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REVENUE CODE MANUAL Blue Cross

CPT codes, descriptions and other data are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Contains Public Information Revision Date: March 31, 2009 1

How to Use This Manual This manual is intended to serve as a guide for hospitals. If explicit instructions have been given by Blue Cross and Blue Shield, these instructions will be referenced within the revenue category. Otherwise hospitals should use the revenue code that best describes the same cost center the charges are assigned to on the. The table has important field information stating requirements for submission. FROM THE LEFT TO THE RIGHT: GENERAL CATEGORY: This is a four-digit numeric identifying the revenue code category. NAME OF CATEGORY: The name of the revenue category. BC: Indicates Blue Cross and Blue Shield of Kansas DETAIL: This field will identify when a need for specific subcategory detail is required for a specific revenue code category. UNITS: This field identifies the method of determining units for a specific revenue code category. HCPCS/CPT: This fields signifies when HCPCS/CPT coding is required for a specific revenue code category. DESCRIPTION: A verbal description of revenue category. SUBCATEGORY: This field reveals the valid subcategories (fourth digit of the revenue category) for the particular revenue category listed. STANDARD ABBREVIATION: This field represents any known abbreviations that correspond to the particular subcategory. Example of Table: (General Name of Category Category) 010X

DESCRIPTION: SUBCATEGORY: 0 1 STANDARD ABBREVIATION:

BC

DETAIL UNITS HCPCS/CPT

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The basic guidelines for each revenue code category are based on BCBSKS primary claims only. TYPE OF CLAIM: This section references whether this revenue code category pertains to inpatient only; outpatient only or both. TYPE OF BILL: This section references the type of bills that allow the particular revenue code category. MEDICAL POLICIES: This section will provide links to any medical policies that may be applied to the particular revenue code category. BILLING & CODING GUIDELINES: This section includes any additional billing and coding requirements (e.g. condition codes, occurrence codes, value codes, modifiers, etc.) as well as ICD9-CM and HCPCS diagnosis/procedural coding for the particular revenue code category. REIMBURSEMENT: This section includes reimbursement information regarding this revenue code category. SPECIAL PLAN INSTRUCTIONS: This section includes any special instructions for other plans (e.g. State of Kansas (SOK), Federal Employee Program (FEP), etc.). SECONDARY CLAIMS: This section includes any special instructions for BCBSKS secondary claims. DEFINITIONS: This section includes any special definitions or descriptions related to the revenue code category. REFERENCES: This section includes any references to additional information, clarifications related to this revenue code category.

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Numeric listing of Revenue Codes (CONTROL and click on Blue Numbers)

Revenue Code 001X 002X 010X 011X 012X 013X 014X 015X 016X 017X 018X 019X 020X 021X 022X 023X 024X 025X 026X 027X 028X 029X 030X 031X 032X 033X 034X 035X 036X 037X 038X 039X 040X DESCRIPTION RESERVED FOR INTERNAL PAYER USE HEALTH INSURANCE PROSPECTIVE PAYMENT SYSTEM (HIPPS) ALL-INCLUSIVE RATE ROOM AND BOARD ­ PRIVATE (Medical or General) ROOM AND BOARD-SEMIPRIVATE (Medical or General) SEMI-PRIVATE THREE AND FOUR BEDS PRIVATE (DELUXE) ROOM AND BOARD - WARD (Medical or General) OTHER ROOM AND BOARD NURSERY LEAVE OF ABSENCE SUB ACUTE CARE INTENSIVE CARE CORONARY CARE SPECIAL CHARGES - CANCELLED SURGERY INCREMENTAL NURSING CHARGE RATE ALL-INCLUSIVE ANCILLARY PHARMACY IV THERAPY MEDICAL/SURGICAL SUPPLIES AND DEVICES (ALSO SEE 062X, AN EXTENSION OF 027X) ONCOLOGY DURABLE MEDICAL EQUIPMENT (OTHER THAN RENAL) LABORATORY LABORATORY PATHOLOGICAL RADIOLOGY-DIAGNOSTIC RADIOLOGY-THERAPEUTIC NUCLEAR MEDICINE CT SCAN OPERATING ROOM SERVICES ANESTHESIA BLOOD BLOOD STORAGE AND PROCESSING OTHER IMAGING SERVICES

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041X 042X 043X 044X 045X 046X 047X 048X 049X 050X 051X 052X 053X 054X 055X 056X 057X 058X 059X 060X 061X 062X 063X 064X 065X 066X 067X 068X 070X 071X 072X 073X 074X 075X

RESPIRATORY SERVICES PHYSICAL THERAPY OCCUPATIONAL THERAPY SPEECH-LANGUAGE PATHOLOGY EMERGENCY ROOM PULMONARY FUNCTION AUDIOLOGY CARDIOLOGY AMBULATORY SURGICAL CARE OUTPATIENT SERVICES CLINIC FREE-STANDING CLINIC OSTEOPATHIC SERVICES AMBULANCE SKILLED NURSING (HOME HEALTH) MEDICAL SOCIAL SERVICES (HOME HEALTH) HOME HEALTH AIDE (HOME HEALTH) OTHER VISITS (HOME HEALTH) UNITS OF SERVICE (HOME HEALTH) OXYGEN (HOME HEALTH) MAGNETIC RESONANCE TECHNOLOGY (MRT) MEDICAL/SURGICAL SUPPLIES - EXTENSION OF 027X PHARMACY ­ EXTENSION OF 025X HOME IV THERAPY SERVICES (NOT USED IN KANSAS) HOSPICE SERVICE RESPITE CARE (HHA ONLY) OUTPATIENT SPECIAL RESIDENCE CHARGES TRAUMA RESPONSE CAST ROOM RECOVERY ROOM LABOR ROOM/DELIVERY EKG/ECG ELECTROCARDIOGRAM EEG ELECTROENCEPHALOGRAM GASTRO INTESTINAL SERVICES

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076X 077X 078X 079X 080X 081X 082X 083X 084X 085X 086X 087X 088X 089X 090X 091X 092X 093X 094X 095X 096X 097X 098X 099X 100X 210X 310X

SPECIALTY ROOM ­ TREATMENT/OBSERVATION ROOM PREVENTIVE CARE SERVICES TELEMEDICINE EXTRA-CORPOREAL SHOCK WAVE THERAPY (formally lithotripsy) INPATIENT RENAL DIALYSIS ACQUISITION OF BODY COMPONENTS HEMODIALYSIS - OUTPATIENT OR HOME PERITONEAL DIALYSIS - OUTPATIENT OR HOME CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) OUTPATIENT OR HOME CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD) - OUTPATIENT OR HOME RESERVED FOR DIALYSIS (NATIONAL ASSIGNMENT) RESERVED FOR DIALYSIS (STATE ASSIGNMENT) MISCELLANEOUS DIALYSIS RESERVED FOR NATIONAL ASSIGNMENT BEHAVIORAL HEALTH TREATMENTS/SERVICES-(see 091X, extension of 090X) BEHAVIORAL HEALTH TREATMENTS/SERVICES OTHER DIAGNOSTIC SERVICES MEDICAL REHABILITATION DAY PROGRAM OTHER THERAPEUTIC SERVICES (See 095X an extension of 094X) OTHER THERAPEUTIC SERVICES (EXTENSION OF 094X) PROFESSIONAL FEES (ALSO SEE 097X AND 098X) PROFESSIONAL FEES (EXTENSION OF 096X) PROFESSIONAL FEES (EXTENSION OF 096X AND 097X) PATIENT CONVENIENCE ITEMS BEHAVIORAL HEALTH ACCOMMODATIONS ALTERNATIVE THERAPY SERVICES ADULT CARE

CONTROL AND CLICK ON BLUE INFORMATION Appendix A IV INFUSION AND INJECTION BILLING Appendix B Appendix C 2007 Blue Cross Add-On Codes Wound Care

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ALPHABETICAL UB04 REVENUE CODE LIST 0374 Acupuncture Anesthesia 0636 Adenosine 039X Administration ­ Blood 033X Administration ­ Chemo Appendix A Administration ­ Chemo 045X Administration ­ Drugs 071X Administration ­ Drugs 076X Administration ­ Drugs 051X Administration ­ Drugs Appendix A Administration - Drugs 027X Admissions Kits 0997 Admission Kits 0947 Air Fluidized Support Bed 0100 All Inclusive Rate 054X Ambulance ­ Supplies/Services 049X Ambulatory Surgical Care 0371 Anesthesia Incident to Radiology 0372 Anesthesia Supplies Incident to Other Diagnostic Services 037X Anesthesia ­ Supplies Only 0964 Anesthetist 0321 Angiography 0636 Antihemophilic Factor 0636 Anti-Emetic Drugs 041X Arterial Blood Gases 0921 Arterial Puncture (HCPCS 36600) 0323 Arteriography 0322 Arthrography 0229 Attempted Surgery 047X Audiology 0391 Autologous ­ Blood 0917 Biofeedback 0313 Biopsy ­ Lab Pathology 063X Biological Response Modifier - Drug 0724 Birthing Center 0391 Blood Administration 039X Blood Autologous (Purchased) 0385 Blood ­ Leucocytes (Purchased 039X) 0381 Blood ­ Packed Red Cells (Purchased 039X) 0383 Blood ­ Plasma (Purchased 039X) 0384 Blood ­ Platelets (Purchased 039X) 039X Blood Purchased 039X Blood ­ Storage & Processing 038X Blood ­ Whole Blood 032X Bone Mineral Density Studies Contains Public Information Revision Date: March 31, 2009 7

098X 084X 0481 0732 048X 0943 0700 0274 0300 085X 035X 0636 0331 0335 0332 Appendix A 0324 052X 051X 0946 0947 032X 036X 075X 0255 0636 0636 021X 0480 0200 0270 0170 0964 0387 035X 0352 0351 0320 0311 0722 032X 0942 080X 088X

CAH Method II CAPD (Continuous Ambulatory Peritoneal Dialysis) Cardiac Catheter Lab Test Cardiac Monitoring Cardiology Testing Cardiac Rehabilitation Cast Room Catheter Kits Catheterization (Specimen Collection HCPCS P9615) CCPD (Continuous Cycling Peritoneal Dialysis) Coronary Computed Tomographic Angiography (CCTA) Chemotherapy Drugs ­ Inj., IV, oral ­ outpatient (Rev code 025X inpatient) Chemotherapy ­ Injected (Administration) Chemotherapy ­ IV (Administration) Chemotherapy ­ Oral (Administration) Chemotherapy Administration Chest X-ray Clinic ­ Rural Health Clinic ­ Hospital-Based Complex Medical Equipment Routine Complex Medical Equip. Conscious Sedation - Radiology Conscious Sedation ­ Upper and Lower GI (Surgery) Conscious Sedation ­ Upper and Lower GI Contrast Media MRI & Radiology ­ High Osmolar Contrast Media MRI & Radiology ­ High Osmolar Contrast Media ­ Low Osmolar Coronary Care Unit (CCU) Coronary Angiography Cranial Spinal ICU Crash Cart Respirator Crib Rental for Birthing Room Certified Registered Nurse Anesthetists (CRNA) Cryoprecipitate ­ (Purchased 39X) CT Scan CT Scan ­ Body CT Scan ­ Head Cystogram Cytology ­ Lab Pathology Delivery Room Dual Energy X-ray Absorptiometry (DEXA)(see Bone Mineral Density) Diabetic Education (Blue Cross Approved Only) Dialysis ­ Inpatient Dialysis ­ Miscellaneous 8

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0881 025X 0720 029X 081X 0278 0254 025X 0636 0740 0730 0922 0901 0450 0750 0634 0634 0636 0730 0750 048X 0730 0801 082X 0636 0255 0731 065X 0413 0278 023X 0261 0412 Appendix A 045X 051X 071X 076X 020X 0276 0412 045X Appendix A 051X 071X

Dialysis ­ Ultrafiltration Discarded Drugs Distressed Baby Cart DME (durable medical equipment) Donor Organs Dorsal Implants Drugs Incident to Other Diagnostic Services Drugs Incident to Radiology Drugs Requiring Detail Coding Electroencephalogram (EEG) Electrocardiogam (EKG/ECG) Electromyelogram Electroshock Treatment Emergency Room Endoscopic Procedures (Gastrointestinal) Erythropoietin (EPO) Less than 10,000 units ­ ESRD Erythropoietin (EPO) Greater than 10,000 units ­ ESRD Erythropoietin (EPO) ­ Non-ESRD Fetal Monitoring Gastrointestinal Services Heart Catheterization Heart Monitor Hemodialysis ­ Inpatient Hemodialysis ­ Outpatient or Home High Osmolar Contrast Material (HOCM) ­ Outpatient High Osmolar Contrast Material (HOCM) ­ Inpatient Holter Monitor Hospice Services Hyperbaric Oxygen Therapy Implants Incremental Nursing Charge Infusion Pump (Discrete Unit only) Inhalation Service (by Respiratory Therapist) Injection ­ Administration Injection ­ Administration Injection ­ Administration Injection ­ Administration Injection ­ Administration Intensive Care Unit (ICU) Intraocular Lens Inhalation Positive Pressure Breathing (IPPB) Intravenous (IV) ­ Administration Intravenous (IV) ­ Administration Intravenous (IV) ­ Administration Intravenous (IV) ­ Administration 9

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076X 0634 0258 0260 0367 030X 031X 0721 0996 0224 0790 0636 0401 0403 027X 0622 0621 0361 076X 061X 0612 0255 0612 0175 011X,012X 0255 0271 034X 017X 0731 0762 043X 0434 028X 036X 0636 081X 0362 0274 0274 092X 040X 094X 0500 0300

Intravenous (IV) ­ Administration Intravenous (IV) Persantine Intravenous (IV) Solution Intravenous (IV) Therapy (Discrete Service Unit only) Kidney Transplant (Operating Room) Laboratory Clinical/Diagnostic Laboratory Pathological Labor Room Late Discharge ­ Patient Convenience Late Discharge ­ Medically Necessary Lithotripsy Osmolar Contrast Material (LOCM and HOCM) Outpatient Mammography (Diagnostic) Mammography (Screening) Medical Supplies Medical/Surgical Supplies Incident to Other Diagnostic Services Medical/Surgical Supplies Incident to Radiology Minor Surgery ­ Operating Room Missed Appointments Magnetic Resonance Imaging (MRI) MRI Brain MRI ­ Contrast Media MRI ­ Spinal Neonatal ICU Non-Covered Inpatient Non-Ionic Contrast Material (Also see 0254, 0320, 0350,0636) Non-Sterile Supply Nuclear Medicine Nursery Obstetrical (OB) Stress Test Observation Room Occupational Therapy Occupational Therapy ­ Evaluation Oncology (Discrete Unit only) (Also see 033X, 063X) Operating Room Oral Anti-Nausea Drug Organ Acquisition Organ Transplant (Operating Room) Orthotic Devices Ostomy Supplies Other Diagnostic Services Other Imaging Services Other Therapeutic Services Outpatient Services/Inpatient Claim Outpatient ­ Invasive via Blood Specimen for Clinical Lab use HCPCS 10

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0920 0270 0278 0274 0300 0311 0922 0912 099X 0920 083X 0636 025X 042X 0424 0920 0404 Appendix A 027X 077X 011X 014X 0274 090X 0912 0460 0419 0333 034X 032X 033X 034X 011X,012X 0710 0941 0304 011X,012X 041X 0410 011X,012X 011X,012X 0403 077X 012X

82792 Oximetry ­ Non-Invasive, Ear or Pulse Oxygen ­ Administered at the Hospital Pain Implants Pacemaker Panel Tests Pap Smear (Diagnostic) Pap Smear (Screening) Partial Hospitalization ­ Psych Patient Convenience Items Peripheral Vascular Lab Peritoneal Dialysis ­ Outpatient Persantine, IV Pharmacy (Covered/Non-Covered) Physical Therapy Physical Therapy ­ Evaluation Polysomnography (Sleep Studies) Position Emission Tomography (PET) Pre-Administration IVIG Pressure Bandage Preventative Care Services Private Room and Board Private room and Board ­ Deluxe Prosthetic Devices Psychiatric/Psychological Treatment Psychiatric Therapy ­ Individual Pulmonary Function Pulmonary Rehabilitation Programs Radiation Therapy Radioisotope Lab Radiology ­ Diagnostic Radiology ­ Therapeutic Radionuclides/Radiopharmaceuticals Readmissions Recovery Room Recreational Therapy Renal Dialysis ­ Non-Routine Lab Repeat Admissions Respiratory Services Respiratory Therapy (By Therapist only) Room Rates Same Day Admission/ Transfer Screening Mammography Screening Services Semiprivate Room and Board 11

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0920 027X 044X 0444 0440 0441 0272 0482 0622 027X 0480 0253 0273 0623 0732 0993 0421 0929 0360 0482 0761 0401 0771 Appendix A 0636 0300 015X 0360

Sleep Lab/Sleep Disorder Clinic ­ Diagnostic Special Garments, i.e. for Burn Patients Speech ­ Language Therapy Speech ­ Language Therapy Evaluation Speech ­ Language Therapy Inpatient Speech ­ Language Therapy Outpatient Sterile Supply Stress Test ­ Treadmill Supplies Incident to Other Diagnostic Services Surgical Supplies Swan-Granz Catheter Take Home Drugs Take Home Supplies Take Home Dressings Telemetry Telephone TENS/PENS Instruction only Transtelephonic Pacemaker Monitoring Transurethral Microwave Thermotherapy Treadmill (Stress Test) Treatment Room Ultrasound Vaccines, Administration Vaccines, Administration Vaccines, Drug Venipuncture (HCPCS 36415) Ward Room and Board YAG Laser (Performed in OR)

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TOTAL CHARGE 0001

BC

N/A DETAILS N/A UNITS N/A HCPCS DESCRIPTION: On the paper UB-04 report the total for all revenue codes as indicated in field locator (FL) 47 (Total Charges) and FL 48 (Noncovered Charges) on line 23 of the last page of the UB-04. For electronic transactions, report the total charge in the appropriate data segment/field ­ Loop 2300 CLM02

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002X

HEALTH INSURANCE PROSPECTIVE PAYMENT SYSTEM (HIPPS)

BC

DETAIL UNITS HCPCS/CPT DESCRIPTION: This revenue code is used to indicate a HIPPS rate code. STANDARD ABBREVIATION:

SUBCATEGORY: 0 - Reserved 1 - Reserved 2 - Skilled Nursing Facility ­ PPS 3 - Home Health PPS 4 - Inpatient Rehabilitation Facility ­ PPS 5 - Reserved 6 - Reserved 7 - Reserved 8 - Reserved 9 - Reserved

SNF PPS (RUG)

HH PPS REHAB PPS (CMG)

TYPE OF CLAIM: Inpatient BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims. SECONDARY CLAIMS: Revenue codes 0022, 0023, and 0024 are allowed when Medicare is the primary payer. For revenue code 0022: 21X, 18X (Skilled Nursing Facility/swing bed PPS) For revenue code 0023: 32X, 33X (Home Health) For revenue code 0024: 11X (inpatient rehabilitation facility/distinct unit) MEDICARE ADVANTAGE: Although these are not products that BCBSKS sells, we will recognize them for our BlueCard® members. From the Medicare Cahaba Web Site, the following is a list of type of bills we will accept and pass onto the members Home Plan for Medicare Advantage home health claims: · · · · 320 ­ Non payment claim 322 ­ Request for Anticipated Payment (RAP) 329 ­ Final claim for HH episode 34X ­ HHA visits provided on an outpatient basis. ('X' denotes the frequency of bill. Refer to the Medicare Claims Processing Manual (CMS Pub 100-04), Ch. 25, 75.1 to determine the correct frequency)

A HIPPS code must be included on the claim.

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The date on the HIPPS code line reflects the assessment date and may or may not fall within the statement covers dates on the claim.

DEFINITIONS: Revenue Code 0022 represents Resource Utilization Group (RUG) classification for Medicare SNF PPS claims. Revenue Code 0024 represents Inpatient Rehabilitation Facility (IRF) DRG grouping for Medicare inpatient rehabilitation claims.

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010X

ROOM AND BOARD ­ SEMIPRIVATE (Two Beds)

BC

DETAIL UNITS HCPCS/CPT # of IP Days Not Required

DESCRIPTION: Flat fee charge incurred on either a daily basis or total stay basis for services rendered. Charge may cover room and board plus ancillary services or room and board only. SUBCATEGORY: STANDARD ABBREVIATION: 0 - All-inclusive Room and Board Plus Ancillary ALL INCLUDE R&B/ANC 1 - All-inclusive Room and Board ALL INCLUDE R&B

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: Revenue code 0100 is used by psychiatric hospitals, substance abuse facilities, and military hospitals. All charges are lumped under this revenue code with units equaling the days the patient was an inpatient. The day of discharge is not counted towards calculating the inpatient days.

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011X

ROOM AND BOARD ­ PRIVATE (One Bed)

BC

DETAIL UNITS HCPCS/CPT # of IP Days Not Required

DESCRIPTION: Routine service charges for accommodations in a single-bed room. Most third party payers require that private rooms be separately identified. STANDARD ABBREVIATION: SUBCATEGORY: ROOM-BOARD/PVT 0 ­ General Classification MED-SUR-GY/PVT 1 ­ Medical/Surgical/Gyn OB/PVT 2 ­ Obstetrics (OB) PEDS/PVT 3 ­ Pediatric PSYCH/PVT 4 ­ Psychiatric HOSPICE/PVT 5 ­ Hospice DETOX/PVT 6 ­ Detoxification ONCOLOGY/PVT 7 ­ Oncology REHAB/PVT 8 ­ Rehabilitation OTHER/PVT 9 ­ Other

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X, 21X, 18X BILLING & CODING GUIDELINES: This section includes instruction for the following (in this order): Units Routine & Nursing Services Room Rates Specialty Rooms Same Day Admission and Transfer Repeat Admissions Date of Death on Day of Admission Bundling Rules Excluded Inpatient Rehabilitation or Inpatient Psychiatric Units Inpatient Claims Denied and/or Not Medically Necessary Inpatient Admission Changed to Outpatient Services Provided Under Arrangements to Inpatients Units: Units are equal to the number of days the patient occupied the inpatient bed. The date of discharge is not counted.

