Monday, July 25, 2016

Billing Guide for partial hospitalization

Partial Hospitalization

• Submit partial hospitalization services with the following revenue codes:

• 0912, 0913 or 0915

o If a separate contract for the hospital and psych DPU are in effect, submit partial hospitalization services and inpatient services on separate UB-04 claim forms.

• Florida Blue considers partial hospitalization to be an outpatient service.

• Partial hospitalization for psychiatric or substance abuse admissions is calculated as follows:

o Partial Days (including beginning and ending dates) x Per Diem.


DRGs are statistically meaningful medical groupings used for the purpose of categorization and reimbursement of hospital services.
• DRGs allow for more uniform billing based upon the member’s diagnosis and procedures, age, sex, and discharge status.

• Reimbursement for DRG cases is based on discharge date.

• Exception: A newly established participating provider, under a DRG contract, will have the first year of claims reimbursed based on the admission date of the inpatient claim.

• Deaths and transfers are reimbursed based on the assigned DRG and payment hierarchy logic. There are no special reimbursement arrangements applicable to deaths and transfers.

• A list of DRGs, along with length of stay trim points and relative weights, is contained in your hospital’s Agreement.

Outlier Cases

Outlier cases are exceptions to typical inpatient DRG cases. Refer to your Agreement for which outlier method applies.
There are three types of outlier cases but not limited to:

• Low length of stay outlier - Low Length is a case in which the member stays in the hospital fewer days than the low length of stay trim point.

• High length of stay outlier - High Length is a case in which the member stays in the hospital a greater number of days than the high length of stay trim point.

• High charge outlier- High charge is a case in which total covered charges exceed the high charge threshold.

Saturday, July 23, 2016

CPT CODE G0296, G0297 COVERAGE and payment Guide

Health Care Common Procedure Coding System (HCPCS) Codes

Effective for claims with dates of service on and after February 5, 2015, the following HCPCS codes are used for lung cancer screening with LDCT:

** G0296 – Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)

** G0297 – Low dose CT scan (LDCT) for lung cancer screening

In addition to the HCPCS code, these services must be billed with ICD-10 diagnosis code Z87.891 (personal history of tobacco use/personal history of nicotine dependence), ICD-9 diagnosis code V15.82.

NOTE: Contractors shall apply contractor-pricing to claims containing HCPCS G0296 and G0297 with dates of service February 5, 2015, through December 31, 2015. 

CMS reviewed the evidence for lung cancer screening with low dose computed tomography (LDCT) and determined that the criteria listed above were met, enabling CMS to cover this “additional preventive service” under Medicare Part B.

CMS issued NCD 210.14 on August 21, 2105, that provides for Medicare coverage of screening  for lung cancer with LDCT. Effective for claims with dates of service on and after February 5, 2015, Medicare beneficiaries must meet all of the following criteria:

** Be 55–77 years of age;
** Be asymptomatic (no signs or symptoms of lung cancer);
** Have a tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
** Be a current smoker or one who has quit smoking within the last 15 years; and,
** Receive a written order for lung cancer screening with LDCT that meets the requirements described in the NCD.

Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary’s medical record, and must contain the following information:

** Date of birth;
** Actual pack–year smoking history (number);
** Current smoking status, and for former smokers, the number of years since quitting smoking;
** A statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and,
** The National Provider Identifier (NPI) of the ordering practitioner.

Counseling and Shared Decision-Making Visit

Before the first lung cancer LDCT screening occurs, the beneficiary must receive a written order for LDCT lung cancer screening during a lung cancer screening counseling and shared decision-making visit that includes the following elements and is appropriately documented in the beneficiary’s medical records:

** Must be furnished by a physician (as defined in section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) as defined in section1861(aa)(5) of the Act); and

** Must include all of the following elements:

o Determination of beneficiary eligibility including age, absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;

o Shared decision-making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false  positive rate, and total radiation exposure;

o Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of co-morbidities, and ability or willingness to undergo diagnosis and treatment;

o Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions; and,

o If appropriate, the furnishing of a written order for lung cancer screening with LDCT. Written orders for subsequent annual LDCT screens may be furnished during any appropriate
visit with a physician or qualified non-physician practitioner (PA, NP, or CNS)

Wednesday, July 20, 2016

Urgent Care Centers CPT code list

Urgent Care Centers (UCCs0 are the delivery of ambulatory care in a facility dedicated to unscheduled, walk-in care outside a hospital emergency department.

