVICES
VISIT CHARGE WITH PROCEDURE
When the patient meets the visit criteria defined on the previous page, but
during the same visit the patient does have a diagnostic test/procedure,
injection, surgical procedure or other service, the visit level may still be
charged. A modifier -25 must be appended to the visit charge to indicate to
the payers that there were separate and distinct procedures performed.
Visit with -25 modifier and Procedure Charge Scenario
Mrs. Smith is being seen by the pain management specialist at the hospital for
her back pain. She is unsure of the origin of her pain and her treatment
options. She would like further evaluation. She is greeted in the pain
management clinic with a history taken by the hospital nurse before being
seen by the physician. The physician reviews her symptoms and history and
recommends an epidural injection. The physician performs the epidural
injection while the patient is still in the office.
8

9. CLINIC AND EMERGENCY SERVICES
PROCEDURE ONLY
When the patient’s reason for coming to the hospital is for a scheduled
diagnostic test/procedure, injection, surgical procedure or other service it is
not appropriate to also charge for a visit unless the patient presents a new
problem or there is some degree of medical decision. Time spent preparing
the patient, including any related evaluation prior, is included in the procedure
charge.
Procedure Charge Only Scenario
Mrs. Smith is being seen by the pain management specialist at the hospital for
her back pain. She has been scheduled for an epidural injection. The physician
performs the epidural injection in the clinic.
9

10. CLINIC AND EMERGENCY SERVICES
PROCEDURE ONLY
When the patient’s reason for coming to the hospital is for a scheduled
diagnostic test/procedure, injection, surgical procedure or other service it is
not appropriate to also charge for a visit unless the patient presents a new
problem or there is some degree of medical decision. Time spent preparing
the patient, including any related evaluation prior, is included in the procedure
charge.
Procedure Charge Only Scenario
Mrs. Smith is being seen by the pain management specialist at the hospital for
her back pain. She has been scheduled for an epidural injection. The physician
performs the epidural injection in the clinic.
10

11. CLINIC AND EMERGENCY SERVICES
CY2011 OPPS UPDATE
CMS has not made revisions regarding the guidelines for clinic and
emergency services E/Ms. Continue to utilize internal guidelines.
Critical Care in the Facility Setting
CMS clarified in the final rule that, consistent with the 2011 CPT guidelines, hospitals may
begin reporting all of the ancillary services and their associated charges separately when
they are provided in conjunction with critical care.
However, hospitals will not receive separate payment for these ancillary services.
If code 99291 is present on the claim with any of the specified ancillary procedure codes,
the IOCE will change the status indicator of the ancillary procedure code from Q[#] to N
for packaging.
There is an exception to the packaged payment status of ancillary services when they are
not provided in conjunction with critical care services. Hospitals may use modifier -59 to
indicate when an ancillary procedure or service is distinct or independent from critical
care when performed on the same day but in a different encounter. Payment for such
services will not be packaged into the payment for critical care.
11

12. CLINIC AND EMERGENCY SERVICES
CY2011 OPPS UPDATE
Physician Supervision of Therapeutic Services
CMS clarified in the final rule that therapeutic services performed in
hospitals must be done under direct physician supervision.
The definition only requires that the supervising physician or NPP be
“immediately available to furnish assistance and direction throughout
the performance of the procedure.”
Examples of Outpatient Therapeutic Services:
Clinic/emergency department visits
Observation services
Drug infusions and blood transfusions
Outpatient psychiatric services
Wound debridement
Cardiac and pulmonary rehabilitation
12

13. CLINIC AND EMERGENCY SERVICES
CY2011 OPPS UPDATE
Tobacco Cessation Counseling
Starting January 1, 2011, hospitals will have two new HCPCS codes for
reporting covered tobacco cessation counseling services.
HCPCS codes C9801 and C9802 will be deleted December 31, 2010, and
replaced with HCPCS codes G0436 and G0437.
G0436 - Smoking and tobacco cessation counseling visit for the
asymptomatic patient; intermediate, greater than 3 minutes, up to 10
minutes
G0437 - Smoking and tobacco cessation counseling visit for the
asymptomatic patient; intensive, greater than 10 minutes
Specific coverage and coding guidelines
http://www.cms.gov/manuals/downloads/clm104c18.pdf
13