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Routine & Nursing Services: Inpatient services provided by the floor nurse are not separately billable. Routine services are generally included in the provider's daily room and board charge. Routine services are composed of two components: · · General routine services; Special care units (SCU's), including coronary care units (CCUs); and intensive care units (ICU's)

Room charge include: (Per Intitutional Provider Manual/Benefits/Exclusions) · Regular room (including bed ­ a separate charge cannot be made for special beds although a separate charge can be made for special types of mattresses if ordered by a physician) · General dietary services · Patient room supplies routinely furnished to all inpatients including admission or comfort kits. · General nursing services Examples include (not included in IPM): Administration of medication or blood Respiratory treatments Glucose testing or any other bedside lab tests performed by nursing staff Bedside procedures Room Rates: Private Room Rates: Most Blue Cross policies only cover semi-private room charges. If a patient occupies a private room, the average semi-private room rate allowance is applied. The patient will be responsible for charges in excess of this rate. If the facility has only private beds, this becomes the average semi private room rate and no patient responsibility will be applied. Some hospitals have different rates for their semi-private and private SPECIALTY rooms (i.e. telemetry room, isolation room, etc.) versus their acute care room rates. If the patient is in a private specialty room, the provider should bill the room charge with a semi-private specialty revenue code. Registering Room Rates: Room rates must be registered when there is a change in the number of beds or the rates change. Blue Cross requires that providers update their room rates using the form available on the Blue Cross Web site: http://www.bcbsks.com/CustomerService/Providers/forms.htm

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According to Newsletter BC-97-7, the following rates need to register include:

Acute Hospitals:

Room rates Special care unit room rates Partial-day rates Room rates Partial-day rates Room rates

Psychiatric Hospitals:

Rehabilitation Hospitals: Rural Primary Care

Hospitals:

Room rates Special care unit room rates Partial-day rates Medicare swing-bed rates Medicare outpatient payment rates

Veterans Affairs (VA) Hospitals:OMB rates Other Specialty Hospitals:

Room rates Other rates as appropriate

Rates can also be sent using the online form to: Institutional Relations Department CC442D2 Blue Cross and Blue Shield of Kasnas 1133 SW Topeka Blvd Topeka KS 66629-0001 FAX: (785) 290-0734 Specialty Rooms: Some facilities set room rates by specialty care units due to the cost of care. For example, there may be telemetry rooms, orthopedic rooms, isoloation rooms. These rooms may have different rates based on the costs associated with nursing, equipment and supplies used. These rates should also be reported to Blue Cross and Blue Shield of Kansas (http://www.bcbsks.com/CustomerService/Providers/forms.htm) Same Day Admission and Transfer Provider should submit the claim showing the Statement Covers Period ­ FROM and THROUGH dates to be the same for room and board and ancillaries.

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Repeat Admissions Repeat admissions per physician orders should be billed as two claims, however, these cases may be reviewed and if it is determined they should be combined, the provider will be notified. Hour of admission and discharge should be included.

Date of Death on the Day of Admission When the date of death is the day of admission, all charges are billable as covered. Bundling Rules Charges for services rendered to an outpatient who is admitted into acute care before midnight of the following day are included in the payment allowance for the inpatient stay and must be billed to BCBSKS on the inpatient claim. This applies only to outpatient services performed at the same facility where the patient is subsequently admitted. This rule does not apply to free-standing rehabilitation, psychiatric or specialty hospitals, but does apply to hospital-based units. To prevent claim overpayments, BCBSKS implemented the following claim processing guidelines around January 1, 2003: Claims from Contracting Providers When an outpatient claim is paid and BCBSKS receives an inpatient claim with service dates that indicate the outpatient bundling rule applies, we will return the inpatient claim to the provider indicating the outpatient charges should be added to the inpatient claim. A new inpatient claim should be submitted. At the same time the outpatient claim will be adjusted resulting in either an automatic deduct or refund request (depending on the hospital) to recoup the payment. When an inpatient claim is paid and BCBSKS receives an outpatient claim with service dates that indicate the outpatient bundling rule applies, we will return the outpatient claim indicating the charges should be added to the inpatient claim and a "corrected" inpatient claim should be submitted.

The information in this section DOES NOT apply to free-standing psychiatric, rehabilitation or specialty hospitals.

Excluded Inpatient Rehabilitation or Inpatient Psychiatric Units Newsletter BC-07-13, HP-07-10, SA-07-10, HHA-07-10, DC-07-10, dated 6/15/07 Effective for claims received on and after May 23, 2007 For acute care hospitals with an excluded rehabilitation or psychiatric unit: · When a patient is admitted to the rehab/psych unit, the hospital must pre-certify the admission and bill the claim with the applicable NPI. · Hospitals will bill a separate inpatient claim for each different NPI. Contains Public Information Revision Date: March 31, 2009 20

·

d to

When hospitals pre-certify an inpatient admission, they must identify if the patient is acute or if they reside in the excluded unit. · The billed claim should match the pre-certification. · If the patient is admitted to acute care and later transferred to the excluded psychiatric or rehabilitation unit (or vice versa), split the inpatient claim and bill multiple claims using the separate NPIs. · If a patient is admitted acute and later transferred to the excluded unit or vice versa, the care must be pre-certified in each unit, using the online system to pre-certify acute care. The pre-certification of psychiatric or rehabilitation services must be done by telephone. · If a patient is treated at a hospital as an outpatient and is admitted as an inpatient before midnight of the following day, the outpatient services must be included on the inpatient claim. This rule applies to admissions to inpatient acute, rehabilitation or psychiatric excluded units. · The payment allowance for care in an excluded psychiatric or rehabilitation unit will be a per diem per day. A letter with this rate is sent to the provider. · The payment allowance for rehabilitation and psychiatric care billed with a NPI number different from the acute NPI is based on the contract (i.e. per diem rate for rehab/psych distinct units). · If hospital has a unique contractual arrangement with BCBSKS, the allowance is based on that contract. Blue Cross and therefore, have not been included in this payment logic.)

Inpatient Claims Denied and/or Not Medically Necessary If an inpatient admission is not medically necessary, Blue Cross will allow services (omitting room and board charges) according to the member's outpatient benefits. Providers should bill an outpatient claim with line item dates of service, applicable HCPCS and units. Room and Board charges should be billed as non-covered, according to the following information which is taken from the Blue Cross Institutional Provider Manual, which can be found on the BCBS Web site: BCBSKS - Customer Service - Providers - Publications - Institutional - Manuals Section 6, section V THE INFORMATION BELOW APPLIES TO INPATIENT HOSPITAL CLAIMS PAID BASED ON THE DRG PAYMENT PROCESS. This guideline does not apply to inpatient hospital services that are paid based on a daily per diem. Guidelines for per diem paid hospital claims have not changed and are outlined in the BCBSKS Institutional Provider Manual, Section VI. When a patient is admitted as an inpatient, BCBSKS medical review staff determines the inpatient medical necessity of the stay based on information Contains Public Information Revision Date: March 31, 2009 21

furnished by the hospital. If during the stay, our medical review staff determines that care no longer meets our inpatient medical necessity criteria, the date on which this determination is made is the first non-covered day rather than the last covered day. Physician Discharges the Patient on the SAME Day BCBSKS Issues the Denial Notice If hospital staff receives a denial notice from BCBSKS medical review, and if the physician discharges the patient the same day, there are no non-covered days. The hospital will submit a claim for the complete stay, admission through discharge. There is no room and board charge for the day of discharge. Physician DOES NOT Discharge the Patient on the Day BCBSKS Issues the Denial Notice If the physician does not discharge the patient the same day the hospital staff receives the inpatient medical necessity denial notice from BCBSKS medical review and if the patient remains an inpatient beyond the first non-covered day, the hospital will: · File one hard copy claim reporting the charges for the entire admission. This includes the date of admission through the date when the physician discharges the patient. · Report the covered and non-covered room and board charges on separate billing lines. · The covered room and board "units" and charges would include the days beginning with the day of admission and up to but not including the day BCBSKS notified the hospital that the stay no longer meets inpatient medical necessity criteria. · The non-covered room and board "units" and charges would begin with the day the hospital was notified of the non-coverage through the date of the physician discharge so the discharge day does not count as a unit nor are the room and board charges for this day.) When BCBSKS processes the claim, we will: · Remove the non-covered room and board charges from the original claim and process them separately. These charges will be denied as a provider write-off unless the provider attaches a copy of a Notice of Personal Financial Obligation (NOPFO) signed by the patient. If the NOPFO is included with the claim, the non-covered room and board charges will be denied as the patient's responsibility. · The "from" and "through" dates on the original claim will be changed to reflect only the covered dates of service. The DRG payment calculation will be determined based on the number of covered days plus the ancillary charges incurred during the complete stay (including ancillary charges on the non-covered days).

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The following example illustrates how a claim will be processed when a physician does not discharge the patient on the day that BCBSKS issues the denial notice. DATE OF ADMISSION: BCBSKS ADVISES HOSPITAL PATIENT NO LONGER MEETS INPATIENT ACUTE CRITERIA: PHYSICIAN DISCHARGES PATIENT: 4/1/09

4/8/09 4/10/09

When the hospital submits the claim they will show: · · · · Statement covers period for the complete stay "from" date 040109 and "through" date 041009 Room and board for the covered days totaling 7 units. On a separate billing line, room and board for the non-covered days totaling 2 units. Ancillary charges for the entire stay.

BCBSKS will:

Split the room and board charges for the two non-covered days onto a

separate claim and deny the charges. This claim will show "from" and "through" dates of 040809-041009 and 2 units. If a Notice Of Personal Financial Obligation (NOPFO) signed by the patient/member is included with the claim, the charges will be denied as the member's responsibility. If no NOPFO is sent in, the charges will be denied as a provider write-off. Process all the remaining charges showing a statement covers period "from" and "through" dates of 040109-040809 for 7 units. The DRG payment calculation will be based on the covered acute days and the ancillary charges for the complete stay. Inpatient Admission Changed to Outpatient BCBSKS expects facilties to determine whether the patient is an inpatient or outpatient prior to filing the claim. However, it is in the best interest of the provider to determine whether a patient is inpatient or outpatient prior to the patient's discharge from the facility. Documentation in the patient record should include physician orders for the level of care that is submitted to BCBSKS. Failure to pre-certify an inpatient admission will result in a penalty. Services Provided Under Arrangements to Inpatients Charges (with revenue codes) for all services provided to an inpatient of a Contains Public Information Revision Date: March 31, 2009 23

facility must be included on an inpatient institutional claim with the exception of ambulance charges. Examples of such charges are CT scans at another hospital, surgically inserted prosthetic devices and charges for the technical components of all services performed outside the hospital. This limitation does not include the professional component of diagnostic services such as pathology, radiology or cardiology. The professional component would be billed on the CMS-1500 claim form. Include on all inpatient billings, charges for hospital services provided to BCBSKS members that are obtained from another organization (related or unrelated), except the technical component of anatomical laboratory, while an inpatient in the hospital. Hospitals that do not have an anatomical laboratory, that are obtaining this service from another source, are not required to include the technical component in the inpatient charges. Hospitals that have an anatomical laboratory must include the technical component in the inpatient charges. This exception applies to anatomical laboratory services only. The cost for supervision of a hospital department by a physician is an administrative expense of the hospital. SECONDARY CLAIMS: Medicare Lifetime Reserve Days & Plan 65: · BCBSKS Plan 65/Disability Plan picks up the Medicare coinsurance for Lifetime Reserve Days. · The patient must exhaust the sixty (60) Medicare Lifetime Reserve Days before further benefits will be paid by Plan 65/Disability Plan. · After the Medicare hospital inpatient coverage (including lifetime reserve days) is exhausted, Plan 65 coverage extends coverage for an additional 365 days per lifetime. Coverage of the Medicare Part A eligible expenses for hospitalization is paid at the diagnostic related group (DRG) day outlier per diem or other appropriate standard of payment. The day Medicare benefits are exhausted should be on the claim. Precert activity should begin on that date. Medicare Exhausted Benefits BCBSKS uses the BCBSKS allowance to determine payment in these situations. REIMBURSEMENT Freestanding skilled nursing facilities are paid per diem. Hospital-based skilled unit/swingbed (per contract): CAP ­ Hospitals with a skilled nursing unit or swing-bed will be reimbursed at the lesser of charge or CAP MAP based on the MS-DRG assigned to the inpatient skilled stay.

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Blue Choice ­ Hospitals with a skilled nursing unit or swing-bed will not be reimbursed, as there is no coverage for this benefit. When a non Map'd DRG applies, reimbursement will be the provider's charge less the appropriate discount as specified by the member's network (i.e. Blue Choice). If the patient does not have an inpatient skilled-level-of-care benefit, the contracting provider may bill the patient for the non-covered room and board charges if the patient was given a written (NOPFO) prior to the services being rendered. Inpatient Rehabilitation Units (hospital-based): For acute-care hospitals with Medicare certified rehabilitation units (same NPI), when the rehabilitation stay follows an acute stay, a separate daily allowance will apply for each day that a patient resides in that rehabilitation unit. For acute-care hospitals with Medicare certified rehabilitation units that have separate NPIs, the inpatient stay will be paid by specific per diem rate. See MAP listing. Inpatient Psychiatric Units (hospital-based): For acute-care hospitals with Medicare certified psychiatric units that have separate NPIs, the inpatient stay will be paid by specific per diem rate. See MAP listing. REFERENCES: For more information regarding claims billing for denied days see: BCBSKS Customer Service - Providers - Publications - Institutional - Manuals - Institutional Relations Manuals Section 6.

BC-97-7 Newsletter (Registration of Room Rates and Notification of New or Expanded Services): http://www.bcbsks.com/CustomerService/Providers/Publications/institutional/newsletters/ 1997/970514977RegistrationofRoomRates.htm

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DETAIL # of IP Days UNITS Not Required HCPCS/CPT DESCRIPTION: Routine service charges for accommodations in a semi-private room. Most third party payers require that semi-private rooms be identified. STANDARD ABBREVIATION: SUBCATEGORY: ROOM-BoardARD/2 BED 0-General classification MED-SUR-GY/2 SEMI 1-Medical/Surgical/Gyn OB/SEMI-PVT 2-Obstetrics (OB) PEDS/SEMI-PVT 3-Pediatric PSYCH/SEMI-PVT 4-Psychiatric HOSPICE/SEMI-PVT 5-Hospice DETOX/SEMI-PVT 6-Detoxification ONCOLOGY/ SEMI 7-Oncology REHAB/SEMI-PVT 8-Rehabilitation OTHER/SEMI-PVT 9-Other

012X

ROOM AND BOARD ­ SEMI-PRIVATE (Two Beds)

BC

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X, 21X, 18X BILLING & CODING GUIDELINES: This section includes instruction for the following (in this order): Units Routine & Nursing Services Room Rates Specialty Rooms Same Day Admission and Transfer Repeat Admissions Date of Death on Day of Admission Bundling Rules Excluded Inpatient Rehabilitation or Inpatient Psychiatric Units Inpatient Claims Denied and/or Not Medically Necessary Inpatient Admission Changed to Outpatient Services Provided Under Arrangements to Inpatients Units: Units are equal to the number of days the patient occupied the inpatient bed. The date of discharge is not counted. Routine & Nursing Services: Inpatient services provided by the floor nurse are not separately billable. Routine services are generally included in the provider's daily room and board charge. Routine services are composed of two components:

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· ·

General routine services; and Special care units (SCU's), including coronary care units (CCUs) and intensive care units (ICU's)

Room charge include: (Refer to Institutaionl Provider Manual/Benefits/Exclusions) · Regular room (including bed ­ a separate charge cannot be made for special beds although a separate charge can be made for special types of mattresses if ordered by a physician) · General dietary services · Patient room supplies routinely furnished to all inpatients including admission or comfort kits. · General nursing services Examples include: Administration of medication or blood Respiratory treatments Glucose testing or any other bedside lab tests performed by nursing staff Bedside procedures Room Rates: Private Room Rates: Most Blue Cross policies only cover semi-private room charges. If a patient occupies a private room, the average semi-private room rate allowance is applied. The patient will be responsible for charges in excess of this rate. If the facility has only private beds, this becomes the average semi private room rate and no patient responsibility will be applied. Some hospitals have different rates for their semi-private and private SPECIALTY rooms (i.e. telemetry room, isolation room, etc.) versus their acute care room rates. If the patient is in a private specialty room, the provider should bill the room charge with a semi-private specialty revenue code. Registering Room Rates: Room rates must be registered when there is a change in the number of beds or the rates change. Blue Cross requires that providers update their room rates using the form available on the Blue Cross Web site: http://www.bcbsks.com/CustomerService/Providers/forms.htm According to Newsletter BC-97-7, the following rates need to register include:

Acute Hospitals:

Room rates Special care unit room rates Partial-day rates Room rates Partial-day rates 27

Psychiatric Hospitals:

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Rehabilitation Hospitals: Rural Primary Care

Room rates

Hospitals:

Room rates Special care unit room rates Partial-day rates Medicare swing-bed rates Medicare outpatient payment rates

Veterans Affairs (VA) Hospitals:OMB rates Other Specialty Hospitals:

Room rates Other rates as appropriate

Rates can also be sent using the online form to: Institutional Relations Department CC442D2 Blue Cross and Blue Shield of Kasnas 1133 SW Topeka Blvd Topeka KS 66629-0001 FAX: (785) 290-0734 Specialty Rooms: Some facilities set room rates by specialty care units due to the cost of care. For example, there may be telemetry rooms, orthopedic rooms, isolation rooms. These rooms may have different rates based on the costs associated with nursing, equipment and supplies used. These rates should also be reported to Blue Cross and Blue Shield of Kansas (http://www.bcbsks.com/CustomerService/Providers/forms.htm) Same Day Admission and Transfer Provider should submit the claim showing the Statement Covers Period ­ FROM and THROUGH dates to be the same. Repeat Admissions Repeat admissions per physician orders should be billed as two claims. However, these cases may be reviewed and if it is determined they should be combined, the provider will be notified. Date of Death on the Day of Admission When the date of death is the day of admission, consider the day and charge as covered.

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Bundling Rules Charges for services rendered to an outpatient who is admitted into acute care before midnight of the following day are included in the payment allowance for the inpatient stay and must be billed to BCBSKS on the inpatient claim. This applies only to outpatient services performed at the same facility where the patient is subsequently admitted. This rule does not apply to free-standing rehabilitation, psychiatric or specialty hospitals. These bundling rules DO apply to hospital-based units. To prevent claim overpayments, BCBSKS implemented the following claim processing guidelines around January 1, 2003: Claims from Contracting Providers When an outpatient claim is paid and BCBSKS receives an inpatient claim with service dates that indicate the outpatient bundling rule applies, we will return the inpatient claim to the provider indicating the outpatient charges should be added to the inpatient claim. A new inpatient claim should be submitted. At the same time the outpatient claim will be adjusted resulting in either an automatic deduct or refund request (depending on the hospital) to recoup the payment. When an inpatient claim is paid and BCBSKS receives an outpatient claim with service dates that indicate the outpatient bundling rule applies, we will return the outpatient claim indicating the charges should be added to the inpatient claim and a "corrected" inpatient claim should be submitted.

The information in this section DOES NOT apply to free-standing psychiatric, rehabilitation or specialty hospitals.

Excluded Inpatient Rehabilitation or Inpatient Psychiatric Units Newsletter BC-07-13, HP-07-10, SA-07-10, HHA-07-10, DC-07-10, dated 6/15/07 Effective for claims received on and after May 23, 2007 For acute care hospitals with an excluded rehabilitation or psychiatric unit: · When a patient is admitted to the rehab/psych unit, the hospital must pre-certify the admission and bill the claim with the applicable NPI. · Hospitals will bill a separate inpatient claim for each different NPI. · When hospitals pre-certify an inpatient admission, they must identify if the patient is acute or if they reside in the excluded unit. · The billed claim should match the pre-certification. · If the patient is admitted to acute care and later transferred to the excluded psychiatric or rehabilitation unit (or vice versa), split the inpatient claim and bill multiple claims using the separate NPIs. · If a patient is admitted acute and later transferred to the excluded unit or vice versa, the care must be pre-certified in each unit, using the online system to pre-certify acute care. The pre-certification of psychiatric or rehabilitation services must be done by telephone. Contains Public Information Revision Date: March 31, 2009 29

·

· · ·

If a patient is treated at a hospital as an outpatient and is admitted as an inpatient before midnight of the following day, the outpatient services must be included on the inpatient claim. This rule DOES apply to admissions to inpatient acute, rehabilitation or psychiatric excluded units. The payment allowance for care in an excluded psychiatric or rehabilitation unit will be a per diem per day. A letter with this rate is sent to the provider. The payment allowance for rehabilitation and psychiatric care billed with a NPI number different from the acute NPI is based on the contract (i.e. per diem rate for rehab/psych distinct units). If hospital has a unique contractual arrangement with BCBSKS, the allowance is based on that contract.

Inpatient Claims Denied and/or Not Medically Necessary If an inpatient admission is not medically necessary, Blue Cross will allow services (omitting room and board charges) according to the member's outpatient benefits. Providers should bill an outpatient claim with line item dates of service, applicable HCPCS and units. Room and Board charges should be billed as non-covered, according to information below.

When BCBSKS processes the claim, we will: · Remove the non-covered room and board charges from the original claim and process them separately. These charges will be denied as a provider write-off unless the provider attached a copy of a Notice of Personal Financial Obligation (NOPFO) signed by the patient. If the NOPFO is included with the claim, the non-covered room and board charges will be denied as the patient's responsibility. · The "from" and "through" dates on the original claim will be changed to reflect only the covered dates of service. The DRG payment calculation will be determined based on the number of covered days plus the ancillary charges incurred during the complete stay (including ancillary charges on the non-covered days).

