CPT code for wound care - 97597, 97598

Billing Guidelines

*A. Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. Active wound care is performed to remove devitalized and/or necrotic tissue to promote healing of a wound on the skin. These services are billed when an extensive cleaning of a wound is needed prior to the application of dressings or skin substitutes placed over or onto a wound that is attached with dressings.
2. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed.
*3. CPT 97597 and/or CPT 97598 are typically used for recurrent wound debridements.
*4. CPT 97597 and/or CPT 97598 are not limited to any specialty.

Coding Guidelines
1. Active wound care, performed with minimal anesthesia is billed with either CPT code 97597 or 97598.

*2. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047.

*3. CPT code 11044 or CPT code 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory care center (ASC).


4. The following HCPCS codes are considered a dressing and therefore bundled into the procedure.

Q4104 Integra BMWD skin sub
Q4105 Integra DRT skin sub
Q4107 Graftjacket skin sub
Q4108 Integra matrix skin sub
Q4110 Primatrix skin sub
Q4111 Gammagraft skin sub
Q4112 Cymetra allograft
Q4113 Graftjacket express allograf
Q4114 Integra flowable wound matri
*Q4115 Alloskin, per square centimeter
*Q4116 Alloderm, per square centimeter
*Q4117 Hyalomatrix, per square centimeter
*Q4118 Matristem micromatrix, 1 mg
*Q4119 Matristem wound matrix, per square centimeter
*Q4120 Matristem burn matrix, per square centimeter
*Q4121 Theraskin, per square centimeter


• Electrical Stimulation and Electromagnetic Therapy of Specified Wounds

For the purposes of this LCD, wound care is defined as care of wounds that are refractory to healing or have complicated healing cycles either because of the nature of the wound itself or because of complicating metabolic and/or physiological factors. This definition excludes the following:
• management of acute wounds, or

• the care of wounds that normally heal by primary intention such as clean, incised traumatic wounds, or
• surgical wounds that are closed primarily and other postoperative wound care not separately payable during the surgical global period.

Various methods to promote wound healing have been devised over time. Physicians and health care providers must understand that many of these methods are expensive and unproven by valid scientific literature, and would be considered investigational. Wound care involves the evaluation and treatment of a wound, including identifying potential causes of delayed wound healing and the modification of treatment when indicated. Wound evaluations may require a comprehensive medical evaluation, vascular evaluation, orthopedic evaluation, functional evaluation, metabolic/nutritional evaluation, and a plan of care. Reduction of pressure and/or control of infection have been shown to facilitate healing and may reduce the need for repeated debridement services.

Medicare coverage for wound care on a continuing basis for a given wound in a given patient is contingent upon evidence documented in the patient's record that the wound is improving in response to the wound care being provided. Evidence of improvement includes measurable changes in the following:

• Drainage
• Inflammation
• Swelling
• Pain and/or tenderness
• Wound dimensions (surface measurements, depth)
• Granulation tissue
• Necrotic tissue/slough
• Tunneling or undermining

Wound care must be performed in accordance with accepted standards for medical and surgical treatment of wounds. The goal of most chronic wound care should be eventual wound closure with or without grafts, skin replacements, or other surgery (such as amputation, wound excision, etc.). Adjunctive measures include but are not limited to appropriate control of complicating factors such as pressure (e.g., off-loading, padding, appropriate footwear), infection, vascular insufficiency, metabolic derangement and/or nutritional deficiency. With appropriate management, it is expected that, in most cases, a wound will reach a state at which its care should be performed primarily by  the patient

and/or the patient’s caregiver with periodic physician assessment and supervision. Wound care that can be performed by the patient or the patient’s caregiver will be considered to be maintenance care. In rare instances, due to severe underlying debility or other factors such as operability, the goal of wound care provided in outpatient settings may be only to prevent progression of the wound.

Dressing Changes for Wound Debridement

• Wet dressings: Water and medication can be applied to the skin with dressings (finely woven cotton, linen, or gauze) soaked in solution. Wet compresses, especially with frequent changes, provide gentle debridement.

• Dry dressings: Used to provide gentle debridement, protect the skin, hold medications against the skin, keep clothing and sheets from rubbing, or keep dirt and air away. Such dressings may also prevent patients from scratching or rubbing the wound.

• Advanced dressings: Used with increasing frequency to provide gentle debridement in the treatment of acute wounds, chronic venous, diabetic and pressure ulcers. A variety of dressings are available including transparent films, foams, hydrocolloids, and hydrogels.

• Dressing changes (removal and subsequent reapplication) alone do not require the skills of physicians, podiatrists, physical therapists, occupational therapists or wound care nurses and in fact are usually performed by non-physician providers.

1. Medicare would expect that wound care may be necessary for the following types of wounds:
o Surgical wounds that must be left open to heal by secondary intention.
o Infected open wounds induced by trauma or surgery.
o Wounds associated with complicating autoimmune, metabolic, vascular or pressure factors.

Active Wound Care Management 

Debridement is indicated whenever necrotic tissue is present on an open wound. Debridement may also be indicated in cases of abnormal wound healing or repair. This procedure includes wound assessment; debridement; application of ointments, creams, sealants, and other wound coverings; and instructions for ongoing care. The routine application of a topical or local anesthetic does not elevate active wound care management to surgical debridement. Debridement may be categorized as selective or non-selective.

o Wound Care Selective Debridement (CPT codes 97597, 97598) includes:

* Removal of specific, targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue by sharp dissection including scissors, scalpel, curettes, and tweezers/forceps. This procedure typically requires no anesthesia and there is generally no bleeding associated with it.

o Wound Care Non-Selective Debridement (CPT code 97602) includes:

* Blunt Debridement: Blunt debridement is the removal of necrotic tissue by cleansing, scraping, chemical application or wet to dry dressing technique. It may also involve the cleaning and dressing of small or superficial lesions. Generally this is not a skilled service and does not require the skills of a physician, podiatrist, therapist, or wound care nurse.

* Enzymatic Debridement: Debridement with topical enzymes is used when the necrotic substances to be removed from a wound are protein, fiber and collagen. The manufacturer’s product insert contains indications, contraindications, precautions, dosage and administration guidelines; it is the clinician’s responsibility to comply with those guidelines.

* Autolytic Debridement: This type of debridement is indicated where manageable amounts of necrotic tissue are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found in wound fluids are sequestered under synthetic dressings.

