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MIR-2006-6AB, June 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Processing of Outpatient Prospective Payment System (OPPS) Claims with Certain Drug Administration Code Pairs
Provider Types Affected
Providers submitting claims to Medicare fiscal intermediaries (FIs) for drug administration services
Provider Action Needed
Impact to You
This special edition article is being provided by the Centers for Medicare & Medicaid Services (CMS) to address concerns about Correct Coding Initiative (CCI) edits on coding for drug administration services under the Outpatient Prospective Payment System (OPPS).
What You Need to Know
Change Request (CR) 5011 (Transmittal 896) instructed FIs to implement CCI edits (Version 12.0) for drug administration services paid under the OPPS and furnished on or after April 1, 2006. When an OPPS claim triggers a CCI edit, the entire claim is not rejected or returned. Instead, only one line item is rejected (i.e., the CCI edits identify pairs of codes that are not appropriately reported together unless an edit permits use of a modifier to signal that the codes represent separate and distinct services/procedures). Hospitals have subsequently expressed concerns about the impact of these CCI edits on coding for drug administration services under the OPPS, and this special edition instructs your FI regarding resolution to these concerns.
What You Need to Do
See the Background and Additional Information sections of this article for further details.
Background
CMS updated payment policies for drug administration services furnished under the Hospital OPPS in the Medicare Claims Processing Manual (Pub. 100-04, Chapter 4, Section 230) with CR4258 (Transmittal 785CP, dated December 16, 2005; http://www.cms.hhs.gov/transmittals/downloads/R785CP.pdf  ) effective January 1, 2006. Subsequently, the updated payment policies contained in the manual revision generated requests to clarify the new manual language.
Therefore, in order to support continued hospital implementation efforts of correct coding concepts for drug administration services, CMS added clarifying language to the existing policies in the Medicare Claims Processing Manual (Pub.100-04, Chapter 4, Section 230) with the release of CR4388 (Transmittal 902, dated April 7, 2006; http://www.cms.hhs.gov/transmittals/downloads/R902CP.pdf ) effective January 1, 2006.
Issue
CMS instructed FIs to implement Version 12.0 of the CCI edits for drug administration services paid under the OPPS and furnished on or after April 1, 2006, in CR5011 (Transmittal 896, dated March 24, 2006; http://www.cms.hhs.gov/transmittals/downloads/R896CP.pdf ) effective April 1, 2006.
When an OPPS claim triggers a CCI edit, the entire claim is not rejected or returned. Instead, only one line item is rejected. That is, the CCI edits identify pairs of codes that are not appropriately reported together unless an edit permits use of a modifier to signal that the codes represent separate and distinct services/procedures.
Hospitals have subsequently expressed concerns about the impact of these CCI edits on coding for drug administration services under the OPPS.
Solution
To address these concerns, CMS is providing this special edition article to instruct FIs to:
- Institute a process (via the claims processing system used by the FIs) that will add Healthcare Common Procedure Coding System (HCPCS) modifier -59 (Distinct Procedural Service; http://www.cms.hhs.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf ), where appropriate, to the line item containing the HCPCS code in column 2 of the following code pairs (reported with dates of service on or after April 1, 2006 through June 30, 2006) to enable claims to process to payment without triggering a line item rejection and CCI edit.
| HCPCS Codes |
| Column 1 |
Column 2 |
C8950 |
C8952 |
C8953 |
C8950 |
C8953 |
C8952 |
C8954 |
C8950 |
C8954 |
C8952 |
C8954 |
C8953 |
- After the previous step has been taken, FIs should notify providers that they may submit adjustment bills to receive payment if one of the codes in any of the above code pairs has been rejected for payment.
Note: Version 12.1 of the CCI edits (which will be incorporated in the July 2006 OPPS Outpatient Code Editor (OCE) update) will not include CCI edits for the six code pairs listed above.
Additional Information
If you have any questions, please contact your intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: SE0635
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A
Related CR Transmittal #: N/A
Implementation Date: N/A
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