14. OUTPATIENT OBSERVATION SERVICES
“Observation care is a well-defined set of specific, clinically appropriate
services, which include ongoing short term treatment, assessment, and
reassessment, that are furnished while a decision is being made regarding
whether patients will require further treatment as hospital inpatients or if
they are able to be discharged from the hospital. “
– Medicare Claims Processing Manual
Specific coding and billing requirements exist for payment:
Physician Order
Documentation
HCPCS/CPT requirements
Calculation of Hours
14

15. OUTPATIENT OBSERVATION SERVICES
Physician Order
The physician documentation should clearly differentiate an order for
outpatient observation from an order for inpatient admission. The
reason for observation must be stated in the orders for observation.
Physicians should not use the term “admit” when placing the patient in
observation. This term could confuse staff responsible for indicating
the appropriate status in the bed tracking systems, request for
documentation requirements, internal flags for processing of
laboratory and pharmacy orders, etc.
Inadequate Documentation:
“Place in observation due to a large amount of alcohol ingestion”.
Adequate Documentation:
“Place in observation due to large amount of alcohol ingestion and the risk of
hypoxia and aspiration”.
15

16. OUTPATIENT OBSERVATION SERVICES
Documentation
Medical records will be expected to demonstrate the consistency
between the physician order (physician intent), the services actually
provided (inpatient or outpatient) and the medical necessity of those
services, including the medical appropriateness of the inpatient or
observation stay. The medical record must clearly support the medical
necessity for observation and should include a timed order to observe
which will support the number of hours billed.
Every page of the record must be legible and include appropriate
patient identification information (e.g., complete name, dates of
service(s)). The record must include the physician or non-physician
practitioner responsible for and providing the care of the patient.
16

17. OUTPATIENT OBSERVATION SERVICES
Calculation of Hours
Observation time begins at the clock time documented in the patient’s
medical record, which coincides with the time that observation care is
initiated in accordance with a physician’s order.
Observation time ends when all medically necessary services related to
observation care are completed. For example, this could be before
discharge when the need for observation has ended, but other
medically necessary services not meeting the definition of observation
care are provided (in which case, the additional medically necessary
services would be billed separately or included as part of the
emergency department or clinic visit)
Hospitals should round to the nearest hour.
17

18. OUTPATIENT OBSERVATION SERVICES
Calculation of Hours
Observation services should not be billed concurrently with diagnostic
or therapeutic services for which active monitoring is a part of the
procedure (e.g., colonoscopy, chemotherapy).
In situations where such a procedure interrupts observation services,
hospitals would record for each period of observation services the
beginning and ending times during the hospital outpatient encounter
and add the length of time for the periods of observation services
together to reach the total number of units reported on the claim for
the hourly observation services HCPCS code G0378 (Hospital
observation service, per hour).
– Medicare Claims Processing Manual
18

19. OUTPATIENT OBSERVATION SERVICES
Calculation of Hours
Observation time ends when all medically necessary services related to
observation care are completed. For example, this could be before
discharge when the need for observation has ended, but other
medically necessary services not meeting the definition of observation
care are provided (in which case, the additional medically necessary
services would be billed separately or included as part of the
emergency department or clinic visit).
Alternatively, the end time of observation services may coincide with
the time the patient is actually discharged from the hospital or
admitted as an inpatient.
– Medicare Claims Processing Manual
19

20. OUTPATIENT OBSERVATION SERVICES
HCPCS/CPT requirements
Hospitals should report G0378 when observation services are provided
to patients receiving outpatient observation services. The numbers of
units reported are equal to the number of hours in observation. If the
period of observation spans more than 1 calendar day, all of the hours
for the entire period of observation must be included on a single line
and the date of service for that line is the date that observation care
begins.
Hospitals should report G0379 when observation services are the
result of a direct admission into outpatient observation services
without an associated emergency room visit, hospital outpatient clinic
visit, or critical care service on the day of initiation of outpatient
observation services.
Revenue Codes 0760 or 0762 may be used on the UB0413X bill type to
report observation services.
20

21. OUTPATIENT OBSERVATION SERVICES
21

22. INFUSIONS AND INJECTIONS
Infusion therapy and injections can include both chemotherapeutic and non-
chemotherapeutic pharmaceuticals.
To report, refer to CPT Codes 96360 – 96549
UB-04 revenue codes are specific to the type of therapy (e.g. chemo – 0335)
A hierarchy was created for facilities to report infusion therapy services.
The initial code should be selected using a hierarchy whereby chemotherapy services are
primary to therapeutic, prophylactic, and diagnostic services which are primary to hydration
services.
Infusions are primary to pushes, which are primary to injections.
Facilities are to follow this hierarchy and it supersedes
parenthetical instructions for add-on codes that suggest an
add-on of a higher hierarchical position may be reported in
conjunction with a base code of a lower position.
22