* Mechanical Debridement: Wet-to-dry or dry-to-dry dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-dry dressings should be used cautiously as maceration of surrounding tissue may hinder healing.

Wound Care Surgical Debridements (CPT codes 11000, 11001, 11004, 11005, 11006, 11008, 11010, 11011, 11012, 11042, 11043, 11044, 11045, 11046, and 11047)

o Conditions that may require surgical debridement of large amounts of skin include: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal infections), severe eczema, bullous skin diseases, extensive skin trauma (including large abraded areas with ground-in dirt), or autoimmune skin diseases (such as pemphigus).

o Surgical debridement occurs only if material has been excised and is typically reported for the treatment of a wound to clear and maintain the site free of devitalized tissue including but not limited to necrosis, eschar, slough, infected tissue, abnormal granulation tissue etc., and should be accomplished to the margins of viable tissue. Surgical excision includes going slightly beyond the point of visible necrotic tissue until viable bleeding tissue is encountered in some cases.

o These procedures can be very effective but represent extensive debridement. They may be complex in nature and may require the use of general anesthesia.

Negative Pressure Wound Care (NPWT), electrically powered (CPT codes 97605, 97606)

o Negative pressure wound therapy (NPWT) is a method of wound care to manage wound exudates and promote wound closure. The vacuum assisted drainage collection (i.e., NPWT) cleanses the wound by removing fluids and stimulates the wound bed, reduces localized edema, and improves local oxygen supply.

o Electrically powered NPWT (CPT codes 97605, 97606) involves the application of controlled or intermittent negative pressure to a properly dressed wound cavity. Suction (negative pressure) is applied under airtight wound dressings to promote the healing of open wounds resistant to prior treatments.

o Electrically powered NPWT (CPT codes 97605, 97606) for nonhealing wounds is medically necessary when at least ONE of the following conditions is met:

* There are complications of a surgically created wound (e.g., dehiscence, post sternotomy disunion with exposed sternal bone, post sternotomy mediastinitis, or postoperative disunion of the abdominal wall).

* There is a traumatic wound (e.g., preoperative flap or graft, exposed bones, tendons, or vessels) and a need for accelerated formation of granulation tissue not achievable by other topical wound treatments (e.g., the individual has comorbidities that will not allow for healing times usually achievable with other available topical wound treatments).

* There is a chronic, nonhealing ulcer with lack of improvement for at least the previous 30 days despite standard wound therapy, including the application of moist topical dressings, debridement of necrotic tissue (if present), maintenance of an adequate nutritional status, and weekly evaluations with documentation of wound measurements (i.e., length, width, and depth) in ONE of the following clinical situations:

- Chronic Stage III or Stage IV pressure ulcer - Chronic diabetic neuropathic ulcer - Chronic venous ulcer Wound care should employ comprehensive wound management including appropriate control of complicating factors such as unrelieved pressure, infection, vascular and/or uncontrolled metabolic derangement, and/or nutritional deficiency in addition to appropriate debridement. Medicare payment for professional wound care procedures requires that all applicable adjunctive measures are also employed as part of comprehensive wound management. Wound care in the absence of such measures, when they are indicated, is not considered to be medically reasonable and necessary.

2. Debridement will be considered not reasonable and necessary for a wound that is clean and free of necrotic tissue or in the absence of abnormal wound healing.

3. Debridements are considered selective or non-selective unless the medical record supports that a surgical excisional debridement was performed.

4. Selective debridement should only be provided under a certified plan of care.

5. Since the overall goal of care is healing and not palliation, it is neither reasonable nor medically necessary to continue a given type of wound care if evidence of wound improvement as outlined in this LCD cannot be shown in two to four weeks.

6. It would not be expected that an individual wound would be repeatedly debrided of skin and subcutaneous tissue because these tissues typically do not regrow very quickly. Such debridements performed more frequently than once a week could be subject to medical review. Coverage for prolonged, repetitive debridement services will be considered through the redetermination process.

The medical record must contain adequate documentation of complicating circumstances to support additional services as reasonable and necessary.

7. Autolytic debridement is contraindicated for infected wounds.

8. Debridement of extensive eczematous or infected skin, represented by CPT codes 11000 and 11001 is not appropriate for debridement of a localized amount of tissue normally associated with a circumscribed lesion. Examples of this are ulcers, furnucles, and localized skin infections.

9. The use of a sharp instrument does not necessarily substantiate the performance of surgical excisional debridement.

10.Surgical debridement will be considered not reasonable and necessary when documentation indicates the wound is without infection, necrosis, devitalized, fibrotic, nonviable tissues or foreign matter and has pink to red granulated tissue. When utilized, it is expected that the frequency of debridement will decrease over time.

11. Wound debridement utilizing experimental or investigational methods are considered not reasonable and necessary. Therefore, it would not be reasonable and necessary to report these services with any CPT code.

12.Investigational treatments are noncovered by Medicare as not medically necessary. The patient can be requested to pay for investigational treatment under waiver of liability provisions of Medicare law, but an Advance Beneficiary Notice must be obtained for the beneficiary to be liable for such payment.

13.When performed in conjunction with another wound care service, the dressing change is considered an integral component of that service and is not separately billable.

14.A wound that shows no improvement after 30 days requires a new approach, which may include a physician reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.

15.Procedures performed for cosmetic reasons or to prepare tissues for cosmetic procedures are statutorily excluded from coverage by Medicare.

16.Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia are included in the reimbursement for wound care services and are not separately payable.

17.The following procedures are considered part of an E/M service or wound care management services, and are not separately covered:

o removal of necrotic tissue by cleansing and dressing, including wet or dry-todry dressing changes;
o cleaning and dressing small or superficial lesions; and
o removal of coagulated serum from normal skin surrounding an ulcer.

18.Disposable non-powered mechanical or single use non-electrically powered or battery powered NPWT (CPT codes 97607, 97608) for any indication is considered not medically reasonable and necessary.

19.NPWT is contraindicated for the following wound types/conditions:

o Necrotic tissue with eschar present
o Untreated osteomyelitis
o Non-enteric and unexplored fistulas
o Malignancy in the wound
o Exposed vasculature
o Exposed nerves
o Exposed anastomotic site
o Exposed organs

CPT feraheme j code , Q0138, Q0139, J1750, 11756, J2916

Ferumoxytol (Feraheme)

Ferumoxytol is covered for the FDA-approved ages – 18 years of age and older.

a. FDA-Approved Indications

Ferumoxytol is covered for all of the following FDA-approved indications:
1. iron deficiency anemia in adult beneficiaries who are hemodialysis dependent with chronic kidney disease (HDD-CKD);
2. iron deficiency anemia in adult beneficiaries who are non-dialysis dependent with chronic kidney disease (NDD-CKD); and
3. iron deficiency anemia in adult beneficiaries who are peritoneal dialysis dependent with chronic kidney disease (PDD-CKD).