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The following example illustrates how a claim will be processed when a physician does not discharge the patient on the day that BCBSKS issues the denial notice. DATE OF ADMISSION BCBSKS ADVISES HOSPITAL PATIENT NO LONGER MEETS INPATIENT ACUTE CRITERIA PHYSICIAN DISCHARGES PATIENT 4/1/09 4/8/09 4/10/09

When the hospital submits the claim they will show: · · · · Statement covers period for the complete stay "from" date 040109 and "through" date 041009 Room and board for the covered days totaling 7 units. On a separate billing line, room and board for the non-covered days totaling 2 units. Ancillary charges for the entire stay.

BCBSKS will:

Split the room and board charges for the two non-covered days onto a

separate claim and deny the charges. This claim will show "from" and "through" dates of 040809-041009 and 2 units. If a Notice Of Personal Financial Obligation (NOPFO) signed by the patient/member is included with the claim, the charges will be denied as the member's responsibility. If no NOPFO is sent in, the charges will be denied as a provider write-off. Process all the remaining charges showing a statement covers period "from" and "through" dates of 040109-040809 for 7 units. The DRG payment calculation will be based on the covered acute days and the ancillary charges for the complete stay. Inpatient Admission Changed to Outpatient BCBSKS expects facilties to determine whether the patient is considered an inpatient or outpatient prior to filing the claim. However, it is in the best interest of provider to determine whether a patient is inpatient or outpatient prior to the patient's discharge from the facility. Documentation in the patient record should include physician orders for the level of care that is submitted to BCBSKS. Failure to pre-certify an inpatient admission could result in a penalty. Services Provided Under Arrangements to Inpatients Charges (with revenue codes) for all services provided to an inpatient of a facility must be included on an inpatient institutional claim with the exception of Contains Public Information Revision Date: March 31, 2009 31

the

ambulance charges. Examples of such charges are CT scans at another hospital, surgically inserted prosthetic devices and charges for the technical components of all services performed outside the hospital. This limitation does not include the professional component of diagnostic services such as pathology, radiology or cardiology. The professional component would be billed on the CMS-1500 claim form. Include on all inpatient billings, charges for hospital services provided to BCBSKS members that are obtained from another organization (related or unrelated), except the technical component of anatomical laboratory, while an inpatient in the hospital. Hospitals that do not have an anatomical laboratory, that are obtaining this service from another source, are not required to include the technical component in the inpatient charges. Hospitals that have an anatomical laboratory must include the technical component in the inpatient charges. This exception applies to anatomical laboratory services only. The cost for supervision of a hospital department by a physician is an administrative expense of the hospital. SECONDARY CLAIMS: Medicare Lifetime Reserve Days & Plan 65: · BCBSKS Plan 65/Disability Plan picks up the Medicare coinsurance for Lifetime Reserve Days. · The patient must exhaust the sixty (60) Medicare Lifetime Reserve Days before further benefits will be paid by Plan 65/Disability Plan. · After the Medicare hospital inpatient coverage (including lifetime reserve days) is exhausted, Plan 65 coverage extends coverage for an additional 365 days per lifetime. Coverage of the Medicare Part A eligible expenses for hospitalization is paid at the diagnostic related group (DRG) day outlier per diem or other appropriate standard of payment. Medicare Exhausted Benefits BCBSKS uses the BCBSKS allowance to determine payment in these situations. REIMBURSEMENT Freestanding skilled nursing facilities are paid per diem. Hospital-based skilled unit/swingbed (per contract): CAP ­ Hospitals with a skilled nursing unit or swing-bed will be reimbursed at the lesser of charge or CAP MAP based on the MS-DRG assigned to the inpatient skilled stay. Blue Choice ­ Hospitals with a skilled nursing unit or swing-bed will not be reimbursed, as there is no coverage for this benefit.

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When a non Map'd DRG applies, reimbursement will be the provider's charge less the appropriate discount as specified by the member's network (i.e. Blue Choice). If the patient does not have an inpatient skilled-level-of-care benefit, the contracting provider may bill the patient for the non-covered room and board charges if the patient was given a written notice (NOPFO) prior to the services being rendered. Inpatient Rehabilitation Units (hospital-based): For acute-care hospitals with Medicare certified rehabilitation units (same NPI), when the rehabilitation stay follows an acute stay, a daily allowance will apply for each day that a patient resides in that rehabilitation unit. For acute-care hospitals with Medicare certified rehabilitation units that have separate NPIs, the inpatient will be paid by specific per diem rate. See MAP listing. Inpatient Psychiatric Units (hospital-based): For acute-care hospitals with Medicare certified psychiatric units that have separate NPIs, the inpatient will be paid by specific per diem rate. See MAP listing. REFERENCES: For more information about claims billing for denied days see BCBSKS Customer Service - Providers - Publications - Institutional - Manuals - Institutional Relations Manuals Section 6.

BC-97-7 Newsletter (Registration of Room Rates and Notification of New or Expanded Services): http://www.bcbsks.com/CustomerService/Providers/Publications/institutional/newsletters/ 1997/970514977RegistrationofRoomRates.htm

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013X

ROOM & BOARD ­ THREE & FOUR BEDS

DETAIL UNITS HCPCS/CPT

BC

# of IP Days Not Required

DESCRIPTION: Routine service charges incurred for accommodations with three and four beds. STANDARD ABBREVIATION: SUBCATEGORY: ROOM-BOARD/3&4 BED 0 ­ General Classification MED-SUR-GY/3&4 BED 1 ­ Medical /Surgical/Gyn OB/3&4 BED 2 ­ Obstetrics (OB) PEDS/3&4 BED 3 ­ Pediatric PSYCH/3&4 BED 4 ­ Psychiatric HOSPICE/3&4 BED 5 ­ Hospice DETOX/3&4 BED 6 ­ Detoxification ONCOLOGY/3&4 BED 7 ­ Oncology REHAB/3&4 BED 8 ­ Rehabilitation OTHER/3&4 BED 9 ­ Other

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: Most providers do not use this revenue code. NOTE: Use guidelines for 012X

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014X

ROOM & BOARD ­ DELUXE PRIVATE

DETAIL UNITS HCPCS/CPT

BC

# of IP Days Not Required

DESCRIPTION: Deluxe rooms are accommodations substantially in excess of those provided to private room patients. STANDARD ABBREVIATION: SUBCATEGORY: ROOM-BOARD/DLXPVT 0 ­ General Classification MED-SUR-GY/DLXPVT 1 ­ Medical/Surgical/Gyn OB/DLXPVT 2 ­ Obstetrics (OB) PEDS/DLXPVT 3 ­ Pediatric PSYCH/DLXPVT 4 ­ Psychiatric HOSPICE/DLXPVT 5 ­ Hospice DETOX/DLXPVT 6 ­ Detoxification ONCOLOGY/DLXPVT 7 ­ Oncology REHAB/DLXPVT 8 ­ Rehabilitation OTHER/DLXPVT 9 ­ other

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: Most providers do not use this revenue code. NOTE: Use guidelines for 011X

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015X

ROOM AND BOARD - WARD

DETAIL UNITS HCPCS/CPT

BC

# of IP Days Not Required

DESCRIPTION: Routine service charge for accommodations with five or more beds. Most third party payers require ward accommodations to be identified. STANDARD ABBREVIATION: SUBCATEGORY: ROOM-BOARD/WARD 0 ­ General Classification MED-SUR-GY/WARD 1- Medical/Surgical/Gyn OB/WARD 2 ­ Obstetrics (OB) PEDS/WARD 3 ­ Pediatric PSYCH/WARD 4 ­ Psychiatric HOSPICE/WARD 5 ­ Hospice DETOX/WARD 6 ­ Detoxification ONCOLOGY/WARD 7 ­ Oncology REHAB/WARD 8 ­ Rehabilitation OTHER/WARD 9 ­ other

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: Most providers do not use this revenue code. NOTE: Use guidelines for 012X.

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016X

ROOM AND BOARD OTHER

BC

DETAIL UNITS HCPCS/CPT

DESCRIPTION: Any routine service charges for accommodations that cannot be included in the more specific revenue center codes. Provides the ability to identify services as required by payers or individual institutions. Sterile environment is a room and board charge to be used by hospitals that are currently separating this charge for billing. STANDARD ABBREVIATION: SUBCATEGORY: R&B 0 ­ General Classification R&B/STERILE 4 ­ Sterile Environment R&B/SELF 7 - Self Care R&B/OTHER 9 ­ Other

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims.

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017X

NURSERY

DETAIL UNITS HCPCS/CPT

BC

# of IP Days Not Required

DESCRIPTION: Charges for nursing care to newborn and premature infants in nurseries. Per the National Uniform Billing Committee (NUBC) Manual the levels of care correlate to the intensity of the medical service provided to an infant and not the NICU facility certification level assigned by the state. The level of care should be clinically evaluated on a daily basis, typically based on the resources provided to the infact. The assigned revenue code corresponds to the level of care determined during the daily evaluation. The levels of care and resulting revenue codes will, fluctuate during the infant's stay in the facility. STANDARD ABBREVIATION: SUBCATEGORY: NURSERY 0 ­ General Classification NURSERY/LEVEL I 1 - Newborn-Level I NURSERY/LEVEL II 2 ­ Newborn-Level II NURSERY/LEVEL III 3 ­ Newborn-Level III NURSERY/LEVEL IV 4 ­ Newborn-Level IV NURSERY/OTHER 9 ­ Other

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: For BCBSKS, providers should submit separate claims for mother and baby. Revenue code 0174 is considered ICU nursery. Incremental nursing charges are allowed with revenue code 0174 only when the ICU registration of rates documents the registration of ICU rooms and incremental nursing are separate. Units are equal to the number of inpatient days the patient occupied the room. Routine services are not separately billable i.e.: nursing services, isolette, bilirubin lights, and footprints. Equipment that is specifically assigned to the Nursery or ICU is not separately billable. (Refer to the chargeable items list in revenue code section 0270.) SPECIAL PLAN INSTRUCTIONS: Federal Employee Program (FEP) When the newborn remains in the hospital after the mother is discharged and revenue codes 173 or 174 are billed, only one claim is required for the newborn's stay indicating charges from the date of birth to discharge. When the newborn remains in the hospital after the mother is discharged and revenue codes 173 or 174 are not included on the claim, then two claims should be submitted for the newborn. One claim showing the baby's charges until the Contains Public Information Revision Date: March 31, 2009 38

time the mother is discharged and the other providing charges after the mother is discharged. (See newsletter XXX) DEFINITIONS: Subcategories 1-4 are to be used by facilities with nursery services designed around distinct areas and/or levels of care. Levels of care defined under state regulations or other statutes supersede the following guidelines. Level I Level II Routine care of normal full-term or pre-term neonates. (Newborn Nursery*) Low birth-weight neonates who are not sick, but require frequent feeding, and neonates who require more hours of nursing than do normal neonates. (Continuing Care*) Sick neonates who do not require intensive care, but require 6-12 hours of nursing each day. (Intermediate Care*) Constant nursing and continuous cardiopulmonary and other support for severely ill infants. (Intensive Care*)

Level III Level IV

As defined in the guidelines adapted from Chapter 2 (Physical Facilities) of Guidelines for Perinatal Care, Second edition and published by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (1988).

*

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018X

LEAVE OF ABSENCE

(LOA) DETAIL UNITS HCPCS/CPT

BC

# of LOA Days Not Required

DESCRIPTION: Charges for holding a room while the patient is temporarily away from the facility. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification LEAVE OF ABSENCE OR LOA 1 ­ RESERVED 2 ­ Patient Convenience (charges billable) LOA/PT CONV 3 ­ Therapeutic Leave LOA/THERAPEUTIC 4 - ICF/Mentally Retarded- any reason LOA/ICF/MR 5 ­ Nursing Home (for hospitalization) LOA/NURS HOME 9 ­ Other Leave of Absence LOA/OTHER

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X, 21X, 18X BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims. SECONDARY CLAIMS: This revenue code is generally seen on Medicare primary claims.

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019X

SUBACUTE CARE

BC

DETAIL UNITS HCPCS/CPT DESCRIPTION: Accommodation charges for subacute care to inpatients or skilled nursing facilities. SUBCATEGORY: STANDARD ABBREVIATION: 0- General Classification SUBACUTE / GENERAL 1 - Sub-acute Care ­ Level I SUBACUTE/LEVEL I 2 - Sub-acute Care ­ Level II SUBACUTE/LEVEL II 3 - Sub-acute Care ­ Level III SUBACUTE/LEVEL III 4 - Sub-acute Care - Level IV SUBACUTE/LEVEL IV 9 - Other Sub-acute Care SUBACUTE/OTHER

BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims. DEFINITIONS: Accommodation charges for sub-acute care to inpatients in hospitals or skilled nursing facilities. Level I - Skilled Care: Minimal nursing intervention. Co-morbidities do not complicate treatment plan. Assessment of vitals and body systems required 1-2 times per day. Level II - Comprehensive Care: Moderate to extensive nursing intervention Active treatment of co-morbidities - Assessment of vitals and body systems required 2-3 times per day. Level III - Complex Care: Moderate to extensive nursing intervention - Active medical care and treatment of co-morbidities - Potential for comorbidities to affect the treatment plan. Assessment of vitals and body systems required 3-4 times per day. Level IV - Intensive Care: Extensive nursing and technical intervention - Active medical care and treatment of co-morbidities - Potential for comorbidities to affect the treatment plan. Assessment of vitals and body systems required 4-6 times per day. .

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020X

INTENSIVE CARE UNIT

(ICU) DETAIL UNITS HCPCS/CPT

BC

# of Days in ICU Not Required

DESCRIPTION: Routine service charge for medical or surgical care provided to patients who require a more intensive level of care than is rendered in the general medical or surgical unit. Most third party payers require that charges for this service be identified. STANDARD ABBREVIATION: SUBCATEGORY: INTENSIVE CARE OR (ICU) 0 ­ General Classification ICU/SURGICAL 1 ­ Surgical ICU/MEDICAL 2 ­ Medical ICU/PEDS 3 ­ Pediatric ICU/PSYCH 4 ­ Psychiatric ICU/INTERMEDIATE 6 ­ Intermediate ICU ICU/BURN CARE 7 - Burn Care ICU/TRAUMA 8 ­ Trauma ICU/OTHER 9 ­ Other Intensive Care

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: The day the patient is transferred from the ICU is not included in the total number of inpatient days. Blue Cross room rates must be registered when there is a change in the number of beds or the rates change using the rate change form available on the Blue Cross Web site. This category is used for intensive care and /or critical care. Rates using the online form can also be sent to: Institutional Relations Department CC: 442D2 Blue Cross and Blue Shield of Kasnas 1133 SW Topeka Blvd Topeka KS 66629-0001 FAX: (785) 290-0734 Routine services and/or equipment are not separately billable. Examples include oximetry, blood pressure monitors, telemetry, nursing, ventilators, or any equipment expected to be used in an ICU. Incremental nursing charges can be billed separately only when the provider's registration of rates lists room and incremental nursing separately. Providers choose one method of charging; total component for ICU or split ICU and nursing. Contains Public Information Revision Date: March 31, 2009 42

NOTE: IF YOU DO NOT MEET THE REQUIREMENTS FOR THIS LEVEL OF CARE, DO NOT USE THE ICU/CCU ROOM REVENUE CODES. PLEASE NOTIFY THE INSTITUTIONAL RELATIONS DEPARTMENT VIA THE INSTITUTIONAL RELATIONS WEB FORM: https://clyde.bcbsks.com/WebCom/Secure/forms/bcbsks_provider_inquiry.htm OR CALL YOUR PROVIDER REPRESENTATIVE TO ASSURE THAT THE INFORMATION ON FILE CONCERNING YOUR FACILITY IS ACCURATE. See the pages that follow revenue code 021X for ICU/CCU requirements. REFERENCE: BC-97-7 (Room Rates)

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021X

CORONARY CARE UNIT

(CCU)

BC

DETAIL UNITS HCPCS/CPT # of Days in CCU Not Required

DESCRIPTION: Routine service charge for medical care provided to patients with coronary illness who require a more intensive level of care than is rendered in the general medical care unit. If a discrete unit exists for rendering such services, the hospital or third party may wish to identify the service. STANDARD ABBREVIATION: SUBCATEGORY: CORONARY CARE OR (CCU) 0 ­ General Classification CCU/MYO INFARC 1 ­ Myocardial Infarction CCU/PULMONARY 2 ­ Pulmonary Care CCU/TRANSPLANT 3 ­ Heart Transplant CCU/INTERMEDIATE 4 ­ Intermediate CCU CCU/OTHER 9 ­ Other Coronary Care

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: The day the patient is transferred from the ICU is not included in the total number of inpatient days. Blue Cross room rates must be registered when there is a change in the number of beds or the rates change using the room rate change form available on the Blue Cross Web site. Rates using the online form can also be sent to: Institutional Relations Department CC: 442D2 Blue Cross and Blue Shield of Kasnas 1133 SW Topeka Blvd Topeka KS 66629-0001 FAX: (785) 290-0734 This revenue code is not used for Critical Care Unit. Critical Care falls under revenue code 020X. See the following pages for requirements of ICU/CCU. Routine services and/or equipment Routine services and/or equipment are not separately billable. Examples include oximetry, blood pressure monitors, telemetry, nursing, or any equipment expected to be used in an ICU. Incremental nursing charges can be billed separately only when the provider's registration of rates list CCU room and

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incremental nursing separately. Providers choose one method of charging; total component for CCU or split CCU and Nursing. NOTE: IF YOU DO NOT MEET THE REQUIREMENTS FOR THIS LEVEL OF CARE, DO NOT USE THE ICU/CCU ROOM REVENUE CODES. PLEASE NOTIFY THE INSTITUTIONAL RELATIONS DEPARTMENT VIA THE INSTITUTIONAL RELATIONS WEB FORM: https://clyde.bcbsks.com/WebCom/Secure/forms/bcbsks_provider_inquiry.htm OR CALL YOUR PROVIDER CONSULTANT TO ASSURE THAT THE INFORMATION ON FILE CONCERNING YOUR FACILITY IS ACCURATE. REFERENCE: BC-97-7 (Room Rates)

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BLUE CROSS AND BLUE SHIELD OF KANSAS MINIMUM ESSENTIAL REQUIREMENTS FOR APPROVED INTENSIVE/CRITICAL OR CORONARY CARE UNITS The following criteria represents the minimum essential requirements of an intensive/critical and/or coronary care unit enabling a hospital to receive full payments for the Blue Cross patients requiring such care. PHYSICAL ARRANGEMENT The unit must be a multi-bed unit and must be distinctly identifiable as a separate unit. This does not preclude individual rooms within the defined unit. II. STAFFING The ICU/CCU must have its own separate nursing staff headed by a qualified R.N. The unit must be staffed by qualified personnel on a 24-hour basis, while the unit is occupied. "Qualified" is defined to mean those personnel who have received specialized training in intensive or coronary care nursing. EQUIPMENT It is expected that the unit will be fully equipped to carry out all necessary intensive or coronary care functions. Specific equipment will be that deemed necessary and appropriate by the hospital's Intensive/Coronary Care Committee. LIST OF PERSONNEL/EQUIPMENT RECOMMENDED FOR INTENSIVE CARE UNITS A. NURSING Number of clerks per 24 hours Number of LPN's per 24 hours Number of Nurse Assistants per 24 hours Number of RNs per 24 hours B. EQUIPMENT AND SUPPLIES Alternating Pressure Mattress At least one of each sterile tray found in Central Supply plus "clean" trays for certain types of nursing procedures Cardiac Arrest Tray Cardiac Monitor Cardiac Pacemaker EKG Machine ICU/CCU PROGRAMS Emergency Drugs Endo-tracheal Tray External Cardiac Defibrillator Intermittent Positive Pressure Breathing Apparatus IV Cut-Down Tray IV Solutions Lumbar Puncture Tray Piped Oxygen Piped Suction Thoracic Pump Tracheotomy Trays Ventilation Monitors

III.

IV.

C.

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D.

MISCELLANEOUS Cardiac Rooms Cubicle Curtains Emergency Call System and Telephone Multi-Bed Unit

I HEREBY CERTIFY THAT OUR FACILITY IS IN COMPLIANCE WITH THE MINIMUM ESSENTIAL REQUIREMENTS FOR APPROVED INTENSIVE/CRITICAL OR CORONARY CARE UNITS. BLUE CROSS AND BLUE SHIELD OF KANSAS WILL BE NOTIFIED OF ANY CHANGES WHICH COULD AFFECT THE ELIGIBILITY.

___________________________________________________________________ Name of Hospital

__________________________________________________ Signature

__________________ Date

Provider has an intensive/critical care unit. Current Rate:_______________________ Provider has a coronary care unit. Current Rate:_______________

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022X

SPECIAL CHARGES

DETAIL UNITS HCPCS/CPT

BC

224 229 Not Required

DESCRIPTION: Charges incurred during an inpatient stay or on a daily basis for certain services. Some hospitals prefer to identify the components of services rendered in greater detail and thus break out charges for items that normally would be considered part of routine services. STANDARD ABBREVIATION: SUBCATEGORY: SPECIAL CHARGES 0 - General Classification ADMIT CHARGE 1 - Admission Charge TECH SUPPORT CHG 2 - Technical Support Charge UR CHARGE 3 - U.R. Service Charge LATE DISCH/MED NEC 4 - Late Discharge, medically necessary OTHER SPEC CHG 9 - Other Special Charges

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: Only revenue codes 0224 and 0229 can be used. Attempted Surgery Inpatient claims: Attempted surgery is identified with revenue code 0229 on inpatient claims only. ICD-9-CM diagnosis codes V64.1, V64.2, or V64.3 must be present on the claim. Hospitals convert revenue code 0360 (operating room) to revenue code 0229 to avoid edits requiring ICD-9 procedure codes. (When revenue code 0360 is on an inpatient claim, an ICD-9-CM procedure code is required). Outpatient claims: For outpatient situations, if the surgery was cancelled prior to the administration of anesthesia, services provided up to that point should be billed using the appropriate revenue/CPT codes. If the surgery is cancelled after the administration of anesthesia, the revenue/CPT code describing the procedure would be billed. However, the charge should be adjusted to reflect the cancellation of the procedure to assure that proper reimbursement is made in this situation. REIMBURSEMENT: Diagnosis codes V64.1, V64.2 or V64.3 should be used when surgeries are cancelled during an inpatient admission.