23. INFUSIONS AND INJECTIONS
Additional Coding Tips:
If performed to facilitate the infusion or injection, the following services
are included and are not reported separately:
Use of local anesthesia
IV start
Access to indwelling IV, subcutaneous catheter or port
Flush at conclusion of infusion
Standard tubing, syringes, and supplies
Preparation of chemotherapy agents
When multiple drugs are administered, report the service(s) and the
specific materials or drugs for each.
Don’t report infusion for fluids used to administer a drug.
This also includes the administration of fluid to maintain IV line patency during
blood transfusions.
23

24. INFUSIONS AND INJECTIONS
Additional Coding Tips:
When administering multiple infusions, injections or combinations, only
one “initial” service code should be reported, unless protocol requires that
two separate IV sites must be used.
If an injection or infusion is of a subsequent or concurrent nature, even if it is
the first such service within that group of services then a subsequent or
concurrent code from the appropriate section should be reported, e.g., the
first IV push given subsequent to an initial one-hour infusion is reported using
a subsequent IV push code.
It is important to remember that injections are coded per injection, not per
medication.
When reporting codes based on infusion time, use the actual time over
which the infusion is administered.
24

25. INFUSIONS AND INJECTIONS
Additional Coding Tips:
Length of time, calculated by the start and stop times, determines whether
a procedure is coded as an infusion or injection. To ensure accurate coding
and billing, providers must understand the start and stop documentation
requirement. Any infusion less than 15 minutes should be coded as an
intravenous push injection.
In the absence of start and stop time, providers may only request
reimbursement at the IV push level.
Fluid used to administer the drug(s) is considered incidental hydration and
is not separately reportable.
If documentation supports a clinical condition that warrants hydration,
other than one brought about by the requirements of a procedure, the
hydration can be separately billable.
25

26. INFUSIONS AND INJECTIONS
Additional Coding Tips:
Outpatient visits (E/M CPTs 99201- 99215) can be reported in the infusion
center setting when identified as a separate and distinct service.
The basic assessment and monitoring of the patient pre and post
injection/infusion is inherent in the procedure and not considered to be
separate and distinct.
When patients receive therapeutic treatment in the outpatient setting, the
first-listed code should represent the diagnosis, condition, problem or other
reason for the encounter/visit that is chiefly responsible for the outpatient
services provided.
The only exception to this rule is that when the primary reason for the
encounter is chemotherapy, radiation therapy or rehabilitation, the
appropriate V-code for the service should be sequenced as the first-listed code
and the diagnosis or problem for which the service is provided is coded in
subsequent positions. - V58.11, “Encounter for antineoplastic chemotherapy”,
or V58.12, “Encounter for antineoplastic immunotherapy”
26

27. PHARMACEUTICALS
Hospitals must report all appropriate HCPCS codes and charges for separately
payable drugs, in addition to reporting the applicable drug administration
codes.
Hospitals should also report the HCPCS codes and charges for drugs that are
packaged into payments for the corresponding drug administration or other
separately payable services.
Drugs are billed in multiples of the dosage specified in the HCPCS code long
descriptor.
If the drug dose used in the care of a patient is not a multiple of the HCPCS code
dosage descriptor, the provider rounds to the next highest unit based on the HCPCS
long descriptor for the code in order to report the dose provided.
If the full dosage provided is less than the dosage for the HCPCS code descriptor
specifying the minimum dosage for the drug, the provider reports one unit of the
HCPCS code for the minimum dosage amount.
27

28. PHARMACEUTICALS
Several outpatient drugs are classified as self-administrable and are not
covered by Medicare.
The only ordinarily noncovered, self-administered outpatient drugs covered under
Medicare are insulin administered in an emergency situation to a patient in a
diabetic coma and antiemetics in limited situations.
Oral radiopharmaceuticals can be captured and billed.
Each line item billed as not covered or associated with an ABN must be identified
with a HCPCS code and associated modifier. This includes all OPPS packaged items
and those items traditionally not billed with HCPCS codes in the past.
Report the most specific HCPCS code available to describe the item or service. If no
specific HCPCS code exists, report HCPCS code A9270, “Non covered item/service”
with revenue code 0637.
Outpatient claims submitted with a revenue code 0637 without a HCPCS will
be returned to the provider.
28