Billing Units

The appropriate procedure code(s) used determines the billing unit(s).
1. Ferumoxytol (Feraheme) and iron sucrose (Venofer): 1 billing unit = 1 mg.
2. Iron dextran (INFeD and DexFerrum): 1 billing unit = 50 mg.
3. Sodium ferric gluconate complex in sucrose (Ferrlecit): 1 billing unit = 12.5 mg.
4. Medicaid covers appropriate administration codes when billed with Q0138, Q0139, J1750, J1756, or J2916 on the same day of service.

National drug codes (NDC) 59338-0775-01 Feraheme 510 mg/17 mL, 1 vial 59338-0775-10 Feraheme 510 mg/17 mL, 10 vials

Indication and contraindication

• Feraheme® (ferumoxytol) Injection for intravenous (IV) use is indicated for the treatment of iron deficiency anemia in adult patients with chronic kidney disease.

• Feraheme is contraindicated in patients with known hypersensitivity to Feraheme or any of its components. Warnings and precautions

• Serious hypersensitivity reactions, including anaphylactic-type reactions, some of which have been life-threatening and fatal, have been reported in patients receiving Feraheme. Observe patients for signs and symptoms of hypersensitivity during and after Feraheme administration for at least 30 minutes and until clinically stable following completion of each administration.

Only administer the drug when personnel and therapies are immediately available for the treatment of anaphylaxis and other hypersensitivity reactions. Anaphylactic-type reactions, presenting with cardiac/cardiorespiratory arrest, clinically significant hypotension, syncope, and unresponsiveness have been reported in the post-marketing experience. In clinical studies, serious hypersensitivity reactions were reported in 0.2% (3/1,726) of subjects receiving Feraheme. Other adverse reactions potentially associated with hypersensitivity (e.g., pruritus, rash, urticaria or wheezing) were reported in 3.7% (63/1,726) of subjects. • Severe adverse reactions of clinically significant hypotension have been reported in the post-marketing experience. In clinical studies, hypotension was reported in 1.9% (33/1,726) of subjects, including three patients with serious hypotensive reactions. Monitor for signs and symptoms of hypotension following each  Feraheme administration.

• Excessive therapy with parenteral iron can lead to excess storage of iron with the possibility of iatrogenic hemosiderosis. Patients should be regularly monitored for hematologic response during parenteral iron therapy, noting that lab assays may overestimate serum iron and transferrin bound iron values in the 24 hours following administration of Feraheme.

• As a superparamagnetic iron oxide, Feraheme may transiently affect magnetic resonance diagnostic imaging studies for up to 3 months following the last Feraheme dose. Feraheme will not affect X-ray, CT, PET, SPECT, ultrasound, or nuclear imaging. Adverse reactions

• In clinical trials, the most commonly occurring adverse reactions in Feraheme treated patients versus oral iron treated patients reported in = 2% of chronic kidney disease patients were diarrhea (4.0% vs. 8.2%), nausea (3.1% vs. 7.5%), dizziness (2.6% vs. 1.8%), hypotension (2.5% vs. 0.4%), constipation (2.1% vs. 5.7%) and peripheral edema (2.0% vs. 3.2%).

• In clinical trials, adverse reactions leading to treatment discontinuation and occurring in 2 or more Feraheme treated patients included hypotension, infusion site swelling, increased serum ferritin level, chest pain, diarrhea, dizziness, ecchymosis, pruritus, chronic renal failure, and urticaria. Post-marketing safety experience

• The following adverse reactions have been identified during post-approval use of Feraheme. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

• The following serious adverse reactions have been reported from the post-marketing spontaneous reports with Feraheme: life-threatening anaphylactic-type reactions, cardiac/cardiorespiratory arrest, clinically significant hypotension, syncope, unresponsiveness, loss of consciousness, tachycardia/rhythm abnormalities, angioedema, ischemic myocardial events, congestive heart failure, pulse absent, and cyanosis. These adverse reactions have occurred up to 30 minutes after the administration of Feraheme. Reactions have occurred following the first dose or subsequent doses of Feraheme

Feraheme, when added to intravenous infusion bags containing either Sodium Chloride Injection, USP (normal saline), or 5% Dextrose Injection, USP, at concentrations of 2-8 mg elemental iron per mL, should be used immediately, but may be stored at controlled room temperature (25°C ± 2°C) for up to 4 hours.

The dosage is expressed in terms of mg of elemental iron, with each mL of Feraheme containing 30 mg of elemental iron. Evaluate the hematologic response (hemoglobin, ferritin, iron and transferrin saturation) at least one month following the second Feraheme injection. The recommended Feraheme dose may be readministered to patients with persistent or recurrent iron deficiency anemia.

For patients receiving hemodialysis, administer Feraheme once the blood pressure is stable and the patient has completed at least one hour of hemodialysis. Monitor for signs and symptoms of hypotension following each Feraheme injection. Inspect parenteral drug products visually for the absence of particulate matter and discoloration prior to administration.

Serious hypersensitivity reactions, including anaphylactic-type reactions, some of which have been life-threatening and fatal, have been reported in patients receiving Feraheme. Observe patients for signs and symptoms of hypersensitivity during and after Feraheme administration for at least 30 minutes and until clinically stable following completion of each administration. Only administer the drug when personnel and therapies are immediately available for the treatment of anaphylaxis and other hypersensitivity reactions [see Adverse Reactions (6.1)].

Anaphylactic type reactions presenting with cardiac/cardiorespiratory arrest, clinically significant hypotension, syncope, and unresponsiveness have been reported in the post-marketing experience [see Adverse Reactions from Postmarketing Spontaneous Reports (6.2)]. In clinical studies, serious hypersensitivity reactions were reported in 0.2% (3/1,726) of subjects receiving Feraheme. Other adverse reactions potentially associated with hypersensitivity (e.g., pruritus, rash, urticaria or wheezing) were reported in 3.7% (63/1,726) of these subjects.