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Blue Cross accepts modifiers, but they do not change the reimbursement on the claim.

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023X

INCREMENTAL NURSING CHARGE

BC

DETAIL UNITS HCPCS/CPT Required # of Hours Not Required

DESCRIPTION: Extraordinary charges for nursing services assessed in addition to the typical charge for room and board. STANDARD ABBREVIATION: SUBCATEGORY: NURSING INCREM 0 ­ General Classification NUR INCR/NURSERY 1 ­ Nursery NUR INCR/OB 2 ­ OB NUR INCR/ICU 3 ­ ICU (includes transitional care) NUR INCR/CCU 4 ­ CCU (includes transitional care) NUR INCR/HOSPICE 5 ­ Hospice (not allowed on Blue Cross claim) NUR INCR/OTHER 9 ­ Other

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: When a separate rate is identified for revenue code 0174, 020X, or 021X, revenue codes 0233, 0234, or 0239 can be billed. Revenue code 0235 is not allowed.

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024X

ALL INCLUSIVE ANCILLARY

BC

DETAIL UNITS HCPCS/CPT

Not Required DESCRIPTION: A flat-rate charge incurred on either a daily basis or total stay basis for ancillary services only. Rationale: Hospitals billing in this manner may wish to segregate these charges. STANDARD ABBREVIATION: SUBCATEGORY: ALL INCL ANCIL 0 ­ General Classification ALL INCL BASIC 1 ­ Basic ALL INCL COMP 2 ­ Comprehensive ALL INCL SPECIAL 3 ­ Specialty ALL INCL ANCIL/OTHER 9 ­ Other All-Inclusive Ancillary

TYPE OF CLAIM: Inpatient TYPE OF BILL: 86X BILLING & CODING GUIDELINES: Revenue code 0240 is used by Veterans Administration Hospital on inpatient claims only and represents only the ancillary charges. There must be a separate charge for the room and board on the claim. If the inpatient stay is not medically necessary, two claims will be submitted. Once claim will be indicate the inpatient room and board charges in the noncovered column., while the second claim will be billed providing all ancillary charges on an outpatient claim, following outpatient billing guidelines.

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025X

PHARMACY (also see 063x, an extension of 025x)

BC

DETAIL UNITS HCPCS/CPT X Not Required Required for OP 0251-0259

DESCRIPTION: Charges for medication produced, manufactured, packaged, controlled, assayed, dispensed and distributed under the direction of licensed pharmacist. Additional breakdowns are provided for items that individual hospitals may wish to identify because of internal or third party payer requirements. Subcode 4 is for hospitals that do not bill drugs used for other diagnostic services as part of the charge for the diagnostic service. Sub code 5 is for hospitals that do not bill drugs used for radiology under radiology revenue codes as part of the radiology procedure charge. STANDARD ABBREVIATION: SUBCATEGORY: PHARMACY 0 - General Classification can be used on in or outpatient claims. DRUGS/GENERIC 1 - Generic Drugs DRUGS/NONGENERIC 2 - Non-generic Drugs DRUGS/TAKEHOME 3 - Take Home Drugs DRUGS/INCIDNT OTHER ODX 4 - Drugs Incident to Other Diagnostic Services DRUGS/INCIDENT RAD 5 - Drugs Incident to Radiology DRUGS/EXPERIMT 6 - Experimental Drugs DRGS/NONSCRPT 7 - Non-Prescription Drugs IV SOLUTIONS 8 - IV Solutions DRUGS/OTHER 9 - Other Drugs/Other

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 21X, 18X, 72X, 85X BILLING & CODING GUIDELINES: This section includes instructions for the following (in order): Outpatient Drugs Not Separately Chargeable Pharmacy Fees Drug Administration Contrast Material Take Home Drugs Pharmacy Consultations Vaccines Routine Drugs for ESRD Composite Rate Non-routine Drugs for ESRD Composite Rate If a new new procedure, device, or drug is being used, contact the BCBSKS provider consultant with the appropriate detailed information to obtain a pure code and payment information for that service. Drugs that are ordered but not administered are not separately billable. Contains Public Information Revision Date: March 31, 2009 52

Drugs that are usually self administered are covered when administered to an outpatient or inpatient according to the member's contract. Outpatient or inpatient drugs and biologicals administered directly into an item of durable medical equipment or a prosthetic device are separately billable under Blue Cross. Outpatient Drugs Outpatient drugs provided during the encounter are covered. This includes oral and injectable drugs. HCPCS should be used when available. If the drug has a HCPCS code, bill the code with revenue code 0636. HCPCS J3490 (not otherwise classified) should not be billed. Bill charges for an unidentified drug using revenue code 25X. See Also "Drug Administration" below. Not Separately Chargeable Pharmacy Fees Includes IV additive fees, mixing fees, dispensing fees, or compounding fees. Cost of the services should be included in the overall cost of pharmacy and not billed as a separate charge. Drug Administration Inpatient: Administration of a drug by a nurse is not separately billable on an inpatient claim. This is part of routine nursing and the cost is included in the room and board charge. Outpatient: When billing for covered outpatient pharmacy items, the cost for administering the drug is a billable service. The charge for administration includes both the cost of the room and the nurse's time to administer the drug (administration is billed as one charge per CPT/HCPCS description). See Appendix A in this manual for billing instructions. The revenue code for drug administration should reflect the patient type and room occupied, i.e.: ER patient - 0450, Observation - 0760, Treatment Room - 0761, Clinic Room - 0510. Refer to these sections for billing instructions for drug administration. Administration of a drug in the operating room and/or recovery room is not separately billable on inpatient or outpatient claims. NOTE: The drug cost is separately billable. Contrast Material Inpatient: High osmolar contrast material should be billed under revenue code 0255.

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Low osmolar contrast material can be billed under either revenue code 0254 or 0255. Outpatient: Outpatient claims for high osmolar contrast material (HOCM) should be billed with revenue code 0636 and the appropriate HCPCS: Q9958 Q9959 Q9960 Q9961 Q9962 Q9963 Q9964 HOCM <=149 mg/ml iodine, 1ml HOCM 150-199mg/ml iodine,1ml HOCM 200-249mg/ml iodine,1ml HOCM 250-299mg/ml iodine,1ml HOCM 300-349mg/ml iodine,1ml HOCM 350-399mg/ml iodine,1ml HOCM >= 400 mg/ml iodine,1ml

Outpatient claims for low osmolar contrast material (LOCM) must be billed under revenue code 0636. DO NOT INCLUDE THE LOCM CHARGE IN THE DIAGNOSTIC SERVICE CHARGE. Units must indicate the number of milliliters administered. The record must also reflect the amount (in milliliters (ml)) administered to the patient: Q9965 Q9966 Q9967 Q9951 LOW OSMOLAR CONTRAST MATERIAL, 100-199 mg/ml iodine, 1 ml LOW OSMOLAR CONTRAST MATERIAL, 200-299 mg/ml iodine, 1 ml LOW OSMOLAR CONTRAST MATERIAL, 300-399 mg/ml iodine, 1 ml LOW OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML IODINE CONCENTRATION, PER ML

Take Home Drugs May be covered either in the form of: · a stand alone drug program that applies a deductible per prescription, or · drug coverage which is included as part of the medical benefit package and is subject to the contract deductible/coinsurance (e.g. major medical). BCBSKS commonly refers to this type of coverage as embedded drug coverage. A hospital pharmacy is not considered a contracting pharmacy provider and therefore, is not required to submit a drug claim for a BCBSKS member who obtains a prescription drug from them for use outside the hospital. The hospital may collect the charge for the take home drug from the member. The member Contains Public Information Revision Date: March 31, 2009 54

must then file a claim for reimbursement, using Form 34-4 which can be obtained from the customer service center or at the MEMBER SERVICES section of our web site www.bcbsks.com. Hospitals are asked to assist the member by furnishing them with a statement that includes: · provider name, address, phone number · patient name · date prescription filled · name and strength of drug · national drug code (NDC) · quantity and days supply · total charge The member must submit a claim to BCBSKS with the applicable claim form, which will usually be the MEMBER CLAIM FORM 34-4. If the drug charge is eligible, reimbursement will be sent to the member. The allowance for the drug will be an amount equal to what would have been allowed had the drug been purchased from a contracting pharmacy. If revenue code 0253 is submitted on a UB-04, the charge may be denied as the member's responsibility. When this occurs, information from the section above describes how the member can file a claim for reimbursement. Pharmacy Consultations (Outpatient Service) This is a non-covered service. If the service is provided, the hospital must issue a Notice of Personal Financial Obligation (NPFO) form. Vaccines Most contracts cover these services inpatient or outpatient. They may be billed under revenue code 025X or 0636 with an appropriate HCPCS code. Routine Drugs for ESRD Composite Rate Certain parenteral items used in the dialysis procedure are covered under the composite rate and may not be billed separately. Drugs that are used as a substitute for any of these items, or are used to accomplish the same effect, are also covered under the composite rate. For home patients choosing Method II payments, these items may be covered without documentation for medical necessity and may be billed by an ESRD facility regardless of where they are furnished. Following is a list of these items:

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Hydralazine Inderal Insulin Lanoxin Levophed Lidocaine Local Anesthetics Mannitol Pressor drugs Protamine Saline Solu-cortef Verapamil The administration of these items (both staff time and supplies) is covered under the composite rate and may not be billed separately. *Albumin may be reasonable and medically necessary for the treatment of certain complications in dialysis patients. In such cases, facilities must submit medical justification (ICD-9-CM code) to show the medical need. If BCBSKS approves, separate payment in addition to the composite rate may be made. However, if albumin is used as a substitute for any parenteral item covered under the composite rate (e.g., as a volume expander), payment for it is included in the facility's composite rate for maintenance dialysis. Non-routine Drugs for ESRD Composite Rate The following categories of drugs (including but not limited to) are separately billable when provided in the dialysis facility to treat the patient's renal condition: Anabolics Analgesics Antibiotics Hematinics Muscle Relaxants Sedatives Thrombolytics* Tranquilizers

Antiarrythmics Antibiotics (when used at home by a patient to treat an infection of the catheter site or peritonitis associated with peritoneal dialysis) Antihistamines Antihypertensives Apresoline (hydralazine) BenadrylDopamine Glucose Dextrose Heparin Heparin antidotes

*Thrombolytics are used to declot central venous catheters. These items may only be billed by an ESRD facility if they are actually administered in the facility by facility staff. Staff time used to administer separately billable parenteral items is covered under the composite rate and may not be billed separately.

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This revenue code category is allowed for type of bill 85X when Medicare is the primary payer. Medicare requires facilities to bill non-covered (i.e. self-administered drugs) with HCPCS A9270 with a GY modifier (statutory excluded service). This coding instruction should not be used when BCBSKS is primary.

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026X

IV THERAPY

DETAIL

BC

260 261 269 Not Required Required for OP

UNITS HCPCS/CPT

DESCRIPTION: Exquipment charge or administration of intravenous solution by specially trained personnel to individuals requiring such treatment. STANDARD ABBREVIATION: SUBCATEGORY: IV THERAPY 0 ­ General Classification IV THER/INFSN PUMP 1 ­ Infusion Pump IV THER/PHARM SVC 2 ­ IV Therapy/Pharmacy Svcs IV THER/DRUG/SUPPLY/DEL 3 ­ IV Therapy/Drug/Supply Delivery IV THER/SUPPLIES 4 ­ IV Therapy/Supplies IV THERAPY/OTHER 9 ­ Other IV Therapy

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X BILLING & CODING GUIDELINES: BCBSKS allows use of revenue codes 0260 and 0269 on outpatient claims only when a distinct unit exists. Revenue code 0261 is not separately billed. REFERENCES: Refer to revenue codes 025X and 063X for billing drugs. Refer to revenue code 027X for supplies. Refer to revenue codes 045X, 076X or Appendix A for drug administration.

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027X

MEDICAL/SURGICAL SUPPLIES AND DEVICES (ALSO SEE 062X, AN EXTENSION OF 027X)

BC

DETAIL UNITS HCPCS/CPT 0274 - # of Devices Preferred

DESCRIPTION: Charges for supply items required for patient care. Additional breakdowns are provided for items that hospitals may wish to identify because of internal third party payer requirements. STANDARD ABBREVIATION: SUBCATEGORY: MED-SUR SUPPLIES 0 ­ General Classification NON-STER SUPPLY 1 ­ Non Sterile Supply STERILE SUPPLY 2 ­ Sterile Supply TAKEHOME SUPPLY 3 ­ Take Home Supplies PROSTH/ORTH DEV 4 ­ Prosthetic/Orthotic Devices PACEMAKER 5 ­ Pacemaker INTRA OC LENS 6 ­ Intraocular Lens 02/TAKEHOME 7 ­ Oxygen ­ Take Home SUPPLY/IMPLANTS 8 ­ Other Implants SUPPLY/OTHER 9 ­ Other Supplies/Devices

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X BILLING & CODING GUIDELINES: This section includes instructions for the following (in order): Prosthetic/Orthotic Devices (PO/OS) Sugical Dressings (SD) Durable Medical Equipment (DME) Other Supplies Take-home Supplies Intraoccular Lens ­ Revenue Code 0276 ESRD Facilities Hospice If there are new procedures, devices, or drugs being used, contact a BCBSKS provider consultant with the appropriate detailed information to obtain a pure code and payment information for that service. Prosthetic/Orthotic Devices (PO/OS) If prosthetics/orthotics and ostomy supplies are provided during an outpatient encounter the charges are billed with revenue code 0274 and the appropriate HCPCS.

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Surgical Dressings (SD) Items listed on the Prosthetic/Orthotic listing with a SD are surgical dressings see also revenue code 0623. Surgical dressings may be billed under revenue code 0270 or 0272. HCPCS are not required. Outpatient take home surgical dressings are billed under revenue code 0623. Refer to revenue code 062X for detailed instructions. Durable Medical Equipment (DME) If the device is not identified as a Prosthetic/Orthotic or Surgical dressing, and the item is provided to the patient for primary use at home, the item is considered DME and must be billed on a CMS 1500 claim form. If the item is used during a patient encounter to treat the patient's condition, it is a routine supply and billed with revenue code 0270. Codes that are considered DME must be billed on a CMS 1500 claim form when provided to the patient for take home use. The facility should obtain a DME provider number and bill accordingly on a CMS1500 claim form to the Blue Cross and Blue Shield of Kansas. If items classified as DME are provided during an inpatient, they are covered and billed as supplies without a HCPCS code. Other Supplies Supply items other than those identified in the previous sections, may be billed separately if documented in the medical record. These are usually billed under the 0270 revenue code. However, other revenue codes such as 0272 may be used. Supply items needed to treat the patient during the encounter, such as needles, dressings, and surgical supplies fall into this category. Some of the items may have a HCPCS but when used during the patient encounter they are billed as general supplies on a UB-04, without a HCPCS. Take-home Supplies Supplies (not to include prosthetic, orthotic, ostomy or take home surgical dressings) dispensed to a patient solely for take home use are considered as DME items. The facility should obtain a DME provider number and bill on a CMS1500 claim form. Intraocular Lens - Revenue code 0276 Although a separate charge is not required for the intraocular lens (IOL), BC prefers a separate charge along with the appropriate HCPCS code for the IOL (CPT codes 66982, 66983, 66984, 66985 and 66986). The IOL is billed under revenue code 0276; the surgical procedure is billed under 036X.

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ESRD Facilities ESRD facilities cannot bill separately for supplies. Supplies are included in the composite rate. Home Health Facilities For home health facilities, supplies are included in the payment for the skilled or therapeutic visit. Hospice TPN, which is for a chronic condition unrelated to the terminal condition and considered palliative, will be reviewed for coverage on an individual consideration basis, subject to the insured's coverage. If TPN is not considered palliative, we assume that the hospice will discharge the patient so that non-hospice benefits under the insured's contract will resume. Drugs for HIV patients are also considered part of the per diem. If not considered palliative, we again assume that the hospice provider will discharge the patient so that non-hospice benefits under the insured's contract will resume. REFERENCE: Prosthetic/Orthotic, Ostomy Two sources Blue Cross and Blue Shield of Kansas uses to verify code classifications.

1. The Medicare Durable Medical Equipment/Prosthetic Orthotic device fee

schedule can be obtained on the CMS web site: http://www.cms.hhs.gov/DMEPOSFeeSched/LSDMEPOSFEE/list.asp# This file provides HCPCS along with a category classification and lists by state. The codes are considered Level II HCPCS and have an alpha character as the first digit. Below is a classification of each code on the fee schedule: · IN -- Inexpensive and Other Routinely Purchased Items · FS --Frequently Serviced Items · CR --Capped Rental Items · OX --Oxygen and Oxygen Equipment · OS --Ostomy, Tracheostomy & Urological Items · SD --Surgical Dressings · PO --Prosthetics & Orthotics · SU --Supplies · TE --Transcutaneous Electrical Nerve Stimulators · TS - Therapeutic Shoes

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2. The HCPCS file also contains the previous information but includes all Level II

codes. The HCPCS file has the long description of each code. This is a large file and contains helpful information such as termination dates, effective dates and cross reference codes. The HCPCS file can be obtained from the CMS Web site at: http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp# This file will indicate the item type in the column titled PI1. An indicator of 37 is an Ostomy supply, 38 is Prosthetic/Orthotic. For BCBSKS, HCPCS are preferred on outpatient claims, but not required. The service may receive additional reimbursement depending on other services billed on the claim. There are no PO/OS, SD on the MAP listing. Hospice Newsletter: http://www.bcbsks.com/CustomerService/Providers/publications/institutional/ne wsletters/1994/940307HP931HospiceMeetingRecap.htm

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Separately Chargeable Supplies for Blue Cross

Items defined as equipment or supplies that are routine or already included in the cost of another item ARE NOT SEPARATELY chargeable. For example, equipment in the operating room should be included in the cost that determines the charge for the OR. Supplies that are not ordered or documented in the medical record are not separately chargeable. The following list is intended to be a guide for hospital personnel in identifying those items or services not separately billable. The list is divided into three categories: EQUIPMENT/SUPPLIES, PROCEDURES, ROUTINE/ADMINISTRATIVE and PATIENT CONVIENCE ITEMS. THIS IS NOT AN ALL-INCLUSIVE LIST. (UPDATED APRIL 2008)

Equipment/Supplies Adaptive device Anesthesia machine/equipment Aqua machine Bair Hugger blankets Band-aids Bed alarms Bed pans Bed rails Bed scale Beds, specialty Bladder scanner Blood pressure monitor (surgery) Blue Pads Breast pump Breast pumps provided to a patient, which are subsequently taken home with the patient, are considered a patient convenience item. They should be billed to the patient under revenue code 0990. See Revenue Code 0320 Also, see Mattresses, specialty The charge for the equipment should be included in the charge for the test. Charges for equipment should be included in the overall charge for the operating room. Charges for equipment should be included in the overall charge for the operating room. Comments

C-Arm Cameras/Video equipment Canes Crutches ­ inpatient

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Equipment/Supplies Crutches ­ outpatient Daily aspirator rental Defibrillator Diapers, adult Diapers, baby Drapes, covers Electrodes-Physical Therapy

Comments This is considered a DME item. The facility must be a DME provider and must bill to Blue Shield on a CMS 1500 claim form.

Defibrillators permanently housed or stored in a room or ancillary department are not separately chargeable.

Film, x-ray Flexible Stockaide Foot cradle Gloves Glucometers Gowns- All types ID band or bracelet Incubator Kinetic machine Lap sponge Leg lifter Lifter Limb holder Linen, blue pads Masks Mattresses, disposable (eggcrate)

When used in physical therapy the electrodes should be bundled into the modality provided. The cost of supplies (e.g., theraband, hand putty, electrodes) used in furnishing covered therapy care is included in the payment for the HCPCS codes billed by the physical therapist, and are, therefore, not separately billable. See Revenue Code 032X

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Equipment/Supplies Mattresses, specialty Moisturizer, nasal ­ Outpatient Monitor, Bispectral Index (BIS) Monitor, blood pressure Monitor, cardiac/heart

Comments A separate charge can be made for specialty mattresses under revenue code 027X, if ordered by physician.

Exception: A separate charge can be made if the equipment is portable AND there is dedicated personnel monitoring the equipment. If the above criteria are not met, the equipment charge should be part of the room charge. Equipment permanently stored or housed in a room or ancillary department is not separately chargeable.

Monitor, dynamap Ointment (protective barrier) ­ outpatient Pads, heating Pads, incontinence Posey belt Reacher Restraints (arm, leg, limb, etc.) Shave prep kit Shoe horn Specimen cups, traps Specimen hat Sponge, long handle or others used in OR Statlocks (to secure IV lines, PICC, etc) Stitz marker Suction machine

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Equipment/Supplies Supplemental nutrition (Ensure, Vivonex, Citrotin, Jevity)

Comments The FDA classifies these items as food. Therefore a separate charge cannot be made. Items classified as drugs can be charged separately.

Swab sticks Syringes Tattoo ink for Endo Telemetry Theraband See Monitor, cardiac/heart Theraband should be bundled into the treatment provided. The cost of supplies (e.g., theraband, hand putty, electrodes) used in furnishing covered therapy care is included in the payment for the HCPCS codes billed by the physical therapist, and are, therefore, not separately billable.

Thermometer, all types Toilet seat lifter, elevator Transfer belt Trapeze (bed treatment) Urine dipsticks done by nursing Video equipment in surgery & radiology Warming blankets Wipes (adult wash cloths) X-ray copies when sent with patient Equipment permanently stored or housed in a room or ancillary department is not separately chargeable. See Revenue Code 0320

Procedure Descriptions Administration Fees (Drugs) while patient is in the OR or recovery room Catheter care ­ inpatient Compounding Fees (Pharmacy)

Comments The administration charge should be included in the overall operating/recovery room charge. Drugs used may be separately billed. Considered part of routine nursing services Considered part of the overall drug charge.

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Procedure Descriptions

Comments

Dispensing Fees (Pharmacy)

Considered part of the overall drug charge.