29. PHARMACEUTICALS
CY2011 CMS OPPS Update
Reporting Pharmaceuticals
CMS continues to strongly urge hospitals to report charges for all
drugs, biologicals, and radiopharmaceuticals, regardless of whether the
items are paid separately or packaged, using the correct HCPCS codes
for the items used.
CMS also restates that “It is also of great importance that hospitals
billing for these products make certain that the reported units of service
of the reported HCPCS codes are consistent with the quantity of a drug,
biological, or radiopharmaceutical that was used in the care of the
patient.”
29

30. PHARMACEUTICALS
CY2011 CMS OPPS Update
Reporting Pharmaceuticals
CMS reminded hospitals, “If two or more drugs or biologicals are mixed
together to facilitate administration, the correct HCPCS codes should be
reported separately for each product used in the care of the patient. The mixing
together of two or more products does not constitute a “new” drug as
regulated by the Food and Drug Administration (FDA) under the New Drug
Application (NDA) process. In these situations, hospitals are reminded that it is
not appropriate to bill HCPCS code C9399. HCPCS code C9399, Unclassified drug
or biological, is for new drugs and biologicals that are approved by the FDA on
or after January 1, 2004, for which a HCPCS code has not been assigned. Unless
otherwise specified in the long description, HCPCS code descriptors refer to the
non-compounded, FDA-approved final product. If a product is compounded and
a specific HCPCS code does not exist for the compounded product, the hospital
should report an appropriate unlisted code such as J9999 or J3490.”
30

31. PHARMACEUTICALS
CY2011 CMS OPPS Update
New Codes
For 2011, fourteen new HCPCS codes that are eligible for separate
payment have been created for reporting drugs and biologicals in the
hospital outpatient setting:
C9274 Crotalidae Polyvalent Immune Fab (Ovine), 1 vial
C9275 Injection, hexaminolevulinate hydrochloride, 100 mg, per study
dose
C9276 Injection, cabazitaxel, 1 mg
C9277 Injection, alglucosidase alfa (Lumizyme), 1 mg
C9278 Injection, incobotulinumtoxin A, 1 unit
C9279 Injection, ibuprofen, 100 mg
J0638 Injection, canakinumab, 1 mg
J1559 Injection, immune globulin (Hizentra), 100 mg
31

32. PHARMACEUTICALS
CY2011 CMS OPPS Update
New Codes
J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g.,
liquid), not otherwise specified, 500 mg
J2358 Injection, olanzapine, long-acting, 1 mg
J7196 Injection, antithrombin recombinant, 50 IU
J7309 Methyl aminolevulinate (mal) for topical administration, 16.8%, 10
mg
Q4118 Matristem micromatrix, 1 mg
Q4121 Theraskin, per square centimeter
32

33. PHARMACEUTICALS
CY2011 CMS OPPS Update
New Codes
J1599 Injection, immune globulin, intravenous, non-lyophilized (e.g.,
liquid), not otherwise specified, 500 mg
J2358 Injection, olanzapine, long-acting, 1 mg
J7196 Injection, antithrombin recombinant, 50 IU
J7309 Methyl aminolevulinate (mal) for topical administration, 16.8%, 10
mg
Q4118 Matristem micromatrix, 1 mg
Q4121 Theraskin, per square centimeter
33

34. DIAGNOSTIC CARDIOLOGY
Diagnostic cardiology includes diagnostic non-invasive testing; such as,
electrocardiograms and echocardiograms.
CPT Coding is fairly straightforward for each test.
Report the technical service only, “without interpretation and report”
The units of service are “1” per test.
Routine electrocardiographic monitoring during surgery does not constitute a
separate charge.
A specific order must be present in documentation, along with a separate, signed,
written, and retrievable report.
Reviewing strips from a telemetry monitoring system is not enough
– “I saw a blip!”, Nurse Sally
The UB revenue code required for reporting comes from 48X. Most providers
default to the general classification of 0480.
34

35. DIAGNOSTIC CARDIOLOGY
CY2011 CPT Updates
Deleted Codes
93012, “Telephonic transmission of post-symptom electrocardiogram
rhythm strip(s), 24 hour attended monitoring, per 30 day period of
time; tracing only”
93014 – physician review with interpretation and report only
To report telephonic transmission of post-symptom electrocardiogram
rhythm strips, see 93268-93272
35