Dental billing covered and non covered services - Medicaid

COVERED SERVICES

This section provides information on Medicaid covered services and is divided into the following subsections that correspond to the categories of services in Current Dental Terminology (CDT) as published by the American Dental Association.

* Diagnostic Services

* Preventive Services

* Restorative Treatment

* Endodontics

* Periodontics

* Prosthodontics (Removable)

* Oral Surgery

* Adjunctive General Services

Providers must use the current CDT procedure codes published by the American Dental Association (ADA) when completing both the claim and PA form. Refer to the Additional Code/Coverage Resource Materials subsection of the General Information for Providers Chapter for additional information regarding coverage parameters.


DIAGNOSTIC SERVICES

CLINICAL ORAL EVALUATION (EXAMINATIONS)

A periodic, comprehensive or problem-focused evaluation is considered a benefit for all beneficiaries only if detailed written documentation of medical and dental findings (both negative and positive) and tests are included in the beneficiary's dental record. (Refer to the General Information for Providers Chapter of this manual for additional information.) Typically, it should include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, periodontal conditions, occlusal relationships, hard and soft tissue anomalies, oral cancer screening, prosthesis condition and usage, etc. Examinations without this documentation are not a covered benefit.

COMPREHENSIVE ORAL EVALUATION

A comprehensive oral evaluation is performed on a new patient or an established patient with significant health changes or absence from treatment for three or more years. The evaluation must include a documented medical and dental history, a thorough evaluation and recording of the condition of extraoral and intraoral hard and soft tissues, including a complete charting of the condition of each tooth and supporting tissues, occlusal relationships, periodontal conditions, including periodontal charting, oral cancer screening and appropriate radiographic studies (radiographs are separately reimbursable). The comprehensive oral evaluation is a covered benefit for all beneficiaries. In addition, a complete treatment plan must be included that addresses the beneficiary’s needs.



PERIODIC ORAL EVALUATION

A periodic oral evaluation is an examination of a patient of record to determine any changes in a beneficiary’s dental and medical health status since a previous comprehensive or periodic examination. The periodic oral evaluation must include a written update of the beneficiary’s dental and medical history, clinically appropriate charting necessary to update and supplement the comprehensive oral examination data, including periodontal screening and appropriate radiographs as necessary to update previous radiograph surveys (radiographs are separately reimbursable). A periodic oral evaluation is a covered benefit once every six months for all beneficiaries, but may not be billed within six months of a Comprehensive Oral Evaluation. In addition, a complete treatment plan must be included that addresses the beneficiary’s needs.


LIMITED ORAL EVALUATION - PROBLEM FOCUSED EXAM

A limited oral evaluation-problem focused exam consists of an examination for diagnosis and observation of a specific oral health problem or complaint, such as injuries to teeth and supporting structures. A limited oral evaluation must include appropriate recording of the beneficiary’s dental and medical history, and charting that is clinically appropriate for the particular problem. In addition, the findings, diagnosis, and treatment plan for the diagnosis must be included in the beneficiary’s chart.

A limited oral evaluation can be billed in conjunction with radiographs and/or extractions(simple or surgical) and considered as a covered benefit. Routine restorative procedures, root canal therapy, elective surgery, and denture services are not considered emergency procedures and cannot be billed in conjunction with a limited oral evaluation. Limited oral evaluation-problem focused exam is a covered benefit for all ages.


PRE-DIAGNOSTIC SERVICES

ORAL EVALUATION, PATIENT <3 b="" years="">

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SCREENING OF A PATIENT <3 b="" years="">

A screening of a patient <3 a="" an="" and="" applications="" as="" be="" billed="" but="" by="" caregiver="" cavity="" conjunction="" counseling="" date="" dentist="" determine="" diagnosis.="" evaluation="" federally="" fluoride="" for="" in="" includes="" inspection="" is="" mandated="" may="" medical="" need="" needed="" not="" of="" on="" or="" oral="" other="" p="" patient="" primary="" provider="" referral="" required.="" same="" screening="" screenings.="" service="" services.="" state="" the="" this="" to="" topical="" varnish="" with="" years="">

ASSESSMENT OF A PATIENT

An assessment of a patient is a clinical evaluation performed by a dental hygienist operating in a public health setting or an approved Public Act 161 of 2005 (PA 161) program. Assessment services performed within the scope of dental hygiene practice can be provided to identify signs of disease, malformation or injury and the need for referral for examination, diagnosis and treatment. An assessment of a patient is a benefit for all ages. The assessment must include written documentation of the beneficiary’s dental and medical history. Written documentation of significant clinical findings and the appropriate referral is required. The assessment code cannot be used when a dentist is on site to perform the examination. An oral examination by the dentist always supersedes the assessment of a patient in place of service settings where the dentist is present. It can be billed in conjunction with other dental hygiene services, but may not be billed on the same date of service as other oral evaluation services.



CONSULTATION

A consultation provided by another dentist or a physician (MD, DO) is a benefit for all beneficiaries. Medicaid defines a consultation as a service rendered by a physician/dental specialist whose opinion or advice is formally requested by another appropriate practitioner (e.g., physician, certified nurse-midwife [CNM], dentist) for the further evaluation and/or management of the beneficiary. The consultant does not render patient care or treatment. If a consultant assumes responsibility for any patient management or treatment, then all services subsequent to the consultation must be billed under the appropriate procedure code (e.g., exams, procedures). If a dentist provides a consultation, the only separately reimbursable services that may be provided in addition to the consultation are radiographs.

A consultation service includes examination and evaluation of the beneficiary, documentation of history and physical examination findings, recommendations, and submission of a written formal consultation report to the requesting practitioner. The dentist requesting the consultation cannot bill the consultation procedure code.

A consultation related to routine dental treatment (e.g., caries) is not a covered benefit.



RADIOGRAPHS

The policy applies to all radiographs and radiographic procedures, both digital and traditional film, unless otherwise stated. (Refer to the Directory Appendix for website information.)

Radiographs are benefits for all beneficiaries and are limited to the number medically necessary to make a diagnosis (other limitations apply to radiographs - see below). The provider must maintain documentation in the beneficiary's file stating the reason the radiographs were necessary, the diagnosis/radiographic findings, treatment plan, and referral if appropriate.


TECHNICAL CONSIDERATIONS AND ADDITIONAL REQUIREMENTS

All radiographs submitted must be diagnostically acceptable and meet the following technical considerations and additional requirements.

Technical Considerations

* All teeth or areas of concern must be visible on the radiographs.