IV flush, IV care, IV administration ­ A procedural charge for an IV flush and /or administration cannot inpatient be billed separately. This is considered a routine cost. However, the materials and supplies used for the IV flush and administration can be charged separately. IV flush ­ outpatient The materials and supplies used for the IV flush can be charged separately. A procedure charge for an IV flush can be made if IV drugs were not administered. Considered part of the overall drug charge.

Mixing Fee (Pharmacy)

Lab call back Labor induction Newborn nursing observation Oxygen setup or administration

This is an administrative expense; no separate charge can be made. The labor and delivery room charge includes induction.

This is a service that can be done by nursing staff. If a hospital chooses to have RT perform the service, this does not make it billable. A separate charge should not be made.

Prep time for bone marrow aspirations Radiology call back Respiratory treatments by nursing staff ­ inpatient Specimen handling and processing fees Stat charges or call back charges Tracheostomy Care or suction inpatient Transfusion reaction investigation charges This is an administrative expense; no separate charge can be made.

This is an administrative expense; no separate charge can be made When provided by nursing, this is a routine service. When provided by RT, it is billable.

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Routine Administrative Items/ Services Additional personnel Additive fees After hours personnel Bedside x-ray charge Educational or training materials or books Emergency charge for x-ray Management consultations Medical social services On-call Charges (operating room) Oxygen transport fees Oxygen stand by Pharmacist analysis fees or profile fees Pre-operative Room Social services/Discharge planning Special diet trays

Comments

Patient Convenience Items ­ Admission/ Hygiene/Comfort Admission kits

Comments If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If no separate charge is made, it is considered a routine cost If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990.

Baby bath Baby wipes Carafes Comb/brushes Cool wipes Cosmetics Cot charges Dental cup Deodorant Hand/body lotion and cream Lip balm Mouth moisturizer

If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990.

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Patient Convenience Items ­ Admission/ Hygiene/Comfort Mouth wash Personal belonging bag Pitchers Powder Shampoo Shaving cream

Comments If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990. If a separate charge is made, the charge must be billed to the patient under revenue code 0990.

Slippers, house shoes Soaps Tissue, Kleenex Toothbrush/toothettes Toothpaste

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028X

ONCOLOGY

DETAIL UNITS HCPCS/CPT

BC

DESCRIPTION: Charges for the treatment of tumors and related diseases. Used only by facilities with distinct units. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification ONCOLOGY 9 ­ Other Oncology ONCOLOGY OTHER

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X BILLING & CODING GUIDELINES: This code is allowed if a separate oncology department and cost center is set up to bill an all-inclusive charge. Use General Classification 0280 only. If there is not a separate department, bill charges under revenue code 033X. Chemotherapy drugs are billed under revenue code 0636.

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029X

DURABLE MEDICAL EQUIPMENT (OTHER THAN RENAL)

BC

DETAIL UNITS # of items

HCPCS/CPT DESCRIPTION: Charge for medical equipment that can withstand repeated use (excluding renal equipment). STANDARD ABBREVIATION: SUBCATEGORY: DME 0 - General Classification DME - RENTAL 1 ­ Rental DME - NEW 2 ­ Purchase of New DME DME - USED 3 ­ Purchase of Used DME DME - SUPPLIES/DRUGS 4 - Supplies/Drugs for DME Effectiveness (HHA only) DME - OTHER 9 - Other Equipment

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X, 21X, 18X BILLING & CODING GUIDELINES: Inpatient: DME is allowed on Blue Cross inpatient claims only. Outpatient: Outpatient DME must be billed on the CMS 1500 claim form to Blue Shield. REFERENCES:

Prosthetic/Orthotic, Ostomy Two sources Blue Cross and Blue Shield of Kansas uses to verify code classifications. 1. The Medicare Durable Medical Equipment/Prosthetic Orthotic device fee

schedule can be obtained on the CMS web site: http://www.cms.hhs.gov/DMEPOSFeeSched/LSDMEPOSFEE/list.asp# This file provides HCPCS along with a category classification and lists by state. The codes are considered Level II HCPCS and have an alpha character as the first digit. Below is a classification of each code on the fee schedule: · IN -- Inexpensive and Other Routinely Purchased Items · FS --Frequently Serviced Items · CR --Capped Rental Items · OX --Oxygen and Oxygen Equipment · OS --Ostomy, Tracheostomy & Urological Items · SD --Surgical Dressings · PO --Prosthetics & Orthotics · SU --Supplies Contains Public Information Revision Date: March 31, 2009 71

· ·

TE --Transcutaneous Electrical Nerve Stimulators TS - Therapeutic Shoes

2. The HCPCS file also contains the previous information but includes all Level II

codes. The HCPCS file has the long description of each code. This is a large file and contains helpful information such as termination dates, effective dates and cross reference codes. The HCPCS file can be obtained from the CMS Web site at: http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ANHCPCS/list.asp# This file will indicate the item type in the column titled PI1. An indicator of 37 is an Ostomy supply, 38 is Prosthetic/Orthotic. For BCBSKS, HCPCS are preferred on outpatient claims, but not required. The service may receive additional reimbursement depending on other services billed on the claim. The Blue Cross MAP listing does not include MAPs for prosthetic, orthotic, ostomy or surgical dressing NCDC codes.

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030X

LABORATORY

DETAIL UNITS HCPCS/CPT

BC

303 & 304 # of tests performed/completed Required for OP

DESCRIPTION: Charges for the performance of diagnostic and routine clinical laboratory tests. A breakdown of the major areas in the laboratory is provided in order to meet hospital needs or third party billing requirements. STANDARD ABBREVIATION: SUBCATEGORY: LAB 0 ­ General Classification CHEMISTRY TESTS 1 ­ Chemistry IMMUNOLOGY TESTS 2 ­ Immunology RENAL - HOME 3 - Renal Patient (Home) NON - RTNE DIALYSIS 4 - Non-Routine Dialysis HEMATOLOGY TESTS 5 ­ Hematology BACT & MICRO TESTS 6 ­ Bacteriology & Microbiology UROLOGY TESTS 7 ­ Urology OTHER LAB TESTS 9 - Other Laboratory

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 14X, 18X, 21X, 22X, 72X, 85X Note: There are lab services that have specific medical policies. Refer to the following website link for guidelines. · · · · · BRAC I and BRAC II Testing Fetal Fibronectin Gene Expression Assay for Breast Cancer Treatment Homocysteine Testing Nuchal Translucency

BCBSKS - Medical Review - Institutional - Medical Policies BILLING & CODING GUIDELINES: This section includes instructions for the follow (in order): Outpatient Clinical Lab Reference Diagnostic Lab Travel Allowance Blood Testing Dialysis Laboratory Health Fairs General lab services may be billed using revenue code 0300. Detail billing is required when performing non-routine dialysis lab (revenue code 0304). Contains Public Information Revision Date: March 31, 2009 73

NOTE: If patient is admitted as inpatient by midnight of the following day, all outpatient services are bundled onto the inpatient claim. Outpatient Clinical Lab Outpatient lab is paid on the lab fee schedule except when the services are performed with an ER encounter (revenue code 0450), or observation (revenue code 0762), or a MAP'd surgery. The lab services performed during ER and observation will be priced at the outpatient discount rate. Lab performed on the day of a MAP'd surgery will be packaged with the surgical MAP allowance. Reference Diagnostic Lab Lab is subject to the Blue Cross fee schedule only when revenue codes 045X or 0762 are not present on the claim. If one of these revenue codes is present, the lab service will be processed at the provider's outpatient rate or included in the surgical MAP whichever is applicable. Travel Allowance Blue Cross does not allow separate reimbursement for this service. If submitted, the charge will be processed as a contractual write-off. Blood Testing Tests performed on blood products are not separately billable as a lab service. These charges should be bundled into the blood product, revenue code 039X, as processing costs. Lab tests performed on patient specimens are separately billable under 030X. Dialysis Laboratory When routine dialysis lab services are performed by a facility other than the dialysis facility, they are reimbursed at the ESRD composite rate. Costs of certain ESRD laboratory services performed by either a facilities own dialysis staff or by an independent laboratory (by arrangement) are included in the composite rate payment calculation.

Rules for Laboratory Services Included in the Composite Rate: - - - - Laboratory tests routinely performed for outpatient dialysis patients No additional documentation of medical necessity is required Specimen collection is included in the composite rate for any patient dialyzed in an ESRD facility When any of these tests are performed at a frequency greater than specified, the additional laboratory tests are separately billable and covered IF the documentation supports the medical necessity. 74

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Separately Billable Laboratory Services - Includes all ESRD-related laboratory tests not covered under the composite rate - Medical necessity documentation is required - 2 Categories: All ESRD tests identified as separately billable All tests previously listed as covered under the composite rate when performed at a frequency greater than specified Laboratory Tests Provided by ESRD Facility Routine laboratory tests that are included under the composite rate should NOT be billed separately Laboratory tests that fall outside the composite rate (excluded) should be billed separately. Laboratory Tests Provided by Independent Laboratory When the laboratory test is INCLUDED under the composite rate: The independent laboratory bills the ESRD facility The service is included in the composite rate and is NOT billed separately When the laboratory test is EXCLUDED from the composite rate: The Independent laboratory may bill for the laboratory service.

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LABORATORY SERVICES INCLUDED IN THE COMPOSITE RATE Intermittent Peritoneal Dialysis (IPD) and Continuous Cyclying Peritoneal Dialysis (CCPD) Per Treatment ­ All hemotocrit, hemogloblin, and clotting time tests furnished incident to dialysis teatments; Weekly ­ (1) Prothrombin time for patients on anticoagulant therapy, and (2) Serum Creatinine; Weekly or Thirteen Per Quarter ­ BUN; Monthly ­ Serum Calcium, Serum Potassium, Serum Chloride, CBC, Serum Bicarbonate, Serum Phosphorous, Total Protein, Serum Albumin, Alkaline Phosphatase, aspartate amino transferase (AST) (SGOT) and LDH; and Automated (Panel) Battery of Tests ­ If an automated battery of tests, such as the Comprehensive Metabolic Panel or Basic Metabolic Panel, is performed and contains most of the tests listed in one of the weekly or monthly categories, it is not necessary to separately identify any tests in the battery that are not listed. Continuous Ambulatory Peritoneal Dialysis (CAPD) Monthly - Total Protein; BUN; Albumin; Creatinine Phosphatase; Sodium Alkaline; LDH; Potassium AST; SGOT; CO2; HCT; Calcium; HGB; Magnesium Dialysate; Protein Phosphate LABORATORY SERVICES EXCLUDED FROM THE COMPOSITE RATE (separately billable) Hemodialysis, IPD, CCPD, and Hemofiltration Every 3 months - Serum Aluminum & Serum Ferritin CAPD Every 3 months ­ WBC; RBC; Platelet count Every 6 months - Residual renal functions; 24 hour urine volume Contains Public Information Revision Date: March 31, 2009 76

Health Fair Services Coverage for any service, including those provided at a health fair, is determined by the member's contract with BCBSKS. If the member has benefits for a service they receive at a health fair, the provider is required to submit a claim and payment would be allowed. See the examples below. If a facility offers services at a health fair (or any type of promotion) at a discounted rate, BCBSKS expects to be billed that discounted rate for all services provided to their members during that same time frame. This requirement can be found in the BCBSKS Policies and Procedures for contracting hospital types and reads as follows: "If the Contracting Provider, through a short-term promotion such as a health fair, offers services for a reduced price, BCBSKS must also be billed the lower rate during that time frame." SCENARIO #1 ­ health fair is offering lab services 1. 2. 3. 4. Done on hospital grounds. Done with hospital equipment. Done by hospital personnel. The patient is not registered as an outpatient and there is no direct physician care (no physician orders).

SCENARIO #2 ­ health fair is offering lab services. 1. Done off hospital grounds. 2. Specimens are brought back to the hospital and ran on hospital equipment. 3. Hospital personnel volunteers at the health fair but lab personnel is used to run the specimens. 4. The patient is not registered as an outpatient and there is no direct physician care (no physician orders). Most BCBSKS member contracts do not cover lab services without a physician order.

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031X

LABORATORY PATHOLOGY

BC

DETAIL UNITS HCPCS/CPT # of times test conducted (generally 1 unit per specimen) Required for OP

DESCRIPTION: Charges for diagnostic and routine laboratory tests on tissues and culture. STANDARD ABBREVIATION: SUBCATEGORY: PATHOLOGY LAB 0 ­ General Classification CYTOLOGY TESTS 1 ­ Cytology HYSTOLOGY TESTS 2 ­ Histology BIOPSY TESTS 4 ­ Biopsy PATH LAB OTHER 9 ­ Other Laboratory Pathology

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X BILLING & CODING GUIDELINES: Codes that may fall under this revenue code are: 80500-80502, 88300-88365, 88104-88125, 88160-88199. Inpatient: (Under Arrangement) Hospitals that have an anatomical laboratory must include the technical component in the inpatient charges. This exception applies to anatomical laboratory services only. The cost for supervision of a hospital department by a physician is an administrative expense of the hospital. Outpatient: Most facilities are paid based on the lab fee schedule rate for that specific facility. CPT codes ranging from 88300-88309 are considered add-on services and are paid an additional MAP rate. Diagnostic Pap Smears Use revenue code 0311 and the appropriate CPT code for reporting diagnostic pap smears along with a current and specific diagnosis. Screening Pap Smears Use revenue code 0922 and the appropriate CPT code for reporting screening pap smears along with a current and specific diagnosis.

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032X

RADIOLOGY ­ DIAGNOSTIC

BC

DETAIL UNITS HCPCS/CPT Per Test/HCPCS Description Required for OP

DESCRIPTION: Charges for diagnostic radiology services including interpretation of radiographs and fluorographs. Includes: taking, processing, examining and interpreting radiographs, and fluorographs. A breakdown is provided of the major areas and procedures that individual hospitals or third party payers may wish to identify. STANDARD ABBREVIATION: SUBCATEGORY: DX X-RAY 0 ­ General Classification DX X-RAY/ANGIO 1 ­ Angiocardiography DX X-RAY/ARTHO 2 ­ Arthrography DX X-RAY/ARTER 3 ­ Arteriography DX X-RAY/CHEST 4 ­ Chest X-ray DX X-RAY/OTHER 9 ­ Other

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X NOTE: There are specific radiology diagnostic tests that have medical policies. Please refer to the following website link for guidelines. · · Bone Mineral Density Studies Computed Tomographic Angiography (CTA) BCBSKS - Medical Review - Institutional - Medical Policies BILLING & CODING GUIDELINES: This section includes instruction for the follow (in order): Contrast Material Injections Used in Radiology Conscious Sedation and Drugs Used in Radiology Items Not Separatately Chargeable Interventional Radiology Radiopharmaceuticals Outpatient Claims require HCPCS/CPT and units. Line item date of service is preferred. Some radiology procedures are MAP'd. Refer to your facility outpatient MAP listing for details. Contrast material, interventional radiology, and pharmacy services are eligible for additional reimbursement and must be billed on a separate line item under the appropriate revenue code. CPT codes that may fall into this revenue code section include: 70012-76092 and 76094-76999.

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Contrast Material ­ (For further details-see revenue code 0636): Outpatient claims that include contrast material must have a separate charge under revenue code 0636 with the appropriate HCPCS to receive payment in addition to the radiology procedure. If the charges are combined, you will not receive additional payment. CT's are MAP'd as well as the contrast material, thus, it is important to use the appropriate HCPCS code and unit value to describe the contrast material. Injections used in Radiology A separate administration charge should not be made to inject contrast material or radiopharmaceuticals. This service is included in the radiology service. Conscious Sedation and Drugs Used in Radiology Conscious sedation (99141) with CT's or MRI's - A separate charge can be made for conscious sedation, since this service is not an inherent part of these procedures; however, a physician order must be in the medical record. This service is not separately billable when it is an integral part of a service. Items NOT Separately Chargeable Additional charges for film charges, videotape, or cameras should not be made. These items are not separately billable. Also see revenue code 027X regarding other items that are separately billable. Interventional Radiology Procedures should be billed separately. These are billed with surgical CPT codes. Radiopharmaceuticals Radiopharmaceuticals can be billed separately and may receive additional payment (add-on). Radiopharmaceutical CPT/HCPCS include: A4641, A4642, A9500, A9503 and A9505. (See revenue code 0343, 0344) CPT/HPCPS codes 77785, 77786, and 77787 include payment for the radiopharmaceutical in the technical component. When these procedures are performed, do not report radiopharmaceutical codes A4641, A4642, A9500, A9503, or A9505. REIMBURSEMENT: Outpatient claims require HCPCS/CPT and units. Some radiology procedures are MAP'd. Refer to your facility outpatient MAP listing for details. Contrast material, interventional radiology, and pharmacy services are eligible for additional reimbursement and must be billed on a separate line item under the appropriate revenue code.

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033X

RADIOLOGY ­ THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION

BC

DETAIL UNITS HCPCS/CPT Required Per HCPCS Description Required for OP

DESCRIPTION: Charges for therapeutic radiology services and chemotherapy are required for care and treatment of patients. Therapies also include injection and/or ingestion of radioactive substances. A breakdown is provided of the major areas that hospitals or third parties may wish to identify. STANDARD ABBREVIATION: SUBCATEGORY: RADIOLOGY THERAPY 0 - General Classification RAD-CHEMO-INJECT 1 ­ Chemotherapy Admin ­ Injected RAD-CHEMO-ORAL 2 ­ Chemotherapy Admin ­ Oral RAD-RADIATION 3 ­ Radiation Therapy RAD-CHEMO-IV 5 ­ Chemotherapy Admin ­ IV RADIOLOGY OTHER 9 ­ Other Radiology ­ Therapeutic

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X BILLING & CODING GUIDELINES: Some of the HCPCS that may be billed under this revenue code include 7726177799. This is not an all-inclusive list. Chemotherapy Administration Revenue codes 0331, 0332, 0335 represents the facility charge for administration (nurses' cost), room and set up for chemotherapy. These same costs are not separately billable on inpatient claims when provided by the floor nurse. Following are the revenue code CPT billing instructions for outpatient claims. NOTE: Billing instructions for the administration of chemotherapy and nonchemotherapy can be found at the end of this manual Appendix A.

2009 Codes 96402 96402 96405 96406 96409 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic Chemotherapy administration; intralesional, up to and including 7 lesions Chemotherapy administration; intralesional, more than 7 lesions Chemotherapy administration; intravenous, push technique, single or initial ubstance/drug

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96411 96413 96415 96416

Chemotherapy administration; intravenous, push technique, each additional ubstance/drug (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous technique; up to 1 hour, single or initial substance/drug Chemotherapy administration, intravenous technique; each additional hour, 1 ­ 8 hours Chemotherapy administration, intravenous technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump. (See 96521-96523 for refilling & maintenance of a portable pump) Chemotherapy administration, intravenous technique; each additional sequential infusion (different substance or drug), up to 1 hour (List separately in addition to code for primary procedure) Use 96417 in conjunction with 96413. Report only once per sequential infusion. Report 96415 for additional hour(s) of sequential infusion. Chemotherapy administration, intra-arterial; push technique Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour Chemotherapy administration, intra-arterial; infusion technique, each additional hour (List separately in addition to code for primary procedure). Use 96423 in conjuction with 96422. Report 96423 for infusion intervals of greater than 30 minutes beyond 1-hour increments) Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours) requiring use of portable or implantable pump Chemotherapy administration into plural cavity, requiring and including thoracentesis Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture Refilling and maintenance of portable pump Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) Irrigation of implanted venous access device for drug delivery systems Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents Unlisted chemotherapy procedure

96417

96420 96422 96423

96425 96440 96445 96450 96521 96522 96523 96542 96549

Outpatient Non-Chemotherapy Drug Administration Separate charges for outpatient administration can be made as described in Appendix A. These are MAP'd add-on services. Therefore it is important to code each service with the appropriate units in order to receive additional reimbursement for the administration of the non-chemotherapy drug. If there is more than one encounter in a day, bill each IV administration on separate lines.

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Radiation Oncology These services are separately billable and are not subject to a MAP. NOTE: There is a medical policy for these specific services. Refer to the website for guidelines.

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034X

NUCLEAR MEDICINE

DETAIL UNITS HCPCS/CPT

BC

Per HCPCS Description Required for OP

DESCRIPTION: Charges for procedures,tests and radiopharmeuticals performed by a department handling radioactive materials as required for diagnosis and treatment of patients. A breakdown is provided in case hospitals desire or are required to identify the type of service rendered. STANDARD ABBREVIATION: SUBCATEGORY: NUCLEAR MEDICINE or (NUC MED) 0 - General Classification NUC MED/DX 1 ­ Diagnostic NUC MED/RX 2 ­ Therapeutic NUC MED/DX RADIOPHARM EFF10/1/04 3 - Diagnostic Radiopharmaceuticals NUC MED/RX RADIOPHARM EFF10/1/04 4 - Therapeutic Radiopharmaceuticals NUC MED/OTHER 9 ­ Other

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X NOTE: There is a medical policy for these specific services. Refer to this website link for guidelines. Computed Tomographic Angiography (CTA)

BCBSKS - Medical Review - Institutional - Medical Policies

BILLING & CODING GUIDELINES: Radiopharmaceuticals These services should be billed using revenue code 0343 or 0344, not under revenue code 0636. ALL FACILITIES should include in their charges, the costs associated with specially trained personnel to handle and compound radiopharmaceuticals, waste, spoilage and transportation costs. Hospitals should set charges properly for these radiopharmaceuticals, accounting for acquisition costs, plus preparation and handling. Units should be billed according to the dose and code descriptions. Tracer Codes Required for PET Scans PET scans see revenue code 040X. Tracer codes may be separately billed.