36. DIAGNOSTIC CARDIOLOGY
CY2011 CPT Updates
Revised Codes
93224, “External electrocardiographic recording up to 48 hours by
continuous rhythm recording and storage; includes recording, scanning
analysis with report, physician review and interpretation”
93225 – recording (includes connection, recording and
disconnection)
93226 – scanning analysis with report
93227 – physician review and interpretation
Revised to describe external electrocardiographic recording for up to
48 hours
The term “wearable” has been replaced with “external” for
consistency with other codes.
36

37. DIAGNOSTIC CARDIOLOGY
CY2011 CPT Updates
Revised Codes
93228, “External mobile cardiovascular telemetry with
electrocardiographic recording, concurrent computerized real time
data analysis and greater than 24 hours of accessible ECG data storage
(retrievable with query) with ECG triggered and patient selected events
transmitted to a remote attended surveillance center for up to 30 days;
physician review and interpretation with report”
93229 – technical support for connection and patient instructions
for use, attended surveillance, analysis and physician prescribed
transmission of daily and emergent data reports
The term “wearable” has been replaced with “external” for consistency
with other codes.
37

38. DIAGNOSTIC CARDIOLOGY
CY2011 CPT Updates
Deleted Codes
93230, “Wearable electrocardiographic rhythm derived monitoring for
24 hours by continuous original waveform recording and storage
without superimposition scanning utilizing a device capable of
producing a full miniaturized printout; includes recording,
microprocessor-based analysis with report, physician review and
interpretation”
93231 – recording (includes connection, recording, and
disconnection)
93232 – microprocessor-based analysis with report
93233 – physician review and interpretation
To report external electrocardiographic rhythm derived monitoring for
up to 48 hours, see 93224-93227
38

39. DIAGNOSTIC CARDIOLOGY
CY2011 CPT Updates
Deleted Codes
93235, “Wearable electrocardiographic rhythm derived monitoring for
24 hours by continuous computerized monitoring and non-continuous
recording, and real-time data analysis utilizing a device capable of
producing intermittent full-sized waveform tracings, possibly patient
activated; includes monitoring and real-time data analysis with report,
physician review and interpretation”
93236 – monitoring and real-time data analysis report
93237 – physician review and interpretation
To report external electrocardiographic rhythm derived monitoring for
up to 48 hours, see 93224-93227
39

40. DIAGNOSTIC CARDIOLOGY
CY2011 CPT Updates
Revised Codes
93268, “External patient and, when performed, auto activated
electrocardiographic rhythm derived event recording with symptom-
related memory loop with remote download capability up to 30 days,
24 hours attended monitoring; includes transmission, physician review
and interpretation”
93270 – recording (includes connection, recording, and
disconnection)
93271 – transmission download and analysis
93272 – physician review and interpretation
The term “wearable” has been replaced with “external” for consistency
with other codes.
40

41. RESPIRATORY/PULMONARY
Respiratory and pulmonary services are found in CPT range 94010–94799.
Services include laboratory procedure(s) and interpretation of test results.
If a separate identifiable evaluation and management (E/M) service is
performed, the appropriate E/M service code should be reported in addition
these services.
The respiratory therapy/pulmonary function chargemaster may include
procedures, therapies and supplies.
Services have great potential to be confusing and lend to errors in coding and
charge capture.
Common issues are found across facilities nationwide.
41

42. RESPIRATORY/PULMONARY
General Coding Tips:
Spirometry and flow loop should not be reported together.
When spirometry is performed, this includes vital capacity and/or
maximum voluntary ventilation.
Spirometry with bronchodilator includes a pre and post spirometry.
The demonstration and/or evaluation of patient utilization of an aerosol
generator, nebulizer, metered dose inhaler or intermittent positive
pressure breathing (IPPB) device can only be reported once per day.
42

43. CARDIAC AND PULMONARY REHABILITATION
Cardiac and pulmonary rehabilitation are covered services under CMS, with
specific requirements for HCPCS/CPT coding,, diagnoses and frequency
limitations.
Element Cardiac Rehabilitation Pulmonary Rehabilitation
HCPCS/CPT 93797, 93798 G0424
Diagnoses Acute MI, CABG, Stable Moderate to Severe COPD
Angina, Heart Valve
Repair/Replacement, PTCA,
Heart or Heart/Lung
Transplant
Frequency 2-1 hour sessions/day 2-1 hour sessions/day
36 sessions up to 36 weeks 36 sessions
Services are required to be provided under direct physician supervision.
http://www.cms.gov/manuals/downloads/clm104c32.pdf
43