* Density and clarity of the radiograph must be such that radiographic interpretation can be made without difficulty.

* On a periapical view, the apex of the tooth must be demonstrated clearly, as well as a minimum of one-eighth of an inch of surrounding bone.

* Where pathologic change is in question, healthy bone must be seen surrounding the questionable area.

* Interproximal bone must be visible without the overlapping of interproximal surfaces of teeth under consideration.

* Posterior teeth areas (e.g., demonstrated impactions, developing third molars) must be completely visible.


Additional Requirements

* All film radiographs submitted must be mounted in an x-ray mount, with the exception of a single film which may be submitted in an envelope. Only actual films or diagnostically acceptable duplicates will be accepted.

* Digital radiographs submitted must be regulation film size and printed on diagnostic quality paper.

* All radiographs must be identified with the beneficiary's name and Medicaid ID number.

* All radiographs must have the date the radiograph was taken.

* All full-mouth radiographs and panoramic radiographs must have "right" and "left" identification.

* All radiographs must include the dentist's name and address.


BITEWINGS

Bitewing radiographs are a covered benefit only once in a 12-month period for all beneficiaries.


OCCLUSAL RADIOGRAPHS

An occlusal radiograph is a covered benefit for beneficiaries under age 21 once every three years per arch. All occlusal radiographs, regardless of film size or method of exposure, will be reimbursed at the established fee for a periapical, first film.



PANORAMIC RADIOGRAPHS

A panoramic radiograph is a covered benefit once every five years for all beneficiaries ages five years and older.



FULL MOUTH OR COMPLETE SERIES

A full mouth or complete series is a covered benefit once every five years for all beneficiaries ages five years and older.

A full mouth or complete series consists of:

* A minimum of 10 periapical radiographs in conjunction with a minimum of two bitewing radiographs; or

* An intraoral/extraoral combination of a panoramic radiograph in conjunction with a minimum of two bitewing radiographs.

The maximum reimbursement for any combination of radiographs will not exceed the established fee for a full mouth or complete series. Any combination of 10 or more intraoral radiographs will be considered a full mouth series.

Radiographs submitted for prior authorization and audit purposes will be returned to the provider.




 COPIES OF FULL MOUTH SERIES

When a beneficiary changes dental providers and has had a full mouth series of radiographs taken within the previous 12 months, the expectation is that the dental provider provides a copy of the radiographs to the new dental provider.


RADIOGRAPH SUBMISSION REQUIREMENTS FOR PRIOR AUTHORIZATION

In some cases, pre-op radiographs are necessary to document the presence and/or absence of teeth, related tooth structure, or related chronic pathology within the alveolar process(es).

A full mouth radiograph series must be submitted with PA requests for complete dentures in cases where beneficiaries are receiving their first denture. A full mouth radiograph series is optional for PA requests for replacement of existing complete dentures (i.e., the beneficiary is edentulous, has worn dentures for years, and needs replacement dentures). In this case, the dentist may submit radiographs if they deem them necessary in the evaluation of the beneficiary’s oral condition.
A full mouth radiograph series must be submitted with all PA requests for partial dentures.

A periapical radiograph is required when submitting PA requests for crown coverage. When requesting PA for procedures, the dentist may be required to send radiographs along with the request. (Information regarding the completion of the PA request and the submission of radiographs is contained in the Billing & Reimbursement for Dental Providers Chapter of this manual.)




NONCOVERED SERVICES

The following dental services are excluded from Medicaid coverage:

* Orthodontics

* Gold Crowns, Gold Foil Restorations, Inlay/Onlay restorations

* Fixed Bridges

* Bite Splints, Mouthguards, sports appliances

* TMJ Services

* Services or Surgeries that are experimental in nature

* Dental Devices not approved by the FDA

* Analgesia, Inhalation of Nitrous Oxide

Dental billing overview - Medicaid

DENTAL PROGRAM COVERAGE

EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is available to all Medicaid beneficiaries under the age of 21. This program was established to detect and correct or ameliorate defects and physical and mental illnesses and conditions discovered in children. Under EPSDT, dental services are to be provided at intervals which meet reasonable standards of dental practice.


Primary Care Physicians (PCPs) should provide an oral health screening and caries risk assessment for beneficiaries under 21 years of age at each well child visit. As an oral health intervention, providers should apply fluoride varnish to high-risk children from birth to 35 months of age up to four times in a 12-month time period.

Providers must complete the online Children’s Oral Health training modules and obtain certification prior to providing oral health screenings and fluoride varnish applications. Providers who complete the certification requirements are allowed to bill Medicaid for these services. Specific certification requirements are available on the MDHHS Oral Health website. (Refer to the Directory Appendix for website information). Refer to the Early and Periodic Screening, Diagnosis and Treatment chapter for additional information.


The Dental Periodicity Schedule follows the American Academy of Pediatric Dentistry (AAPD) Recommendations for Pediatric Oral Health Assessment, Preventive Services, and Anticipatory Guidance/Counseling schedule. (Refer to the Directory Appendix for AAPD website information.)

The AAPD guidelines are designed for the care of children developing normally and without contributing medical conditions. The guidelines include recommendations to modify as needed for children with special health care needs, disease or trauma. The AAPD guidelines emphasize the importance of early professional intervention and continuity of care based on the individualized needs of the child.

The guidelines recommend that a child have a first dental visit when the first tooth erupts or no later than 12 months of age. The examination is to be repeated every six months or as indicated by the child’s risk status and susceptibility to disease. The examination includes assessment of pathology and injuries, growth and development, and caries-risk assessment. Based on clinical findings and susceptibility to disease, the timing and frequency of radiographic imaging, oral prophylaxis, and topical fluoride should be provided as determined necessary. Systemic fluoride supplementation should be considered when fluoride exposure is suboptimal.

Anticipatory guidance/counseling should be an integral part of each dental visit. Counseling on oral hygiene, nutrition/dietary practices, injury prevention, and nonnutritive oral habits should be included. A referral for speech/language development should be made as needed. Determined by growth and developmental assessment, the prevention and treatment of developing malocclusion should be evaluated beginning at 2 years of age. Following current policy, caries-susceptible pits and fissures of teeth should have sealants placed as soon as possible after eruption. Children 6 years of age and older should receive counseling on substance abuse and intraoral and perioral piercing. Children 12 years of age and older need third molar assessment and potential removal as deemed medically necessary.