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Tracer Codes: For PET Scan Codes 78491 and 78492: A9555 Supply of Radiopharmaceutical Diagnostic Imaging Agent, Rubidium RB-82, Diagnostic, Per study dose, Up to 60 millicuries Supply of Radiopharmceutical Diagnostic Imaging Agent, Ammonia N-13

A9526

For PET Scan Codes 78459, 78608, 78609, 78811-78816: A9552 Supply of Radiopharmaceutical Diagnostic Imaging Agent, Fluorodeoxyglucose F18, FDG, Diagnostic, Per study dose, Up to 45 millicuries Supply of Radiopharmaceutical Diagnostic Imaging Agent, Not Otherwise Classified (NOTE: This code is subject to a MAP and is considered an addon.)

A4641

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035X

CT SCAN

DETAIL UNITS HCPC/CPT

BC

Per Test/HCPCS Description Required for OP

DESCRIPTION: Charges for computed tomographic scans of the head and other parts of the body. Due to coverage limitations, some third party payers require that the specific test be identified. STANDARD ABBREVIATION: SUBCATEGORY: CT SCAN 0 ­ General Classification CT SCAN/HEAD 1 ­ CT ­ Head Scan CT SCAN/BODY 2 ­ CT ­ Body Scan CT SCAN/OTHER 9 ­ CT ­ Other

TYPE OF CLAIM: Inpatient or Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X NOTE: There is a medical policy for these specific services. Refer to this website link for guidelines. Computed Tomographic Angiography (CTA) BCBSKS - Medical Review - Institutional - Medical Policies BILLING & CODING GUIDELINES: Contrast Material Inpatient: High osmolar contrast material should be billed under revenue code 0255. Low osmolar contrast material can be billed under either revenue code 0254 or 0255. Outpatient: Outpatient claims for high osmolar contrast material (HOCM) should be billed with revenue code 0636 and the appropriate HCPCS: Q9958 Q9959 Q9960 Q9961 Q9962 Q9963 Q9964 HOCM <=149 mg/ml iodine, 1ml HOCM 150-199mg/ml iodine,1ml HOCM 200-249mg/ml iodine,1ml HOCM 250-299mg/ml iodine,1ml HOCM 300-349mg/ml iodine,1ml HOCM 350-399mg/ml iodine,1ml HOCM >= 400 mg/ml iodine,1ml

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Outpatient claims for low osmolar contrast material (LOCM) must be billed under revenue code 0636. DO NOT INCLUDE THE LOCM CHARGE WITH THE DIAGNOSTIC SERVICE CHARGE. Units must indicate the number of milliliters administered. The record must also reflect the amount administered to the patient: Q9951 Q9965 Q9966 Q9967 LOW OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML IODINE CONCENTRATION, PER ML LOW OSMOLAR CONTRAST MATERIAL, 100-199 mg/ml iodine, 1 ml LOW OSMOLAR CONTRAST MATERIAL, 200-299 mg/ml iodine, 1 ml LOW OSMOLAR CONTRAST MATERIAL, 300-399 mg/ml iodine, 1 ml

HCPCS, units, and line item date of service are required. Computed Tomographic Angiography (CTA). CTA services for Blue Cross may or may not be covered. Please review our medical polocies.

0144T

Computed tomography, heart, without contrast material, including image post processing and quantitative evaluation of coronary calcium Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium

0145T

0146T

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0147T

Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology and computed tomographic angiography of coronary arteries (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology in congenital heart disease Computed tomography, heart, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; function evaluation (left and right ventricular function, ejection fraction and segmental wall motion)

0148T

0149T

0150T

0151T

REIMBURSEMENT: Outpatient CT's are subject to a MAP. In order to receive additional outpatient reimbursement for supplies, contrast (see revenue code 0636), or drugs, the services should be billed separately using the specific HCPCS code and appropriate unit value. CT's are designated as an add-on service.

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036X

OPERATING ROOM SERVICES

BC

DETAIL UNITS HCPCS/CPT # of Procedure/HCPCS definition Required for OP

DESCRIPTION: Charges for services provided to patients by specifically trained nursing personnel who provide assistance to physicians in the performance of surgical and related procedures during and immediately following surgery. Permits identification of particular services. STANDARD ABBREVIATION: SUBCATEGORY: OR SERVICES 0 ­ General Classification OR/MINOR 1 ­ Minor Surgery OR/ORGAN TRANS 2 ­ Organ Transplant-other than kidney OR/KIDNEY TRANS 7 ­ Kidney Transplant OR/OTHER 9 ­ Other OR Services

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X BILLING & CODING GUIDELINES: This section includes instructions for the following (in order): Abortion Coverage Cancelled Surgery and Attempted Surgery Outpatient Multiple Surgical Procedures Add-on Outpatient Surgeries Modifiers Medical and Surgical Supplies Not Separately Chargeable Items Observation Recovery Room Cataract Surgery Conscious Sedation for Upper and Lower GI Procedures Outpatient claims must include the appropriate CPT code for the procedures performed. Only in limited situations should the "not otherwise classified" (NOC) code be used. If a facility has a new procedure, device, or drug being used, contact a BCBSKS provider consultant with the appropriate detailed information to obtain a pure code and coverage information for that service or item. Surgical services may be performed in other areas of the hospital. Use the revenue code that describes the area the patient occupied. (i.e., ER patient 0450, Treatment room ­ 0761, etc.) Contains Public Information Revision Date: March 31, 2009 89

Abortion coverage Facilities should contact customer service (1-800-432-3990) regarding coverage of this service. Some policyholders may not have this benefit. Cancelled Surgery and Attempted Surgery Inpatient claims: Attempted surgery should be billed with revenue code 0229 and ICD-9-CM diagnosis code V64.1, V64.2, or V64.3. Hospitals must convert revenue code 0360 (operating room) to revenue code 0229 to avoid edits requiring ICD-9-CM procedure codes. (When revenue code 0360 is on an inpatient claim, an ICD-9-CM procedure code is required). Outpatient claims should reflect the appropriate revenue code where the procedure occurred, 045X, 0360, 0761, 0760 etc., and the CPT code of the intended procedure. For outpatient situations, if the surgery was cancelled prior to the administration of anesthesia, services provided up to that point would be billed using the appropriate revenue /CPT codes. If the surgery is cancelled after the administration of anesthesia, the revenue/CPT code describing the procedure would be billed. However, the charge should be adjusted to reflect the cancellation of the procedure to assure that appropriate reimbursement is made in this situation. Outpatient Multiple Surgical Procedures It is the intent of BCBSKS to accept a surgical CPT billed with zero charges. Add-on Outpatient Surgeries Multiple surgeries may be billed with a single charge on the first line item, and a zero charge on each additional line. If the surgical code has an add-on indicator (Refer to the MAP list-see Appendix B), it must be billed with an actual charge. If an add-on surgical code has a zero charge, there will not be an additional reimbursement on that line item. Modifiers Modifiers are not required. If submitted, there is no impact on reimbursement. BCBSKS will not reject claims if modifiers are submitted.

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Medical and Surgical Supplies This section applies to items that do not fall into Prosthetic/Orthotic, Implantable, or items that are identified with a HCPCS. Other medical surgical items not bundled into the procedure cost are billable on a separate line item under revenue code 027X. In order to bill a separate charge these supplies must be specific to the patient and identified in the medical record. Some facilities have set the surgical price to include equipment and supplies that are routinely used in that area for all procedures. Not Separately Chargeable Items Revenue code 036X includes charges for all personnel, room and fixed or permanently stored equipment. The items below are not separately billable (this is not an all inclusive list). · Pre-operative room charges · Additional personnel fees · After hour fees · On-call charges. Costs related to on-call personnel may be included on the cost report and may be spread across individual charges related to the personnel. · Administration of drugs in the OR or recovery room · Anesthesia equipment · Blood pressure monitor · Other equipment necessary to perform the surgery Refer to revenue code 027X, for instructions on separately chargeable supplies. Observation Observation after surgery should occur only on rare occasions, such as when an unexpected complication due to the surgery occurs and there is a physician order. Refer to revenue code 076X for further details Recovery Room Charges for post-operative recovery room are billed under 071X. Refer to revenue code 071X for billing instructions. Cataract Surgery Although a separate charge is not required for the intraocular lens (IOL), BC prefers a separate charge along with the appropriate HCPCS code for the IOL (CPT codes 66982, 66983, 66984, 66985 and 66986). The IOL is billed under revenue code 0276; the surgical procedure is billed under 036X. Anesthesia for Upper and Lower Scope Procedures Please refer to newsletter BC-07-09 dated March 9, 2007.

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REIMBURSEMENT: Many surgeries are subject to a MAP. If the surgery is not an add-on (see "Blue Cross Add-On" in this section), then all services provided during the surgical encounter are subject to the MAP. Facilities should refer to their specific MAP listing for codes that are considered an add-on. Outpatient Multiple Surgical Procedures It is our intent to look at all the surgery CPT codes reported on the claim and determine which code has the highest MAP. The procedure with the highest MAP will be allowed. Any CPT code that is considered an add-on will be allowed in addition to the surgical MAP. REFERENCES: Multiple surgeries: BC-03-01 (Hospital Billing of Outpatient Surgery)

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037X

ANESTHESIA

DETAIL UNITS HCPCS/CPT

BC

X # of minutes

DESCRIPTION: Charges for anesthesia services in the hospital. SUBCATEGORY: STANDARD ABBREVIATION: 0 - General Classification ANESTHESIA 1 ­ Anesthesia Incident to Radiology ANESTH/INCIDENT RAD 2 ­ Anesthesia Incident to Other DX Services ANESTH/INCDENT OTHER DX 4 ­ Acupuncture ANESTH/ACUPUNC 9 - Other Anesthesia ANESTH/OTHER

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X BILLING & CODING GUIDELINES: This revenue code includes the anesthetic itself and any necessary materials whether disposable or reusable. This should not be used to reflect professional charges of the Anesthesiologist or CRNA. Charges for anesthesia equipment should not be separately billed as this equipment should already be included in the operating room charge. CRNA and anesthesiologist charge must be billed on a CMS 1500 claim form to Blue Shield. Outpatient anesthetic agents having a HCPCS should be billed with revenue code 0636. Refer to the MAP listing to assure the anesthetic agents considered add-ons are identified on the facility charge data master so that all available reimbursement is obtained. Anesthetic agents without a HCPCS can be billed under 0370. Acupuncture - Revenue code 0374 This service is generally not covered by BCBSKS. SPECIAL PLAN INSTRUCTIONS: Acupuncture - Revenue code 0374 FEP (Federal Employee Program) has limited coverage of this service. Please refer to their benefits at: www.fepblue.org SECONDARY CLAIMS: For Medicare facilities that have CRNA exemption, see revenue code 096X.

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038X

Required DETAIL # of pints transfused UNITS Required for OP HCPCS/CPT DESCRIPTION: Charges for blood and blood components. STANDARD ABBREVIATION: SUBCATEGORY: BLOOD & BLOOD COMP 0 - General Classification BLOOD/PKD RD 1 - Packed Red Cells BLOOD/WHOLE 2 - Whole Blood BLOOD/PLASMA 3 ­ Plasma BLOOD/PLATELETS 4 ­ Platelets BLOOD/LEUKOCYTES 5 ­ Leucocytes BLOOD/COMPONENTS 6 - Other Blood Components BLOOD/DERIVATIVES 7 - Other Derivatives (Cryopricipitates) BLOOD/OTHER 9 - Other Blood and Blood Components

BLOOD AND BLOOD COMPONENTS

BC

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 72X, 85X BILLING & CODING GUIDELINES: This section includes instruction for the following: Clarification of Blood Billing Blood Related Charges Lab Services Autogolous/Autogenous Blood Blood Bank ­ Hospital-owned Billing for Blood Administration/Transfusion Services End Stage Renal Dialysis Billing for Split Unit of Blood Billing for Unused Blood Processing Fee Billing for Frozen/Thawed Blood and Blood Products Billing for Irradiation of Blood Products Revenue code 038X is used only if provider pays for the actual blood or blood product itself obtained from a community blood bank, or collects the blood or blood product in the provider's own blood bank and also assesses a charge for the blood, in addition to paying for processing and storage costs. Facilities that do not charge for the actual blood or blood product itself should refer to revenue code 039X. Charges for blood must be documented in the medical record as transfused and clearly reflect the type of product ordered and transfused. Blood not used is not billable. Additional charges for disposable supplies may be billed under 027X category. Contains Public Information Revision Date: March 31, 2009 94

Clarification of Blood (Applies to BCBSKS traditional contracts including the State of Kansas Employee Group)

· Charges for whole blood are NOT COVERED. (Revenue code 038X) · Charges for blood derivatives are covered. (Revenue code 038X) · Charges for blood storage and processing of either whole blood or blood

derivatives are covered. (Revenue code 0390 or 0399) · Charges for blood administration of either whole blood or blood derivatives are covered. (Revenue code 0391) There are currently two HCPCS codes for whole blood: · · P9010 ­ Blood (whole), for transfusions, per unit P9011 ­ Blood (split unit), specify amount

If code P9010 or P9011 is billed with revenue code 038X it will deny. If billed with revenue code 039X it is allow. SUMMARY: · Whole blood HCPCS + 038X revenue code = deny charge as noncovered. · Whole blood HCPCS + 039X revenue code = allow charge. Billing Blood Related Charges - 0 General Classification - 1 packed red cells - 2 whole blood - 3 plasma - 4 platelets - 5 leucocytes - 6 other components - 7 other derivatives - 9 other blood This revenue code is billed only when a charge is being made for the actual blood or blood product. This could be when: · The provider pays (purchases) for the actual blood or blood product from a community blood bank, or · The provider assesses a charge for blood or a blood product that was collected in their own blood bank. This revenue code requires: · Line item date of service · Number of units Contains Public Information Revision Date: March 31, 2009 95

·

Blood products HCPCS

Lab services The hospital may bill the laboratory revenue codes (030X or 031X) along with the HCPCS codes for blood typing and cross matching and other laboratory services related to the patient's own blood specimen. Autologous/Autogenous Blood (Applies to BCBSKS traditional contracts including the State of Kansas Employee Group and Federal Employee Program) Allow all charges related to autologous/autogenous blood when provided in connection with a scheduled covered surgical procedure. This expense is allowed even if the blood is not transfused.* These charges would be billed as part of the inpatient or outpatient claim for the scheduled covered surgical procedure. Any autologous/autogenous blood charges incurred in the absence of a scheduled covered surgical procedure is not considered medically necessary. Providers cannot bill the member for services that are medically unnecessary unless they give the member written notice (Notice of Personal Financial Oblication) in advance of the service. If notice is given, the member is responsible for the charges. If no written notice is given, the charges are a provider write-off.

*

There would be no administration charges for blood not transfused.

Providers should bill the transfusion service and the blood product HCPCS code on the date that the transfusion took place and not on the date when the autologous blood was collected.

Autologous/Autogenous Blood Processing Guidelines 86890 ­ Autologous blood or component, collection processing and storage; predeposited (Lay definition ­ This reports the donation of blood for one's own use. This procedure is used for patients requiring surgery who pre-deposit their own blood for use during the surgery. The procedure is not useful for patients with complex antibody production or extremely rare antibodies that make location of compatible blood nearly impossible.)

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If a claim: · Includes CPT 86890 · Includes surgical CPT code 10000-69999 or includes diagnosis code V64X (persons encountering health services for specific procedures not carried out) Charges will be allowed If a claim: · Includes CPT 86890 · Does not include a surgical CPT code 10000-69999 or does not include diagnosis code V64X (persons encountering health services for specific procedures not carried out) Check for a Blue Cross Notice of Personal Financial Obligation (NOPFO). If a NOPFO is not present, the charges will be denied as a provider write-off to in-state contracting providers. If a NOPFO is present, the charges will be denied as non-covered and the member's responsibility. Blood Bank ­ Hospital-owned Effective 07/01/05 · If a provider pays for the actual blood or blood product obtained from a community blood bank, or collects the blood or blood product in the their own blood bank and also assesses a charge for the blood, in addition to paying for processing and storage costs, the provider must separate the charge for the unit(s) of blood or blood product(s) from the charge for processing and storage services. · The provider reports charges for the blood or blood product using Revenue Code series 038X with the line item date of service (LIDOS), the number of units transfused, and the appropriate blood product HCPCS code. · The provider reports charges for processing and storage services on a separate line using Revenue Code 0390 or 0399 with the LIDOS, the number of units transfused, and the appropriate blood product HCPCS code. Example: Rev Code Description 38X Blood/Blood Product 39X Blood Processing/ Storage

HCPCS P-code P-code

Units 1 1

Date of Service 02/15/07 02/15/07

Charge $XXX $ZZZ

If a hospital purchases blood, or blood products, or runs its own blood bank, it is not appropriate to bill both the blood and blood product in Revenue Code series 038X and an additional blood bank storage and processing charge in Revenue Code 0390. Contains Public Information Revision Date: March 31, 2009 97

Billing for Blood Administration/Transfusion Services Inpatient - Blood administration services provided to an inpatient is not separately chargeable. Outpatient ­ A blood administration/transfusion charge may be separately billed using revenue code 0391 (blood administration), administration CPT code and charges reflecting the cost of the room and personnel. Valid CPT codes include: 36430 36440 36450 36455 36460 Transfusion, blood or blood components Push transfusion, blood, 2 years or under Exchange transfusion, blood; newborn Exchange, transfusion, blood; other than newborn Transfusion, intrauterine, fetal

Blood administration/transfusion services are billed on a per service basis (per encounter) and NOT by the number of units of blood transfused. Providers may set up an hourly charge for the service, but the units on the claim should reflect one (1) per encounter. End Stage Renal Dialysis (ESRD) Facilities Facility staff time used to perform services in the dialysis unit, including time to administer blood (administration charge), is included in the composite rate and may not be billed separately. Billing for Split Unit of Blood HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split and some portion of the unit is transfused to one patient and the other portions are transfused to other patients or to the same patient at other times. When a patient receives a transfusion of a split unit of blood or blood product, providers should bill P9011 for the blood product transfused, as well as CPT 86985 (Splitting, blood products) for each splitting procedure performed to prepare the blood product for a specific patient. EXAMPLE: The provider splits off a 100cc aliquot from a 250 cc unit of leukocyte-reduced red blood cells for a transfusion to Patient X. The hospital then splits off an 80cc aliquot of the remaining unit for a transfusion to Patient Y. At a later time, the remaining 70cc from the unit is transfused to Patient Z. In billing for the services for Patient X and Patient Y, the provider should report the charges by billing P9011 and 86985 in addition to the CPT code for the transfusion service, because a specific splitting service was required to prepare a split unit for transfusion to each of those patients. However, the provider should report only P9011 and the CPT code for the transfusion service for Patient Z because no additional splitting was necessary to prepare the split unit for transfusion to Patient Z. Contains Public Information Revision Date: March 31, 2009 98

Billing for Unused Blood When blood or blood products which the provider has collected in its own blood bank or received from a community blood bank are not used, processing and storage costs incurred by the community blood bank and the provider cannot be charged to the patient. However, certain patient-specific blood preparation costs incurred by the provider (e.g., blood typing and cross-matching) can be charged to the patient under revenue codes 030X or 031X. Patient-specific preparation charges should be billed on the dates the services were provided. Note that some services such as irradiation or freezing and thawing, can be billed when the product is not transfused. Processing Fees Processing and storage costs may include blood product collection, safety testing, retyping, pooling, irradiating, leukocyte reducing, freezing, and thawing blood products, along with the costs of blood delivery, monitoring, and storage. In general, such categories of processing costs are not patient specific. There are specific blood HCPCS codes for blood products that have been processed in varying ways, and these codes are intended to make payment for the variable resource costs of blood products that have been processed differently. The processing and storage costs cannot be billed separately, they are included in the blood product charge. All costs for these services are not separately chargeable and should be bundled in the blood product charge. Billing for Frozen and Thawed Blood and Blood Products In situations where a beneficiary receives a transfusion of frozen blood or a blood product, which has been frozen and thawed for the patient prior to the transfusion, a provider may bill the specific HCPCS code that describes the frozen and thawed product, if a specific code exists, in addition to the CPT code for the transfusion. If a specific HCPCS code for the frozen and thawed blood or blood product does not exist, then the provider should bill the appropriate HCPCS code for the blood product, along with CPT codes for freezing and/or thawing services that are not reflected in the blood product HCPCS code. EXAMPLE: If a provider transfuses the product described by P9057 (red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill additional CPT codes for freezing and/or thawing since charges for freezing and thawing should be included in the charge for using HCPCS code P9057. If a blood product has been frozen and/or thawed in preparation for a transfusion, but the patient does not receive the transfusion of the blood product, the provider may bill the patient for the CPT code that describes the freezing and/or thawing services specifically provided for the patient. The provider should bill the freezing and/or thawing services on the date when the provider is certain the blood product will not be transfused (e.g., Contains Public Information Revision Date: March 31, 2009 99

date of a procedure or date of outpatient discharge), rather than on the date of the freezing and/or thawing services. Billing for Irradiation of Blood Products In situations where a beneficiary receives a medically reasonable and necessary transfusion of an irradiated blood product, a provider may bill the specific HCPCS code which describes the irradiated product, if a specific code exists, in addition to the CPT code for the transfusion. If a specific HCPCS code for the irradiated blood product does not exist, then the provider should bill the appropriate HCPCS code for the blood product, along with CPT code 86945 (irradiation of blood product, each unit). EXAMPLE: If a provider transfuses the product described by P9040 (red blood cells, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill an additional CPT code for irradiation of the blood product since charges for irradiation should be included in the charge for P9040. Note - Although not specifically indicated in the instructions, if the blood product was not transfused it would be appropriate to bill the irradiation services when the provider is certain the blood will not be transfused (i.e., date of a procedure or date of outpatient discharge). SPECIAL PLAN INSTRUCTIONS: Federal Employee Program (FEP) All expenses relating to blood transfusions and administration of blood are covered when provided in connection with a covered surgical procedure just as unless it is donated or replaced. Autologous blood is covered if provided in connection with, or in anticipation of, a scheduled covered surgical procedure. Autologous blood services would not be covered if provided in for an undefined future use. DEFINITIONS: Blood HCPCS Inpatient claims do not require HCPCS. Units represent the number of products as described by the HCPCS.