44. SURGICAL SERVICES
Surgical services are found in the range of CPTs 10000 – 69990
some Category III
G-codes
HIM often will not “code per payer”
Typically captured through use of time-based codes, but no standard
methodology is found.
Involves soft-coding processes
Exception may exist with minor surgical procedures performed in ED, Clinic
or Radiology procedures
Examples: breast biopsies, wound care, intubation, gastric lavage
Pricing includes routine costs ,equipment, overhead, etc.
44

45. SURGICAL SERVICES
CY2011 CMS Updates
Number of updates made including additions, revisions and deletions.
Minimal number of the changes are found ton include procedures that can
either be found hard-coded in the CDM
All CPT updates can be provided in a separate presentation to the group.
45

46. SURGERY - INTEGUMENTARY
Extensive revisions to the integumentary system by removing the term
“excisional debridement” and replacing with only the term “debridement”
Guidelines have been expanded to define wound debridement and
surface area related to debridement of the subcutaneous tissue,
biofilm, epidermis, dermis, muscle, &/or fascia.

47. DEBRIDEMENT
Revision Example – Integumentary:
Editorially revised for standardization of the nomenclature describing
debridement including removal of foreign material at the site of an open
fracture &/or an open dislocation
11010 – Debridement including removal of foreign material at the site of
an open fracture &/or an open dislocation (eg, excisional debridement);
skin and subcutaneous tissues
Old – Debridement including removal of foreign material associated
with open fracture(s) &/or dislocation(s); skin and subcutaneous tissues
11011 – skin, subcutaneous tissue, muscle fascia, and muscle
11012 – skin, subcutaneous tissue, muscle fascia, muscle, and bone

48. DEBRIDEMENT
Deleted codes:
11040 – Debridement; skin partial thickness
11041 skin, full thickness
For debridement of skin, ie epidermis &/or dermis only, see 97597, 97598
Revised codes:
11042, 11043, 11044 - Revised by surface area and depth, and the depth
was further split into 4 levels of wound surface. Also uniformly include a
20 sq cm with add-on codes for additional services.
New codes:
11045, 11046, 11047 - Add-on codes to report each additional 20 sq cm, or
part thereof

49. SURGERY-MUSCULOSKELETAL
Deleted code:
20000 – incision of soft tissue abscess; superficial
Deleted due to overlap and intent of the cutaneous/subcutaneous
codes
To report incision and drainage procedures, cutaneous/subcutaneous,
see 10060, 10061
Revised code:
20005 – Incision and drainage of soft tissue abscess, subfascial (ie, involved
the soft tissue below the deep fascia)
Editorially revised to define the depth of the incision and drainage as
“subfascial” instead of “deep”

50. RESPIRATORY
New code:
Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when
performed, diagnostic, with cell washing, when performed
31634 – with balloon occlusion, with assessment of air leak, with
administration of occlusive substance (eg, fibrin glue), if performed
New code to describe a bronchoscopic technique that has been
performed in the past as part of a last effort to resolve persistent
broncho-pleural fistulas. It is becoming more common as an earlier
therapy for the disease.

51. RESPIRATORY
New codes:
31295 – Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus
ostium (eg, balloon dilation), transnasal or via canine fossa)
31296 – with dilation of frontal sinus ostium (eg, balloon dilation)
31297 – with dilation of sphenoid sinus ostium (eg, balloon dilation)
Created to describe the dilation of sinus ostia by displacement of tissue
utilizing any method

52. RADIATION ONCOLOGY
The process of treating a patient with radiation involves five basic steps:
Consult or new patient exam
Treatment planning
Simulation and Dosimetry
Treatment delivery and management
Follow up
Documentation to support the medical necessity of all procedures and
complementary services must be maintained in the patient’s medical record.
Planned course of therapy
Type and delivery of treatment
Level of clinical management involved
Ongoing documentation of any changes in the course of treatment.
52

53. RADIATION ONCOLOGY
Examples of documentation include, but are not limited to:
Treatment plan for course of therapy
Type and method of delivery of therapy
Clinical management notes
Simulation – request, level, devices, medical necessity, and location
performed
Physics/Dosimetry – calculations and signatures, isodose plans, special
dosimetry, special consults, etc.
Treatments
Procedure notes
Treatment devices
53