ADULT DENTAL PROGRAM

Beneficiaries age 21 and older receive dental benefits that are more limited in coverage. Dental benefits are provided for adult Medicaid and Medicaid Health Plan (MHP) beneficiaries through the Medicaid Fee-For-Service (FFS) Program. Healthy Michigan Plan (HMP) beneficiaries will receive their dental benefits through the Medicaid FFS program until they are enrolled in a health plan. The health plan becomes responsible for the beneficiary’s dental services on the enrollment effective date. Upon enrollment in a health plan, beneficiaries must obtain dental services through the health plan’s dental provider network. The Program of All-Inclusive Care for the Elderly (PACE) is responsible for the coverage of dental benefits for PACE enrollees.


HEALTHY MICHIGAN PLAN DENTAL

Beneficiaries enrolled in a health plan will receive their dental coverage through their health plan. Each health plan contracts with a dental provider group or vendor to provide dental services administered according to the contract. The contract is between the health plan and the dental provider group or vendor, and beneficiaries must receive services from a participating provider to be covered. Questions regarding eligibility, prior authorization or the provider network should be directed to the beneficiary’s health plan.

It is important to verify eligibility at every appointment before providing dental services.

Dental services provided to an ineligible beneficiary will not be reimbursed.

For those beneficiaries who are not enrolled in a health plan, dental services will be provided by enrolled dental providers on a FFS basis.


CSHCS PROGRAM

Dentists providing specialty dental services to Children's Special Health Care Services (CSHCS) Program beneficiaries should refer to the Children’s Special Health Care Services Dental Services Section of this chapter. Refer to the Additional Code/Coverage Resource Materials subsection of the General Information for Providers Chapter for additional information regarding coverage parameters.



PRIOR AUTHORIZATION

Prior authorization (PA) is only required for those services identified in the Dental Chapter and the Medicaid Code and Rate Reference tool. (Refer to the Directory Appendix for website information.)



PRIOR AUTHORIZATION REQUIREMENTS IN CASES OF OVER-UTILIZATION

MDHHS may require a dentist found to be misutilizing services to obtain PA for all or selected dental services separate from those generally requiring authorization. MDHHS is required to explain to the dentist, in writing, the reasons for applying this requirement.


COMPLETION INSTRUCTIONS

The Dental Prior Approval Authorization Request form (MSA-1680-B) is used to obtain authorization. (Refer to the Forms Appendix for instructions for completing the form.) When requesting authorization for certain procedures, dentists may be required to send specific additional information and materials. Based on the MSA-1680-B and the documentation attached, staff approves or disapproves the request and returns a copy to the dentist. Approved requests are assigned a PA number. For billing purposes, the PA number must be entered in the appropriate field on the claim form. An electronic copy of the MSA-1680-B is available on the MDHHS website.


APPROVED PRIOR AUTHORIZATION REQUESTS

An approved PA request confirms that the beneficiary meets Medicaid’s established medical criteria for the services and that the services are Medicaid-covered benefits. This approval does not guarantee eligibility nor verify a beneficiary’s age. It is also not to be considered an authorization for payment.

The dentist is responsible for verifying the beneficiary's Medicaid eligibility and age by checking the eligibility response. Eligibility should be verified prior to each appointment. (Refer to the Enrollment Information subsection of this chapter and the Verifying Beneficiary Eligibility section of the Beneficiary Eligibility chapter for additional information.)

PA is granted under the NPI submitted on the PA form. Provided it is the group NPI, it may be transferred or used by any dentist within the same organization without contacting the MDHHS Dental Prior Authorization Unit.



While a beneficiary is eligible, all treatment authorized must be completed within one year from the date of authorization. If treatment is not completed within one year, the PA request must be updated before continuing treatment. The provider has 15 days prior to the end of the prior authorization period to request a one-time 180-day extension. New prior authorization requests must be submitted for existing PA plans over one year old.

Providers may update the PA request by contacting the Dental Prior Authorization Unit by phone or fax if there are no treatment plan changes. (Refer to the Directory Appendix for contact information.) If a change in the treatment plan is necessary, dentists should submit a new MSA-1680-B with appropriate images and information to the Dental Prior Authorization Unit.

If a PA request is denied, the dentist receives a denial notice. The beneficiary also receives a notice of denial for the requested service along with their notice of appeal rights.


 LOSS OR CHANGE IN ELIGIBILITY

No service is covered after loss of eligibility except for the following services:

* Endodontic Therapy

* Complete and Partial Dentures

* Laboratory-Processed Crowns

Reimbursement for these services is only allowed under the following circumstances:

* Services were started prior to the loss of eligibility.

* For complete or partial dentures and laboratory-processed crowns, impressions were taken prior to the loss of eligibility.

* Services are completed within 30 days of change and/or loss of eligibility. Conditions not eligible for reimbursement include:

* If a beneficiary's Medicaid eligibility is terminated after extractions were performed, but prior to the initial impressions. The extractions alone do not qualify the beneficiary for dentures.

* Immediate dentures.

The date of service on the claim is the date the endodontic therapy was started or the date of the initial impressions for complete or partial dentures and laboratory-processed crowns.



COPAYMENT

A copayment of $3 for each separately reimbursable Medicaid visit may be required for beneficiaries age 21 years and older with the following limitations:

* When more than one reimbursable service is provided during a visit, only one $3 copayment may be charged.

* Where several visits are required to complete a service (such as dentures), only one $3 copayment may be charged.

* Beneficiaries cannot be charged a copayment for procedures that are considered part of normal office operations.

A provider cannot refuse to render service if the beneficiary is unable to pay the required copayment on the date of service.

Some beneficiaries, programs, and places of service are exempt from co-payment requirements. (Refer to the General Information for Providers Chapter for information on exceptions to Medicaid copayment requirements.)


PLACE OF SERVICE

All dental services must be performed in the dental office, public health department dental clinic, dental school, dental hygiene program, or Federally Qualified Health Centers (FQHCs). Special situations may necessitate the provision of services at an alternate site such as a hospital/surgical setting or nursing facility.


ALTERNATIVE SETTINGS
INPATIENT OR OUTPATIENT HOSPITAL SETTING

Admission to an inpatient or outpatient hospital setting for any non-emergency dental service is covered for beneficiaries for the following reasons:

* The patient has a high-risk medical condition;

* The type of procedure requires it to be performed in a hospital setting; or

* Other contributing factors could compromise the safety of the patient, such as age, behavioral problems due to mental impairment, etc.