Code P9010 P9011 P9012 Description Blood (whole), for transfusion, per unit (Blue Cross does not cover ANY charges associated with this code) Blood (split unit), specify amount (Blue Cross will not cover ANY charges associated with this code.) Cryoprecipitate, each unit

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P9016 P9017 P9019 P9020 P9021 P9022 P9023 P9031 P9032 P9033 P9034 P9035 P9036 P9037 P9038 P9039 P9040 P9041 P9043 P9044 P9045 P9046 P9047 P9048 P9050 P9051 P9052 P9053

Red blood cells, leukocytes reduced, each unit Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit Platelets, each unit Platelet rich plasma, each unit Red blood cells, each unit Red blood cells, washed, each unit Plasma, pooled multiple donor, solvent/detergent treated, frozen, each unit Platelets, leukocytes reduced, each unit Platelets, irradiated, each unit Platelets, leukocytes reduced, irradiated, each unit Platelets, pheresis, each unit Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Red blood cells, irradiated, each unit Red blood cells, deglycerolized, each unit Red blood cells, leukocytes reduced, irradiated, each unit Infusion, albumin (human), 5%, 50 ml Infusion, plasma protein fraction (human), 5%, 50 ml Plasma, cryoprecipitate reduced, each unit Infusion, albumin (human), 5%, 250 ml Infusion, albumin (human), 25%, 20 ml Infusion, albumin (human), 25%, 50 ml Infusion, plasma protein fraction (human), 5%, 250 ml Granulocytes, pheresis, each unit Whole blood or red blood cells, leukocytes reduced, cmv-negative, each unit Platelets, hla-matched leukocytes reduced, apheresis/pheresis, each unit Platelets, pheresis, leukocytes reduced, cmv-negative, irradiated, each unit

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P9054 P9055 P9056 P9057 P9058 P9059 P9060

Whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each unit Platelets, leukocytes reduced, cmv-negative, apheresis/pheresis, each unit Whole blood, leukocytes reduced, irradiated, each unit Red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, cmv-negative, irradiated, each unit Fresh frozen plasma between 8-24 hours of collection, each unit Fresh frozen plasma, donor retested, each unit

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039X

ADMINISTRATION, PROCESSING, & STORAGE FOR BLOOD & BLOOD COMPONENTS

BC

DETAIL UNITS HCPCS/CPT # of pints transfused Required for OP

DESCRIPTION: Charges for administration, processing and storage of whole blood, red blood cells, platelets and other blood components. STANDARD ABBREVIATION: SUBCATEGORY: BLOOD/ADMIN/STOR 0 - General Classification BLOOD/ADMIN 1 - Blood Administration (e.g. Transfusions) BLOOD/STORAGE 2 ­ Processing and Storage BLOOD/ADMIN/STOR/OTHER 9 - Other Blood Handling

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X BILLING & CODING GUIDELINES: This section includes instruction for the following: 039X Blood Storage and Processing Blood Bank ­ Community Blood Bank ­ Hospital-owned Billing for Blood Administration/Transfusion Services Clarification of Blood Billing Blood Related Charges Lab Services Autogolous/Autogenous Blood End Stage Renal Dialysis Billing for Split Unit of Blood Billing for Unused Blood Albumin Processing Fee Billing for Frozen/Thawed Blood and Blood Products Billing for Irradiation of Blood Products Facilities that do not charge for the actual blood or blood product itself should refer to revenue code 039X. Revenue code 038X is used only if the provider pays for the actual blood or blood product itself obtained from a community blood bank, or collects the blood or blood product in the provider's own blood bank and also assesses a charge for the blood, in addition to paying for processing and storage costs. Charges for blood must be documented in the medical record as transfused and clearly reflect the type of product ordered and transfused. Blood not used is not billable. Additional charges for disposable supplies may be billed under 027X category. Contains Public Information Revision Date: March 31, 2009 103

039X Blood Storage and Processing - 0 General Classification - 1 Blood Administration - 9 Other Blood Storage and Processing Revenue Code 0390 or 0399 ­ when a hospital obtains blood or blood products from a community blood bank (i.e. Red Cross) there is no charge for the actual blood or blood product. The blood bank does, however, bill the hospital for the processing, storage and related expenses. These revenue codes require: · Line item date of service · Number of units · Blood product HCPCS Revenue codes 0390 or 0399 are not used to report the cost of blood. These revenue codes are used to report the processing and storage expenses. Revenue Code 0391 is used to report charges when blood or blood products are administered and includes charges for the room and administration. While we recommend that revenue code 0391 be used, other revenue codes could also be billed depending on what area the patient occupies (i.e. emergency room 0450, treatment room 0761, etc.). This revenue code requires: · Line item date of service · Units ­ report one unit for each day a transfusion occurs (do not report number of units transfused) · Transfusion HCPCS 36430 through 36460 Revenue code 0391 is not used to report the cost of blood. This revenue code is used to report blood administration expenses. Blood Bank- Community (i.e. Red Cross) Inpatient services are billed under revenue code 0390, a HCPCS is not required. Outpatient services are billed under 0390 with the appropriate HCPCS. The HCPCS are listed at the end of this revenue code section. Blood Bank ­ Hospital-owned If a provider pays for the actual blood or blood product obtained from a community blood bank, or collects the blood or blood product in the their own blood bank and also assesses a charge for the blood, in addition to paying for processing and storage costs, the provider must separate the charge for the unit(s) of blood or blood product(s) from the charge for processing and storage services. Contains Public Information Revision Date: March 31, 2009 104

· ·

The provider reports charges for the blood or blood product using Revenue Code series 038X with the line item date of service (LIDOS), the number of units transfused, and the appropriate blood product HCPCS code. The provider reports charges for processing and storage services on a separate line using Revenue Code 0390 or 0399 with the LIDOS, the number of units transfused, and the appropriate blood product HCPCS code.

Example: Rev Code Description 38X Blood/Blood Product 39X Blood Processing/ Storage

HCPCS P-code P-code

Units 1 1

Date of Service 02/15/07 02/15/07

Charge $XXX $ZZZ

If a hospital purchases blood, or blood products, or runs its own blood bank, it is not appropriate to bill both the blood and blood product in Revenue Code series 038X and an additional blood bank storage and processing charge in Revenue Code 0390. Billing for Blood Administration/Transfusion Services Inpatient - Blood administration services provided to an inpatient is not separately billable. Outpatient ­ A blood administration/transfusion charge may be separately billed using revenue code 0391 (blood administration), administration CPT code and charges reflecting the cost of the room and personnel. Valid CPT codes include: 36430 36440 36450 36455 36460 Transfusion, blood or blood components Push transfusion, blood, 2 years or under Exchange transfusion, blood; newborn Exchange, transfusion, blood; other than newborn Transfusion, intrauterine, fetal

Blood administration/transfusion services are billed on a per service basis (per encounter) and NOT by the number of units of blood transfused. Providers may set up an hourly charge for the service, but the units on the claim should reflect one (1) per encounter. Clarification of Blood (Applies to BCBSKS traditional contracts including the State of Kansas Employee Group)

· Charges for whole blood are NOT COVERED. (Revenue code 038X) · Charges for blood derivatives are covered. (Revenue code 038X) · Charges for blood storage and processing of either whole blood or blood

derivatives are covered. (Revenue code 0390 or 0399) Contains Public Information Revision Date: March 31, 2009 105

· Charges for blood administration of either whole blood or blood derivatives

are covered. (Revenue code 0391) There are currently two HCPCS codes for whole blood: · · P9010 ­ Blood (whole), for transfusions, per unit P9011 ­ Blood (split unit), specify amount

If code P9010 or P9011 is billed with revenue code 038X, it will be denied. If billed with evenue code 039X, it will be allowed. SUMMARY: · Whole blood HCPCS + 038X revenue code = the charge will be denied as non-covered. · Whole blood HCPCS + 039X revenue code = the charge will be allowed. Billing Blood Related Charges - 0 General Classification - 1 packed red cells - 2 whole blood - 3 plasma - 4 platelets - 5 leucocytes - 6 other components - 7 other derivatives - 9 other blood Revenue code 38X is billed only when a charge is being made for the actual blood or blood product. This occurs when: · The provider pays (purchases) for the actual blood or blood product from a community blood bank, or · The provider assesses a charge for blood or a blood product that was collected in their own blood bank. This revenue code requires: · Line item date of service · Number of units · Blood products HCPCS

Lab services The hospital may bill the laboratory revenue codes (030X or 031X) along with the CPT codes for blood typing and cross matching and other laboratory services related to the patient's own blood specimen.

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Autologous/Autogenous Blood (Applies to BCBSKS traditional contracts including the State of Kansas Employee Group and Federal Employee Program) Allow all charges related to autologous/autogenous blood when provided in connection with a scheduled covered surgical procedure. This expense is allowed even if the blood is not transfused (There would not be an administration charge for blood not transfused). The charge would be billed as part of the inpatient or outpatient claim for the scheduled covered surgical procedure. Any autologous/autogenous blood charges incurred in the absence of a scheduled covered surgical procedure is not considered medically necessary. Providers cannot bill the member for services that are medically unnecessary unless they give the member written notice (Notice of Personal Financial Oblication) in advance of the service. If a notice is given, the member is responsible for the charges. If a written notice is not given, the charges are a provider write-off.

Providers should bill the transfusion service and the blood product HCPCS code on the date that the transfusion took place and not on the date when the autologous blood was collected.

Autologous/Autogenous Blood Processing Guidelines 86890 ­ Autologous blood or component, collection processing and storage; predeposited (Lay definition ­ The donation of blood for one's own use. This procedure is used for patients requiring surgery who pre-deposit their own blood for use during the surgery. The procedure is not useful for patients with complex antibody production or extremely rare antibodies that make location of compatible blood nearly impossible.) If a claim: · Includes CPT 86890 · Includes surgical CPT code 10000-69999 or includes diagnosis code V64X (persons encountering health services for specific procedures not carried out) The charges will be allowed.

If a claim: · Includes CPT 86890 · Does not include a surgical CPT code 10000-69999 or does not include diagnosis code V64X (persons encountering health services for specific procedures not carried out)

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If a NOPFO is not present, Blue Cross will deny the charges as a provider writeoff to all in-state contracting providers. If a NOPFO is present, Blue Cross will deny the charges as non-covered and will become the member's responsibility. End Stage Renal Dialysis (ESRD) Facilities Facility staff time used to perform services in the dialysis unit, including time to administer blood (administration charge), is included in the composite rate and may not be billed separately. Billing for Split Unit of Blood HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split and some portion of the unit is transfused to one patient and the other portions are transfused to other patients or to the same patient at other times. When a patient receives a transfusion of a split unit of blood or blood product, providers should bill P9011 for the blood product transfused, as well as CPT 86985 (Splitting, blood products) for each splitting procedure performed to prepare the blood product for a specific patient. EXAMPLE: The provider splits off a 100cc aliquot from a 250 cc unit of leukocyte-reduced red blood cells for a transfusion to Patient X. The hospital then splits off an 80cc aliquot of the remaining unit for a transfusion to Patient Y. At a later time, the remaining 70cc from the unit is transfused to Patient Z. When billing for the services for Patient X and Patient Y, the provider should report the charges by billing with CPT P9011 and 86985 in addition to the CPT code for the transfusion service, because a specific splitting service was required to prepare a split unit for transfusion to each of those patients. However, the provider should report only P9011 and the CPT code for the transfusion service for Patient Z because no additional splitting was necessary to prepare the split unit for transfusion to Patient Z. Billing for Unused Blood When blood or blood products which the provider has collected in its own blood bank or received from a community blood bank are not used, processing and storage costs incurred by the community blood bank and the provider cannot be separately billed. However, certain patient-specific blood preparation costs incurred by the provider (e.g., blood typing and cross-matching) can be billed under revenue codes 030X or 031X. Patient-specific preparation charges should be billed on the dates the services were provided. Note that some services such as irradiation or freezing and thawing, can be billed when the product is not transfused.

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Albumin Some UB-04 editors state that Albumin (CPT codes: P9041, P9045, P9046, P9047) is not a blood product and will not allow these codes to be billed with revenue code 0390. If you are receiving the Albumin from a blood bank, then is it acceptable to use the revenue code that describes the department incurring the cost Normally blood bank costs are billed under revenue code 039X. However, these HCPCS can be billed under revenue code 0636. Processing Fees Processing and storage costs may include blood product collection, safety testing, retyping, pooling, irradiating, leukocyte reducing, freezing, and thawing blood products, along with the costs of blood delivery, monitoring, and storage. In general, such categories of processing costs are not patient specific. There are specific blood HCPCS codes for blood products that have been processed in varying ways, and these codes are intended to make payment for the variable resource costs of blood products that have been processed differently. The processing and storage costs cannot be billed separately. They are included in the blood product charge. All costs for these services are not separately billable and should be bundled in the blood product charge. Billing for Frozen and Thawed Blood and Blood Products In situations where a patient receives a transfusion of frozen blood or a blood product which has been frozen and thawed for the patient prior to the transfusion, a provider may bill the specific HCPCS code that describes the frozen and thawed product, if a specific code exists, in addition to the CPT code for the transfusion. If a specific HCPCS code for the frozen and thawed blood or blood product does not exist, then the provider should bill the appropriate HCPCS code for the blood product, along with CPT codes for freezing and/or thawing services that are not reflected in the blood product HCPCS code. EXAMPLE: If a provider transfuses the product described by P9057 (red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill additional CPT codes for freezing and/or thawing since charges for freezing and thawing should be included in the charge for using HCPCS code P9057. If a blood product has been frozen and/or thawed in preparation for a transfusion, but the patient does not receive the transfusion of the blood product, the provider may bill for the CPT code that describes the freezing and/or thawing services specifically provided for the patient. The provider should bill the freezing and/or thawing services on the date when the provider is certain the blood product will not be transfused (e.g., date of a procedure or date of outpatient discharge), rather than on the date of the freezing and/or thawing services.

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Billing for Irradiation of Blood Products In situations where a patient receives a medically reasonable and necessary transfusion of an irradiated blood product, a provider may bill the specific HCPCS code which describes the irradiated product, if a specific code exists, in addition to the CPT code for the transfusion. If a specific HCPCS code for the irradiated blood product does not exist, then the provider should bill the appropriate HCPCS code for the blood product, along with CPT code 86945 (irradiation of blood product, each unit). EXAMPLE: If a provider transfuses the product described by P9040 (red blood cells, leukocytes reduced, irradiated, each unit), it would not be appropriate to bill an additional CPT code for irradiation of the blood product since charges for irradiation should be included in the charge for P9040. Note - Although not specifically indicated in the instructions, if the blood product was not transfused it would be appropriate to bill the irradiation services when the provider is certain the blood will not be transfused (i.e., date of a procedure or date of outpatient discharge).

SPECIAL PLAN INSTRUCTIONS: Federal Employee Program (FEP) All expenses relating to blood transfusions and administration of blood are covered when provided in connection with a covered surgical procedure as long as the blodd is not donated or replaced. Autologous blood is covered if provided in connection with, or in anticipation of, a scheduled covered surgical procedure. Autologous blood services would not be covered if provided in for an undefined future use. REFERENCES:

Blood HCPCS Inpatient claims do not require HCPCS. Units represent the number of products as, described by the HCPCS. Code P9010 P9011 P9012 P9016 P9017 Description Blood (whole), for transfusion, per unit (Blue Cross does not cover ANY charges associated with this code) Blood (split unit), specify amount (Blue Cross will not cover Any charges associated with this code.) Cryoprecipitate, each unit Red blood cells, leukocytes reduced, each unit Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit

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P9019 P9020 P9021 P9022 P9023 P9031 P9032 P9033 P9034 P9035 P9036 P9037 P9038 P9039 P9040 P9041 P9043 P9044 P9045 P9046 P9047 P9048 P9050 P9051 P9052 P9053 P9054 P9055

Platelets, each unit Platelet rich plasma, each unit Red blood cells, each unit Red blood cells, washed, each unit Plasma, pooled multiple donor, solvent/detergent treated, frozen, each unit Platelets, leukocytes reduced, each unit Platelets, irradiated, each unit Platelets, leukocytes reduced, irradiated, each unit Platelets, pheresis, each unit Platelets, pheresis, leukocytes reduced, each unit Platelets, pheresis, irradiated, each unit Platelets, pheresis, leukocytes reduced, irradiated, each unit Red blood cells, irradiated, each unit Red blood cells, deglycerolized, each unit Red blood cells, leukocytes reduced, irradiated, each unit Infusion, albumin (human), 5%, 50 ml Infusion, plasma protein fraction (human), 5%, 50 ml Plasma, cryoprecipitate reduced, each unit Infusion, albumin (human), 5%, 250 ml Infusion, albumin (human), 25%, 20 ml Infusion, albumin (human), 25%, 50 ml Infusion, plasma protein fraction (human), 5%, 250 ml Granulocytes, pheresis, each unit Whole blood or red blood cells, leukocytes reduced, cmv-negative, each unit Platelets, hla-matched leukocytes reduced, apheresis/pheresis, each unit Platelets, pheresis, leukocytes reduced, cmv-negative, irradiated, each unit Whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each unit Platelets, leukocytes reduced, cmv-negative, apheresis/pheresis, each unit

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P9056 P9057 P9058 P9059 P9060

Whole blood, leukocytes reduced, irradiated, each unit Red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit Red blood cells, leukocytes reduced, cmv-negative, irradiated, each unit Fresh frozen plasma between 8-24 hours of collection, each unit Fresh frozen plasma, donor retested, each unit

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040X

Required DETAIL Per test/HCPCS Description UNITS Required for OP HCPCS/CPT DESCRIPTION: Charges for specialty imaging services for body structures. STANDARD ABBREVIATION: SUBCATEGORY: IMAGING SERVICE 0 ­ General Classification DIAG MAMMOGRAPHY 1 ­ Diagnostic Mammography ULTRASOUND 2 ­ Ultrasound SCRN MAMMOGRAPHY 3 ­ Screening Mammography PET SCAN 4 ­ Positron Emission Tomography OTHER IMAGE SVCS 9 - Other Imaging Services

OTHER IMAGING SERVICES

BC

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X MEDICAL POLICIES: NOTE: There is a medical policy for these specific services. Refer to these websites for guidelines. Computed Tomographic Angiography (CTA): First Trimester Detection of Aneuploidy Using Fetal Ultrasound Assessment of Nuchal Translucency Combined with Maternal Serus Assessment: Positron Emission Tomography (PET):

http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional/policies. htm

BILLING & CODING GUIDELINES: Diagnostic Mammography The CPT codes for diagnostic mammograms are MAP'd and have an add-on indicator. Check the MAP listing for details.

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Diagnostic Mammography Billing Codes HCPCS Code 77051 Definition Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (list separately in addition to code for primary procedure)," can be billed in conjunction with primary service codes G0204 or G0206. Diagnostic mammography, unilateral.

77055

77056 G0204 G0206

Diagnostic mammography, bilateral. Diagnostic mammography, direct digital image, bilateral, all views. Diagnostic mammography, producing direct digital image, unilateral, all views.

Screening Mammography The screening mammography procedure codes listed below should be used when billing Blue Cross. Reimbursement is subject to the MAP allowance or the charge, whichever is less. These services have an add-on indicator. See the MAP listing for details. Screening Mammogram Billing Codes HCPCS Code 77052 Description Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; screening mammography (list separately in addition to code for primary procedure)," can be billed in conjunction with the primary service code G0202 or 77057. Screening mammography, bilateral (two view film study of each breast). Screening mammography, producing direct digital image, bilateral, all views.

77057 G0202

Health Fairs Coverage for any service, including those provided at a health fair, is determined by the member's contract with BCBSKS. If the member has benefits for a service they receive at a health fair, the provider is required to submit a claim and payment would be allowed. See the examples below. Contains Public Information Revision Date: March 31, 2009 114

If services are offered at a health fair (or any type of promotion) for a discounted rate, BCBSKS expects to be billed that discounted rate for all services provided to their members during that same time frame. This requirement can be found in the BCBSKS Policies and Procedures for contracting hospitals and reads as follows: "If the Contracting Provider, through a short-term promotion such as a health fair, offers services for a reduced price, BCBSKS must also be billed the lower rate during that time frame." SCENARIO ­ screening mammography services are being offered at a health fair. 1. Done off hospital grounds. 2. Done with hospital equipment. 3. Done by hospital personnel. Most BCBSKS member contracts cover screening mammogram services without a physician order. Therefore, the screening mammogram MUST be billed to BCBSKS. Computer-Aided Detection (CAD) Screening CAD code 77052 should be listed in addition to 77057 or G0202 These codes may be submitted on Blue Cross claims. The services are subject to MAP payment, and have an add-on indicator in the MAP listing. See the MAP listing for further details. Positron Emission Tomography (PET) SCANS Revenue code 0404 must be used when billing PET Scans. A CPT code is required when billing outpatient services. The Society of Nuclear Medicine has educational material that is helpful with respect to PET, PET/CT and nuclear medicine. However, there is a membership fee. Their web site is: www.snm.org Providers who qualify for the highest level of reimbursement for either service MUST NOTIFY BCBSKS in advance of billing claims. If you fail to notify us, the allowance will be set at the lower maximum allowable payment (MAP). The two levels of reimbursement for PET scans will be based on whether or not the provider has a fixed unit or uses a mobile unit. Providers with a fixed unit will receive the highest allowance. If you have a fixed unit, notify BCBSKS Institutional Relations. Include this information: · · Provider name and address Provider number 115

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· ·

Type and model of fixed PET unit Date fixed unit was installed

Qualifying providers must submit the required documentation to BCBSKS prior to claims being submitted. Send the information to: Institutional Relations cc 442D2 Blue Cross Blue Shield of Kansas 1133 SW Topeka Blvd Topeka, Kansas 66629-0001

PET Codes HCPCS Code 78459 78491 Description

78492 78608 78609 78811 78812 78813 78814

78815

78816

G0219 G0235

Myocardial imaging, positron emission tomography (PET), metabolic evaluation Myocardial imaging, positron emission tomography (PET), perfusion, single study at rest or stress Myocardial imaging, positron emission tomography (PET), perfusion, multiple studies at rest and/or stress Brain imaging, positron emission tomography (PET); metabolic evaluation Brain imaging, positron emission tomography (PET); perfusion evaluation Tumor imaging, positron emission tomography (PET); limited area (e.g., chest, head/neck) Tumor imaging, positron emission tomography (PET); skull base to mid thigh Tumor imaging, positron emission tomography (PET); whole body Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area (e.g., chest, head/neck) Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid thigh Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body PET imaging, whole body; melanoma for non-covered indications PET imaging, any site, not otherwise specified

PET Tracer Codes HCPCS *A9555 A9526 Description Supply of Radiopharmaceutical Diagnostic Imaging Agent, Rubidium RB-82, Diagnostic, Per study dose, Up To 60 Millicuries Supply of Radiopharmaceutical Diagnostic Imaging Agent, Ammonia N-13

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Tracer codes applicable to CPT 78459, 78608, 78609, 78811-78816: Supply of Radiopharmaceutical Diagnostic Imaging Agent, Fluorodeoxyglucose F18, * A9552 FDG, Diagnostic, Per study dose, Up to 45 Millicuries Supply of Radiopharmaceutical Diagnostic Imaging Agent, Not Otherwise Classified A4641¥ ¥ This HCPCS code does have a MAP assignment and is considered an add-on code.