54. RADIATION ONCOLOGY
General Coding and Billing Tips
Date of Service
Since a number of services are considered to be components of major
services performed for treatment planning and delivery, it is necessary
that all services billed include the date of service documented in the
medical record.
Treatment Planning
Treatment planning is generally only reported once for a given course
of treatment since it is directly tied to the course of therapy and to the
site(s) where the therapy will be provided.
A different problem necessitating a new course of radiation therapy
will justify the charge for another treatment planning code.
If additional plans are done, the specific reason for the additional plan
must be documented.
54

55. RADIATION ONCOLOGY
General Coding and Billing Tips
Simulation
Documentation of simulation requires a written record of the
procedure and hardcopy of electronic images and evidence of image
review by physicians including signature or initials and data review.
Dosimetry
The typical course of radiation therapy may require from one to six
dosimetry calculations, depending upon the complexity of the patient's
problem.
Medicare would expect to see documentation in the patient's medical
record that would include any changes in dosimetry calculations and
change in radiation treatment and frequency.
55

56. RADIATION ONCOLOGY
General Coding and Billing Tips
Teletherapy Isodose Plan
The typical course of radiation therapy will require from one to three
isodose plans.
Usually only one plan per volume of interest will be sufficient,
though some patients may require multiple teletherapy plans
during the course of therapy.
Situations that may require an extra teletherapy plan include the
need to change the machine or the volume of interest.
Toward the end of treatment, due to clinical variations of the
patient, another plan may be required.
56

57. RADIATION ONCOLOGY
General Coding and Billing Tips
Teletherapy Isodose Plan
While multiple plan calculations may be required for a given
condition, the one chosen for optimal therapy is the only one that
can be charged.
Only one isodose plan may be reported for a given course of
therapy to a specific treatment area; however, additional
isodose plans may be reported if fields or equipment are
changed for medically necessary conditions.
The addition of a boost, requiring a separate isodose plan, is
separately coded and billed.
57

58. RADIATION ONCOLOGY
General Coding and Billing Tips
Special Teletherapy Port Plan
This service is considered medically necessary only when a plan for a
special beam consideration is required.
Only one plan should be billed per treatment course.
Special Dosimetry
This service is considered medically necessary once per port when the
physician determines that it is necessary to have a measurement of the
amount of radiation that a patient has actually received at a given
point with the final results being utilized to accept or modify the
current treatment plan.
When special dosimetry is employed, the usual frequency will vary
from one to four times during the radiation course.
58

59. RADIATION ONCOLOGY
General Coding and Billing Tips
Treatment Devices
If devices of two separate levels of complexity are used for the same
treatment port, only the device of the highest complexity will be
billable – unless each device has been custom designed for that port.
An individual treatment device may be reported and charged only one
time for the entire course of therapy.
Items that are not billable as treatment devices include sandbags,
pulleys, passive restraints, sponges and pads, armrests, pillows, T-bar,
leg immobilizers.
59

60. RADIATION ONCOLOGY
General Coding and Billing Tips
Physics Planning
Procedure code 77336 can be billed if detailed documentation in the
medical record reflects that all aspects of the patient’s care has been
reviewed and appropriate recommendations have been made as a
result of that review.
A "week" consists of five treatments. The date of service billed for
77336 must be the same date as the last treatment for that week.
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61. RADIATION ONCOLOGY
General Coding and Billing Tips
Special Physics Consultation
Capture for consultative purposes when a problem or special situation arises
during radiation therapy. The procedure requires a detailed written report by
the physicist to the radiation oncologist with reference to the problem being
addressed.
This is not routinely assigned for complex services, such as all 3D services or for
IMRT planning.
Some examples of cases where a special physics consult would be requested
are:
analysis of customized beam modification devices and special blocking
procedures to protect critical organs during treatment
plan development for multiple primary cancers, treated simultaneously
analysis and recommendations for transplanted organ protection
61

62. RADIATION ONCOLOGY
General Coding and Billing Tips
Port Films
CPT code 77417 is a technical service only. No modifier is required.
Documentation in the medical record must verify that the port films were done
as per the physician order.
The date, location and views of the films along with the name of the radiology
technician who performed the imaging must be documented in the medical
record
Port films should be reported as one charge per five fractions of therapy per
portal regardless of the number of films required. Additional films may be
necessary if the patient’s clinical status changes.
62