The dentist/physician must document in the beneficiary’s medical record the condition hat required the dental service to be done in the hospital setting. Hospitalization is not a benefit for the convenience of the dentist or beneficiary or because of apprehension on the part of the beneficiary.

SURGICAL SETTING

For services performed in a surgical setting, the dentist should use the usual and customary (U & C) fee for the service as performed in an office setting. In addition, the CDT procedure code for hospital or ambulatory surgical center call may also be billed if services are provided in a hospital or surgical center. This code may be billed in addition to the appropriate dental procedure code for the actual service performed. This procedure code is not for administrative purposes, such as arranging appointment times, gathering signatures for release forms, etc.



NURSING FACILITIES

Dental services provided to a beneficiary who resides in a nursing facility are the same benefits as those identified in the Covered Services section of this chapter. All dental services provided to a nursing home beneficiary in a nursing facility, or any other place of service, require the written order of a licensed referring physician (MD, DO). The order must be signed and dated by the physician and a copy of this order must be retained in the beneficiary’s medical record and the beneficiary’s dental record. All dental services provided in a nursing facility must be noted in the beneficiary’s medical record. Documentation must include an updated medical history, the patient’s primary concerns, the current oral health status, and the treatment plan and services rendered.


MOBILE DENTAL FACILITIES

A mobile dental facility is defined as a self-contained, intact facility in which dentistry or dental hygiene is practiced that may be transported from one location to another, or a site used on a temporary basis to provide dental services using portable equipment. A mobile dental permit must be obtained by an operator before providing dental services.


Requirements include:

* Completion of the permit application;

* Submission of the required documents;

* Submission of the administrative fee; and

* Memorandum of agreement for follow-up services.

Mobile dental operators can access the Mobile Dental Facility Application and additional information and requirements on the MDHHS website. (Refer to the Directory Appendix for website information.)

To provide dental services and bill Medicaid, a provider must be enrolled in the Community Health Automated Medicaid Processing System (CHAMPS). Instructions for provider enrollment, as well as updating enrollment, can be found on the MDHHS website. (Refer to the Directory Appendix for website information.)

Enrollment as a mobile dental provider is required within 30 days of approval of the Mobile Dental Facility Permit. Groups may select more than one specialty. Dental Hygienists operating in mobile facilities will need to enroll as a mobile provider.


OTHER SITES

All other sites must be prior approved. In order to receive prior authorization (PA), the dental provider must complete the Dental Prior Approval Authorization Request form (MSA-1680-B) for each individual and submit it to the Prior Authorization Section. (Refer to the Forms Appendix for a copy of the form.) Providers should follow the same instructions for submission of the PA request for site of service as they do requests for procedures.

Place of service (POS) 21, 22 , 23

POS code and Description

21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

22 On Campus-Outpatient Hospital A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.  (Description change effective January 1, 2016)

23 Emergency Room – Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.


Reporting Guidelines


• The POS is a required field, entered in the 2400 Place of Service Code loop (segment SV105) of the 837P electronic claim or Item 24B on the CMS-1500 paper claim

• The name, address and ZIP code of where the service(s) were actually performed is required for all POS codes, and is entered in Item 32 on the CMS 1500 claim form or in the corresponding loop on its electronic equivalent

• Must specify the correct location where the service(s) is performed and billed on the claim, since both the POS and the locality address are components of the MPFS

• If the POS is missing, invalid or inconsistent with procedure code on claim form it will be returned as unprocessable (RUC)

• For example, POS 21 (inpatient hospital) is not compatible with procedure code 99211 (Establish patient office or other outpatient visit)

• If a provider specialty other than “69” (Clinical laboratory-billing independently) bills a claim with a POS 81 (Independent laboratory) it will be denied with a claim adjustment reason code (CARC) CO5, refer to Washington Publishing Company (WPC) website http://www.wpc-edi.com/reference/ external link.

Using of POS 23 with modifier 26

Modifier 26 is only appropriate in one of the following places of service:

* Hospital inpatient (place of service 21).
* Hospital outpatient (place of service 22).
* Emergency Room (place of service 23).
* Use of Modifier 26 is not appropriate in conjunction with any other place of service code.

The place of service indicated on the radiologist’s claim, in this case, reflects the location where the CT was performed, not the location where the radiologist actually reviewed the film. If the radiologist indicated a place of service of 11 (office), the service 70450 appended with modifier 26 would be denied for an ineligible place of service. Please note the above also applies to the technical component (TC). Only place of service 21, 22 & 23 are appropriate for TC and PC component. If services are rendered in a freestanding radiology/imaging center then the center would bill globally. In addition, if a specialty physician is over-reading or interpreting the procedure as a consultation in the office (POS 11) the service will not be reimbursed separately from the global component.


The radiologist will submit a claim for the reading and interpreting of the results (the professional component PC) of that diagnostic service with the following claim elements:

CPT Code 70450 Modifier 26

POS 23

The place of service indicated on the radiologist’s claim, in this case, reflects the location where the CT was performed, not the location where the radiologist actually reviewed the film. If the radiologist indicated a place of service of 11 (office), the service 70450 appended with modifier 26 would be denied for an ineligible place of service. Please note the above also applies to the technical component (TC). Only place of service 21, 22 & 23 are appropriate for TC and PC component. If services are rendered in a freestanding radiology/imaging center then the center would bill globally. In addition, if a specialty physician is over-reading or interpreting the procedure as a consultation in the office (POS 11) the service will not be reimbursed separately from the global component.



Will Oxford reimburse the same physician for both an injection (96372-96379) and an Evaluation and Management (E/M) service code on the same date of service if each is performed in a different place of service?

A: Yes, Oxford will separately reimburse the same physician for both an injection procedure and E/M service on the same date of service if each is performed in a different place of service (POS) and the injection was provided in a POS other than 19, 21, 22, 23, 24, 26, 51, 52, and 61. For example, if the patient only receives an injection at a physician’s office (POS 11) and later that day the patient is admitted to the hospital (POS 21), both services, the injection service performed at the physician’s office and the E/M performed later that day at the hospital, would be separately reimbursed because the injection service and E/M service were performed in different locations by the same physician on the same date of service. Injection services are not reimbursable when provided in POS 19, 21, 22, 23, 24, 26, 51, 52, and 61.

Reporting outpatient hospital POS code 19 or 22 is a minimum requirement to trigger the facility payment amount under the Physician Fee Schedule (PFS) when services are provided to a registered outpatient. Therefore, you should use POS code 19 or POS code 22 when you furnish services to a hospital outpatient regardless of where the face-to-face encounter occurs.