Billing Requirements

• Place of service "11" or "20"

• UCCs are reimbursed based on the following E/M CPT codes per the provider’s agreement:

o Level 1

° 99201

° 99202

° 99211

° 99212

o Level 2

° 99203

° 99213

o Level 3

° 99204

° 99205

° 99214

° 99215

• UCCs should itemize all services rendered to the member, including the E/M code.

• To ensure appropriate reimbursement when rendering additional services (i.e., sutures, basic diagnostics, imaging and laboratory tests), the modifier 25 should be applied to the appropriate E/M code.

Monday, July 18, 2016

Revenue code list with description

The following chart identifies revenue codes that require a specific CPT/HCPCS code in field 44 of the UB-04.

Revenue Code        Description           CPT/HCPCS Code

0300 - 0309        Laboratory – Clinical Diagnostic      Code for lab procedure performed

0310 - 0319      Laboratory - Pathology     Code for pathology procedure performed

0320 - 0329           Radiology - Diagnostic      Code for radiology procedure performed

0333                Radiology - Therapeutic   Code for therapeutic radiology procedure performed

0340 - 0349            Nuclear Medicine        Code for nuclear medicine procedure performed

0350 - 0359          CT Scan          Code for CT scan performed

0360 - 0369       Operating Room Services     Code for surgery procedure performed

0400 - 0409       Other Imaging Services     Code for imaging services, such as, mammography, ultrasound, PET, etc.

0450 - 0459         Emergency Room             Code for visit or surgery procedure performed

0460 - 0469              Pulmonary Function        Code for pulmonary function procedure performed

0471                   Audiology                  Code for audiology service performed

Friday, July 15, 2016


Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere (atm) pressure. Either a mono-place chamber pressurized with pure O2 or a larger multi-place chamber pressurized with compressed air where the patient receives pure O2 by mask, head tent, or endotracheal tube may be used.

Hyperbaric Oxygen Therapy serves four primary functions:

It increases the concentration of dissolved oxygen in the blood, which augments oxygenation to all parts of the body; and
It replaces inert gas in the bloodstream with oxygen, which is then metabolized by the body; and
It may stimulate the formation of a collagen matrix and angiogenesis; and
It acts as a bactericide for certain susceptible bacteria.

Developed as treatment for decompression illness, this modality is an established therapy for treating medical disorders such as carbon monoxide poisoning, gas gangrene, acute decompression illness and air embolism. HBO is also considered acceptable as adjunctive therapy in the treatment of sequelae of acute vascular compromise and in the management of some disorders that are refractory to standard medical and surgical care or the result of radiation injury.

Covered Conditions: 

Program reimbursement for HBO therapy is limited to the following conditions:

Acute carbon monoxide intoxication,
Decompression illness,
Gas embolism,
Gas gangrene,
Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.
Progressive necrotizing infections (necrotizing fasciitis),
Acute peripheral arterial insufficiency,
Preparation and preservation of compromised skin grafts (not for primary management of wounds),
Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management,
Osteoradionecrosis as an adjunct to conventional treatment,
Soft tissue radionecrosis as an adjunct to conventional treatment,
Cyanide poisoning,
Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment,
Diabetic wounds of the lower extremities in patients who meet the following three criteria:

a. Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
b. Patient has a wound classified as Wagner grade III or higher; and
c. Patient has failed an adequate course of standard wound therapy.

The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 –days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.


Topical Application of Oxygen

This method of administering oxygen does not meet the definition of HBO therapy as stated above, as its clinical efficacy has not been established. Therefore, Medicare considers the topical application of oxygen not reasonable and necessary. Medicare reimbursement will be limited to therapy that is administered in a chamber (including single or multi-place units)


99183 Hyperbaric oxygen therapy
G0277 Hbot, full body chamber, 30m

Covered ICD-10 diagnoses codes may be downloaded at:, choose the spreadsheet 20.29 HBO Therapy.