63. RADIATION ONCOLOGY
General Coding and Billing Tips
Stereotactic Radiosurgery
For non-Medicare claims CPT codes 77371–77373, and 77432 may be
used to report stereotactic radiosurgery (SRS).
For Medicare claims, report SRS planning with the available CPT
treatment planning codes that most accurately reflect the services
provided, regardless of the mode of treatment delivery planned.
For Medicare claims, the reporting of SRS delivery depends on the
mode of treatment.
Report CPT code 77371 for multisource photon (cobalt-60) SRS, delivery including
collimator changes and custom plugging, complete course of treatment, all lesions
HCPCS code G0173 is used to report linear accelerator based SRS, delivery including
collimator changes and custom plugging, complete course of treatment in one
session, all lesions.
63

64. RADIATION ONCOLOGY
General Coding and Billing Tips
Stereotactic Radiosurgery
Report HCPCS code G0339 for image-guided robotic linear accelerator
based SRS, including collimator changes and custom plugging, complete
course of treatment in one session or first session of a fractionated
treatment.
HCPCS code G0251 is used to report linear accelerator based SRS, delivery
including collimator changes and custom plugging, fractionated
treatment, all lesions, per session, maximum of five sessions per course of
treatment.
Report HCPCS code G0340 for image-guided robotic linear accelerator
based SRS, including collimator changes and custom plugging, second
through fifth sessions, maximum of five sessions per course of treatment.
64

65. RADIATION ONCOLOGY
General Coding and Billing Tips
Intensity modulation radiation therapy (IMRT)
Hospitals should report CPT code 77301 for IMRT planning. IMRT
treatment delivery is reported using CPT code 0073T or 77418.
Hospitals should bill CPT code 77418 for multileaf collimator-based
IMRT delivery and category III CPT code 0073T for compensator-based
IMRT delivery.
Payment for IMRT planning does not include payment for CPT codes
77332–77334 when furnished on the same day.
When services described by CPT codes 77332–77334 are furnished on
the same date of service with 77301, these services should be billed in
addition to the CPT IMRT planning code 77301.
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66. RADIATION ONCOLOGY
General Coding and Billing Tips
Intensity modulation radiation therapy (IMRT)
Hospitals billing for both IMRT treatment planning, CPT code 77301,
and design and construction of complex treatment devices, CPT code
77334, on the same day should append modifier 59 to CPT code 77334.
Hospitals may report other services, CPT codes from range 77401–
77416, or 77418, if they are performed at different treatment sessions
on the same day as IMRT. Append modifier 59 to the appropriate
codes.
66

67. RADIATION ONCOLOGY
CY2011 OPPS Update
Intensity modulation radiation therapy (IMRT)
Hospitals billing for both IMRT treatment planning, CPT code 77301,
and design and construction of complex treatment devices, CPT code
77334, on the same day should append modifier 59 to CPT code 77334.
Hospitals may report other services, CPT codes from range 77401–
77416, or 77418, if they are performed at different treatment sessions
on the same day as IMRT. Append modifier 59 to the appropriate
codes.
67

68. REFERENCES
Federal Register Final Rule for CY2011
http://edocket.access.gpo.gov/2010/pdf/2010-27926.pdf
CMS Addendum A and B Updates
http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage
CMS Internet Only Manuals
http://www.cms.gov/Manuals/IOM/list.asp
CMS Transmittals
http://www.cms.gov/Transmittals/2011Trans/list.asp
CMS Frequently Asked Questions
http://questions.cms.hhs.gov/
CMS HCPCS File
http://www.cms.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp#TopOfPage
68

69. REFERENCES
CMS Device to Procedure & Radiopharmaceutical Edits
http://www.cms.gov/HospitalOutpatientPPS/02_device_procedure.asp#TopOfPage
CMS Integrated Outpatient Code Editor
http://www.cms.gov/OutpatientCodeEdit/
69

70. THANK YOU!

71. PRESENTER INFORMATION
Caroline Rader, MBA, MSHCA, CHC
Associate Director, Navigant Consulting
caroline.rader@navigantconsulting.com
410-463-9867
Deborah S. Zarick, R.N., BSN, CPC, CCS-P, CEMC, CPC-I, CPMA
Associate Director, Navigant Consulting
debbie.zarick@navigantconsulting.com
484-764-6688