The payment policies that currently apply to POS 22 will continue to apply to this POS, and will now also apply to POS 19 unless otherwise stated in Change Request (CR) 9231.

POS 22 - Update on Campus outpatient hospital

This Change Request revises the description of Place of Service (POS) code 22 to On Campus-Outpatient Hospital, and creates a new POS code for Off Campus-Outpatient Hospital.

As an entity covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Medicare must comply with standards and their implementation guides adopted by regulation under this statute. The currently adopted professional implementation guide for the ASC X12N 837 standard requires that each electronic claim transaction include a Place of Service (POS) code from the POS code set maintained by the Centers for Medicare and Medicaid Services (CMS). As a payer, Medicare must be able to recognize as valid any valid code from the POS code set that appears on the HIPAA standard claim transaction.

The POS code set provides setting information necessary to appropriately pay Medicare and Medicaid claims. At times, Medicaid has had a greater need for specificity than has Medicare, and many of the new codes developed over the past few years have been to meet Medicaid’s needs. While Medicare does not always need this greater specificity in order to appropriately pay claims, it nevertheless adjudicates claims with the new codes to ease coordination of benefits and to give Medicaid and other payers the setting information they require.

This Change Request (CR) updates the current POS code set by adding new POS code 19 for “Off CampusOutpatient Hospital” and revising POS code 22 from “Outpatient Hospital” to “On Campus-Outpatient Hospital.” Also, this CR will implement the systems and local contractor level changes needed for Medicare to adjudicate claims with the new and revised codes. Local contractors shall develop policies as needed to adjudicate claims containing new POS code 19 and revised POS code 22 in accordance with Medicare national policy. Contractor editing shall treat POS 19 and POS 22 in the same way. See Title 42 CFR 413.65(a)(2) for a definition of "campus."

Payments for services provided to outpatients who are later admitted as inpatients within 3 days (or, in the case of non-IPPS hospitals, 1 day) are bundled when the patient is seen in a wholly owned or wholly operated physician practice. The 3-day payment window applies to diagnostic and nondiagnostic services that are clinically related to the reason for the patient’s inpatient admission regardless of whether the inpatient and outpatient diagnoses are the same. The 3-day payment rule will also apply to services billed with POS code 19.

As discussed in the CY 2015 Physician Fee Schedule (PFS) final rule with comment period published on November 13, 2014 (79 FR 67572), in order to differentiate between on-campus and offcampus provider-based hospital departments, CMS is creating a new POS code (POS 19) and revising the current POS code description for outpatient hospital (POS 22) as follows:

POS 19: Off Campus-Outpatient Hospital Descriptor: A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS 22: On Campus-Outpatient Hospital

Descriptor: A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

Unless prohibited by national policy to the contrary, Medicare not only recognizes valid POS codes from the POS code set but also adjudicates claims having these codes. Although the Medicare program does not always have the same need for setting specificity as other payers, including Medicaid, adjudicating the claims eases the coordination of benefits for Medicaid and other payers who may need the specificity afforded by the entire POS code set.

Claims for covered services rendered in an Off Campus-Outpatient Hospital setting, or in an On CampusOutpatient Hospital setting, if payable by Medicare, shall be paid at the facility rate. The payment policies that currently apply to POS 22 will continue to apply and will now also apply to POS19 unless otherwise stated.

9231.2 Effective for claims processed on or after January 1, 2016, contractors shall recognize the revised description for place of service (POS) code 22 from “Outpatient Hospital” to “On Campus-Outpatient Hospital”

9231.8 Contractors shall educate physicians/practitioners and other suppliers to use, at a minimum, POS code 19 (Off Campus-Outpatient Hospital) or POS code 22 (On Campus-Outpatient Hospital) when they furnish services to an outpatient of a hospital, irrespective of where the face-to-face encounter occurs. (As discussed under “Special Considerations for Outpatient Hospital Departments”

9231.10 Until notified otherwise by CMS, for claims processed on or after January 1, 2016, contractors shall make any necessary systems changes to process procedure codes submitted with the revised POS code 22 and the new POS code 19 in the same way as they did for claims with 2015 dates of service submitted with POS 22.

Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The CMS furnishes both rates in the MPFSDB update.



Special Considerations for Outpatient Hospital Departments

The place of service (POS) code for “Outpatient Hospital” has been expanded. The description of POS 22 has been revised from “Outpatient Hospital” to “On Campus-Outpatient Hospital” and POS 19 has been created for the “Off Campus-Outpatient Hospital” setting. Throughout this Internet Only Manual (IOM) you may find references to “Outpatient Hospital” that do not differentiate between the “On Campus” or “Off Campus” setting; however, any reference to POS 22 (formerly “Outpatient Hospital”) found anywhere within the IOM is now defined as “On CampusOutpatient Hospital.” In addition, POS 19 will also apply in the majority of situations describing an outpatient hospital setting.

When a physician/practitioner furnishes services to an outpatient of a hospital, payment is made under the PFS at the facility rate. Physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient department (including in a provider-based department of that hospital) or under arrangement to a hospital shall, at a minimum, report the off campusoutpatient hospital POS code 19 or on campus-outpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter. In other words, reporting the outpatient hospital POS code 19 or 22 is a minimum requirement for purposes of triggering the facility payment amount under the PFS when services are provided to a registered outpatient. If the physician/practitioner is aware of the exact setting where the beneficiary is a registered hospital outpatient, the appropriate outpatient facility POS code may be reported consistent with the code list annotated in this section (instead of POS 19 or 22). For example, physicians/practitioners may use POS code 23 for services furnished to a patient registered in the emergency room, POS 24 for patients registered in an ambulatory surgical center, and POS 56 for patients registered in a psychiatric residential treatment center.

NOTE: Physicians/practitioners who perform services in a hospital outpatient department shall use, at a minimum, POS code 19 (Off Campus-Outpatient Hospital) or POS code 22 (On Campus-Outpatient Hospital). Code 19 or 22 (or other appropriate outpatient department POS code as described above) shall be used unless the physician maintains separate office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital as defined in 42. C.F.R. 413.65. Physicians shall use POS code 11 (office) when services are performed in a separately maintained physician office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital. Use of POS code 11(office) in the hospital outpatient department or on hospital campus is subject to the physician self-referral provisions set forth in 42 C.F.R 411.353 through 411.357.

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