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BC 041X RESPIRATORY SERVICES

DETAIL UNITS HCPCS/CPT Per treatment Required for OP

DESCRIPTION: Charges for respiratory services including administration of oxygen and certain potent drugs through inhalation or positive pressure and other forms of rehabilitative therapy. SUBCATEGORY: STANDARD ABBREVIATION: 0 - General Classification RESPIRATORY SVC 2 ­ Inhalation Services INHALATION SVC 3 ­ Hyperbaric Oxygen Therapy HYPERBARIC O2 OTHER RESPIR SVS 9 - Other Respiratory Services

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 32X, 33X, 34X, 85X MEDICAL POLICIES: NOTE: There is a medical policy for these specific services. Refer to this website for guidelines. Hyperbaric Oxygen (HBO) Therapy: http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional/p olicies.htm BILLING & CODING GUIDELINES: Outpatient Respiratory Therapy Services performed by personnel trained to provide RT to patients are separately billable. A separate charge cannot be made for RT performed by the floor nurse to an inpatient. (See Revenue code 011X, 012X). Documentation must be specific, including the treatment provided, time involved and the Respiratory Therapist, or nurse's (outpatient claims) signature. The services provided to outpatients must be billed separately. For example, when a patient presents to the ER, the reimbursement for the E&M code does not include respiratory services. RT services have a payable CPT code. Therefore, facilities should bill each payable service. Medication used to perform the RT service is covered by Blue Cross, and should be billed separately. Although respiratory services can be billed with revenue code 046X, facilities can billl the revenue code that describes where the service was performed. Facilities may have RT set up in the ER, Treatment Room etc.

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Home Health Services Respiratory therapy services provided through a home health agency should be filed using revenue code 0410 and CPT code 94799 (Unlisted pulmonary service or procedure). Arterial Blood Gases This should be billed under revenue code 0300 with the appropriate lab CPT code. Hyperbaric Oxygen Providers can use C1300 or 99183 when billing HBO. HBO is not covered where the treatment of the condition has not been proven to be effective and has a Medical Policy. To view the applicable medical policy go to: HCPCS coding includes: · · 99183 ­ Physician attendance and supervision of hyperbaric oxygen therapy, per session. C1300 ­ Hyperbaric oxygen under pressure, full body chamber, per 30minute interval.

Oxygen Oxygen used during either an inpatient or outpatient encounter is considered a supply and should be coded under revenue code 0270. Oxygen for home use is considered DME and should be billed on a CMS 1500 claim form. Pulmonary Rehabilitation Institional Providers must be pre-approved before billing these services. Hosptial pulmonary rehab service must be billed with revenue code 0419 and HCPCS S9473 (Pulmonary rehabilitation program, non-physician provider, per diem). A global program charge is not separately billable on an inpatient claim. Blue Cross and Blue Shield of Kansas offers coverage for pulmonary rehabilitation programs. Actual coverage is determined by the individual member's contract and referral by their attending physician and/or primary care physician when applicable. A pulmonary rehabilitation program must be approved by BCBSKS before benefits are available. To request approval, submit a detailed program description which supports program criteria compliance. The description must include: · program schedule ­ date/times · services and equipment available · staffing · physician availability · patient assessment Contains Public Information Revision Date: March 31, 2009 119

· charge structure We must also receive a signed attestation certifying the facility's understanding and compliance with the criteria. While the initial program approval will be based upon the program description and attestation, follow-up review will be conducted during routine visits to your facility by our provider consultants or as the result of review activity conducted by our medical review department. · · · Programs will normally be considered approved the first of the month `following' receipt of the attestation and supporting documents. Members will receive eligible benefits for pulmonary rehabilitation programs that BEGIN ON OR AFTER THE PROGRAM APPROVAL DATE Reimbursement by BCBSKS will be based on a maximum allowable payment (MAP) for each day of client participation. It will be necessary to submit your charge structure to us for review. Your daily charge should be inclusive of all services except as outlined in "lll. Other Diagnostic Services" as indicated in the criteria. Hospitals with approved pulmonary rehabilitation programs will report the charges in the UB-04/837I claim format with revenue code 0419, other respiratory services, or 0948* - pulmonary rehab. BCBSKS requires HCPCS S9473 to report pulmonary rehabilitation services. The units field should indicate the number of days the client participated during the billing period. These billing instructions are only applicable to hospitals that have `approved' programs.

·

DO NOT USE HCPCS CODES G0237-G0239 WHEN BILLING OUTPATIENT PULMONARY REHAB TO BLUE CROSS. To review the complete coverage requirements, refer to the BCBSKS Institutional Provider Manual available at

BCBSKS - Customer Service - Providers - Publications - Institutional - Manuals Institutional Relations Manuals

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042X

PHYSICAL THERAPY

DETAIL UNITS HCPCS/CPT

BC

Required for OP Per HCPCS code Description Required for OP

DESCRIPTION: Charges for therapeutic exercises, massage, and utilization of effective date properties of light, heat, cold, water, electricity and assistive devices for diagnosis and rehabilitation of patients who have neuromuscular, orthopedic, and other disabilities. STANDARD ABBREVIATION: SUBCATEGORY: PHYSICAL THERP 0 ­ General Classification PHYS THERP/VISIT 1 ­ Visit PHYS THERP/HOUR 2 ­ Hourly PHYS THERP/GROUP 3 ­ Group PHYS THERP/EVAL 4 ­ Evaluation or Re-evaluation OTHER PHYS THERP 9 ­ Other Physical Therapy

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 32X, 33X, 34X, 85X MEDICAL POLICIES: BILLING & CODING GUIDELINES: Outpatient PT claims must include CPT codes and the appropriate units by code definition. Most therapy codes are subject to a MAP payment. It is very important that the correct codes and units are on all outpatient claims. Documentation and unit guidelines are explained in BC newsletter (See BC-07-15). NOTE: The onset date (occurrence code 11) must also be included on therapy claims; PT, OT and speech therapy - language pathology for groups that require this information. Billing Minutes September 11, 2007 Newsletter:

http://www.bcbsks.com/CustomerService/Providers/Publications/institutional/newsletters/ 2007/091107_OutpatientTherapyServices.htm

In 2004 when BCBSKS began reimbursing outpatient rehabilitation services provided by hospital providers based on a maximum allowable payment (MAP), we provided the following guidance for determining the number of therapy units. DETERMINING WHAT TIME COUNTS TOWARDS 15 MINUTE TIMED CODES Count only the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted. Contains Public Information Revision Date: March 31, 2009 121

Do not count any time the patient is not being treated e.g. resting, waiting for equipment, etc. Time spent delivering each service must be documented in the patient record in order to justify the appropriateness of the service and the units billed. DETERMINING THE NUMBER OF UNITS 1 unit > or equal to 8 minutes to < 23 minutes 2 units > or equal to 23 minutes to < 38 minutes 3 units > or equal to 38 minutes to < 53 minutes 4 units > or equal to 53 minutes to < 68 minutes 5 units > or equal to 68 minutes to < 83 minutes 6 units > or equal to 83 minutes to < 98 minutes 7 units > or equal to 98 minutes to < 113 minutes 8 units > or equal to 113 minutes to < 128 minutes Any code that does not reflect a time value should be billed with one unit for the visit. These guidelines have not been adopted by CPT-4 and until that occurs BCBSKS recommends that these guidelines be used in determining the number of billable therapy units. Modifiers Modifiers are not required and will have no effect on payment. Providers should bill according to services ordered and documented. SPECIAL PLAN INSTRUCTIONS: The State of Kansas group has a limit of 30 visits per calendar year maximum. REFERENCES: Documentation of Physical Therapy Services: http://www.bcbsks.com/CustomerService/Members/State/index.htm

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043X

OCCUPATIONAL THERAPY

BC

DETAIL UNITS HCPCS/CPT Required for OP Per HCPCS Code Description Required for OP

DESCRIPTION: Charges for therapeutic interventions to improve, sustain or restore an individual's level function in performance, of activities of daily living and work, including, therapeutic activities, therapeutic exercises; sensorimotor processing; psychosocial skills training, cognititve retraining, fabrication and application of orthotic devices; and training in the use of orthotic and prosthetic devices; adaptation of environoments; and application of physical agent modalities. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification OCCUPATIONAL THER 1 ­ Visit OCCUP THERP/VISIT 2 ­ Hourly OCCUP THERP/HOUR 3 ­ Group OCCUP THERP/GROUP 4 ­ Evaluation or Re-evaluation OCCUP THERP/EVAL 9 ­ Other Occupational Therapy (may include OCCUP THER/OTHER restorative therapy)

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 32X, 33X, 34X, 85X BILLING & CODING GUIDELINES: Outpatient OT claims must include HCPCS and the appropriate units by code definition. Most therapy codes are subject to a MAP payment. It is very important that the correct codes and units are on all outpatient claims. Use the same documentation guidelines for Blue Cross that applies to Medicare. Refer to the MAP listing for codes. NOTE: The onset date (occurrence code 11) must also be included on therapy claims, PT, OT and speech for groups that require this information. Billing Minutes September 11, 2007 Newsletter:

http://www.bcbsks.com/CustomerService/Providers/Publications/institutional/newsletters/ 2007/091107_OutpatientTherapyServices.htm

In 2004 when BCBSKS began reimbursing outpatient rehabilitation services provided by hospital providers based on a maximum allowable payment (MAP), we provided the following guidance for determining the number of therapy units. DETERMINING WHAT TIME COUNTS TOWARDS 15 MINUTE TIMED CODES

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Count only the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted. Do not count any time the patient is not being treated e.g. resting, waiting for equipment, etc. Time spent delivering each service must be recorded in the patient record in order to justify the appropriateness of the service and the units billed. DETERMINING THE NUMBER OF UNITS 1 unit > or equal to 8 minutes to < 23 minutes 2 units > or equal to 23 minutes to < 38 minutes 3 units > or equal to 38 minutes to < 53 minutes 4 units > or equal to 53 minutes to < 68 minutes 5 units > or equal to 68 minutes to < 83 minutes 6 units > or equal to 83 minutes to < 98 minutes 7 units > or equal to 98 minutes to < 113 minutes 8 units > or equal to 113 minutes to < 128 minutes Any code that does not reflect a time value should be billed with one unit for the visit. These guidelines have not been adopted by CPT-4 and until that occurs BCBSKS recommends that these guidelines be used in determining the number of billable therapy units. SPECIAL PLAN INSTRUCTIONS: The State of Kansas group has a limit of 30 visits per calendar year maximum. http://www.bcbsks.com/CustomerService/Members/State/index.htm

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044X

SPEECH THERAPYLANGUAGE PATHOLOGY

BC

DETAIL UNITS HCPCS/CPT OP Per HCPCS Description Required for OP

DESCRIPTION: Charges for services provided to persons with impaired functional communications skills. STANDARD ABBREVIATION: SUBCATEGORY: SPEECH THERAPY 0 - General Classification SPEECH THERP/VISIT 1 - Visit SPEECH THERP/HOUR 2 - Hourly SPEECH THERP/GROUP 3 - Group SPEECH THERP/EVAL 4 ­ Evaluation or Re-evaluation OTHER SPEECH THERP 9 - Other Speech Therapy

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 32X, 33X, 34X, 85X BILLING & CODING GUIDELINES: Outpatient speech therapy-language patholgy claims must include HCPCS, the appropriate units by code definition, and line item date of service. Most therapy codes are subject to a MAP payment. It is very important that the correct codes and units are on all outpatient claims. Refer to the MAP listing for codes. The onset date (Occurrence code 11) must also be included on therapy claims, PT, OT and speech for groups that require this information. Billing Minutes September 11, 2007 Newsletter: http://www.bcbsks.com/CustomerService/Providers/Publications/institutional/newsl etters/ 2007/091107_OutpatientTherapyServices.htm In 2004 when BCBSKS began reimbursing outpatient rehabilitation services provided by hospital providers based on a maximum allowable payment (MAP), we provided the following guidance for determining the number of therapy units. DETERMINING WHAT TIME COUNTS TOWARDS 15 MINUTE TIMED CODES Count only the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted. Do not count any time the patient is not being treated e.g. resting, waiting for equipment, etc. Time spent delivering each service must be recorded in the patient record in order to justify the appropriateness of the service and the units billed. Contains Public Information Revision Date: March 31, 2009 125

DETERMINING THE NUMBER OF UNITS 1 unit > or equal to 8 minutes to < 23 minutes 2 units > or equal to 23 minutes to < 38 minutes 3 units > or equal to 38 minutes to < 53 minutes 4 units > or equal to 53 minutes to < 68 minutes 5 units > or equal to 68 minutes to < 83 minutes 6 units > or equal to 83 minutes to < 98 minutes 7 units > or equal to 98 minutes to < 113 minutes 8 units > or equal to 113 minutes to < 128 minutes Any code that does not reflect a time value should be billed with one unit for the visit. These guidelines have not been adopted by CPT-4 and until that occurs BCBSKS recommends that these guidelines be used in determining the number of billable therapy units. SPECIAL PLAN INSTRUCTIONS: The State of Kansas group has a limit of 30 visits per calendar year maximum. http://www.bcbsks.com/CustomerService/Members/State/index.htm

045X

EMERGENCY ROOM

DETAIL UNITS HCPCS/CPT

BC

Per Visit Required for OP

DESCRIPTION: Charges for emergency treatment to those ill and injured persons who require immediate unscheduled medical or surgical care. Under the provisions of EMTALA (the Emergency Medical Treatment and Active Labor Act), a hospital with an emergency department must provide upon request and within the capabilities of the hospital, an appropriate medical screening examination and stabilizing treatment to any individual with an emergency medical condition and to any woman in active labor, regardless of the individual's eligibility for Medicare (Consolidated Omnibus Budget Reconciliation Act) [COBRA] of 1985. STANDARD ABBREVIATION: SUBCATEGORY: EMERG ROOM 0 ­ General Classification ER/EMTALA 1 ­ EMTALA Emergency Medical Screening ER/BEYOND EMTALA 2 - ER Beyond EMTALA ER/URGENT 6 ­ Urgent Care OTHER EMERG ROOM 9 ­ Other Emergency Room

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NOTE: Observation or hold beds are not reported under this code. They are reported under revenue code 0762, "Observation Room."

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X BILLING & CODING GUIDELINES: This section includes instructions for the following (in order): Diagnostic Services Provider to ER Patients Multiple ER Visits Same day Critical Care Services Separately Billable for Critical Care or other ER Care Outpatient Clinical Lab Dressing Changes without Debridement Blood Administration in the Emergency Room Drug Administration Antibiotic Injections Surgical Procedures in the Emergency Room Urgent Care Clinics (Revenue Codes 0456 and 0516) This revenue code should only be used to describe unscheduled hospital visits. Charges for scheduled patients should be billed under 076X, 051X etc.

Diagnostic Services Provided to ER Patients Services such as EKGs or venipunctures are often performed in the ER department. When performed in ER by staff operating within their licensure, these services can be billed with revenue code 045X, (i.e. CPT code 93005 EKG/ECG). Lab services, including a venipuncture must be billed under revenue code 0300, even when performed in the ER. Multiple ER Visits Same Day Condition code G0 is not recognized on Blue Cross claims. If the patient was seen in the ER twice in one day, the claim may be processed recognizing only one visit. If this occurs, contact institutional relations @ 785-291-8849 to have the claim adjusted. Many Blue Cross policies have an ER per visit co-pay. Therefore, it is very important that providers use 045X only on unscheduled visits. Critical Care Blue Cross uses the following description for billing this service. Contains Public Information Revision Date: March 31, 2009 127

Critical care includes the care of critically ill and unstable patients who require constant physician attention, whether the patient is in the course of a medical emergency or not. It involves decision making of high complexity to assess, manipulate, and support circulatory, respiratory, central nervous, metabolic, or other vital system function to prevent or treat single or multiple vital organ system failure. It often also requires extensive interpretation of multiple databases and the application of advanced technology to manage the critically ill patient. Critical care is usually, but not always, given in a critical care area such is the coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, a separate charge for critical care can only be made to outpatients. Time that can be reported as critical care is the time spent by the physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be recorded once. When at least 30 minutes of critical care is provided, the hospital will bill CPT code 99291 (and 99292, if appropriate). As the CPT guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines 99291 - Critical care, evaluation and management of the critically ill or critically injured patient; first 30 ­ 74 minutes 99292 - Each additional 30 minutes Services Separately Billable for Critical Care or Other ER Care An example of some services that may be provided to Critical Care or other ER patients: · Intubations - CPT code 31500 · CPR ­ CPT code 92950 This is not an all-inclusive list. All providers should separately bill for any documented service that is medically necessary. Outpatient Clinical Lab Outpatient lab is paid on the lab fee schedule except when the services are performed with an ER encounter (revenue code 0450), or observation (revenue code 0762), or a MAP'd surgery. The lab services performed during ER and observation will be priced at the outpatient discount rate. Lab performed on the day of a MAP'd surgery will be packaged with the surgical MAP allowance. Dressing Changes without Debridement An assessment of the patients' condition, complaints, and the wound itself should be well documented in order to bill an E&M service. If this service is performed on an emergency patient, the dressing change is part of the ER visit code, 99281Contains Public Information Revision Date: March 31, 2009 128

99283. Dressing supplies are separately billable under revenue code 027X. When providing this service to a scheduled patient, see rev code 076X. Blood Administration in Emergency Room When blood is administered to an ER patient, the provider may bill blood administration if provided to a patient receiving emergent or urgent care and should be billed in addition to the ER visit. For scheduled blood transfusions, see revenue code 0391. For instructions billing the blood product see revenue code 038X or 039X. Drug Administration When a drug is administered to an emergency room patient, a charge should be made for the administration of the drug. The administration charge reflects the room and nurses' time. For billing instructions refer to Appendix A at the end of this manual. Antibiotic Injections Use CPT code 96372 to report an injection of an antibiotic. If the antibiotic is given as an IV infusion, use the appropriate code as defined in the infusion instructions. Injection administration is considered a separate service from infusion therapy and is separately billable to BCBSKS. It is appropriate to bill IV infusion therapy, injection, drugs, and supplies separately. IV solutions and packaged drugs are billed using revenue code 25X or 636 if the drug has a HCPCS. Administration charges should be billed using the revenue code describing the location of the service. CPT codes 96360, 96361, 96365, 96366, 96367, 96368, and 96374 are subject to a Maximum Allowable Payment (MAP) and are designated as add-on codes. This means the provider receives a line item payment in addition to other services billed on the claim. Surgical Procedures in the Emergency Room Scheduled surgical services performed in the ER should be billed under 076X rather than 45X. Hospitals should bill a separate charge for ER visits and ER surgical procedures. If a surgical procedure is performed in the ER the charge for the procedure must be billed with the emergency room revenue code. If an ER visit occurs on the same day, a charge should be billed for the ER visit and a separate charge should be billed for the surgical procedure(s) performed. A single charge may be billed for all surgical procedures if more than one procedure is performed in the ER during the same session. EXAMPLE: Contains Public Information Revision Date: March 31, 2009 129

The following is an example of how a claim should be completed under these reporting requirements: Date of Service 7/5/2008 7/5/2008 7/5/2008 7/5/2008 7/5/2008 Revenue Code 0450 0450 0450 0250 0270 HCPCS 99283 12011 12035 Modifier 25 Charges $150 $300 $70 $85

The charge for both surgical procedures in this example is reflected in the $300 charge shown on the line with procedure code 12011. Any surgical procedure performed in the ER, should be separately billed, using the appropriate CPT code. This can be accomplished by submitting a charge for multiple surgical procedures, performed in ER, on each line item or providers can submit surgical charges on the first surgery CPT line, with a zero on each additional surgical line. If the surgical CPT code is subject to MAP reimbursement, the other services may be combined into the MAP rate for the surgical service. Some surgical CPT codes are not subject to the MAP payment when they are provided on the day of the accident.

Urgent Care Clinics (Revenue code 0456 or 0516) In 2007 CMS implemented two types of emergency rooms; Type A and Type B.

At this time, Blue Cross acknowleges these classifications but requests that charges and codes be submitted with Revenue Code 0456 only for Urgent Care Clinics.

Multiple ER visits If there are two ER visits in one day, separate copays will be applied to each.

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046X

PULMONARY FUNCTION

DETAIL UNITS HCPCS/CPT

BC

Per test/HCPCS code description Required for OP

DESCRIPTION: Charges for tests that measure inhaled and exhaled gases and analysis of blood and for tests that evaluate the patient's ability to exchange oxygen and other gases. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification PULMONARY FUNC 9 ­ Other Pulmonary OTHER PULMONARY FUNC

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X BILLING & CODING GUIDELINES: The range of codes that may fall into this revenue code are: 94010-94799. Use the appropriate HCPCS for pulmonary function studies. The correct billing method for arterial blood gas testing is revenue code 0300 with HCPCS 82800, 82803, or 82805.

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131

047X

AUDIOLOGY

DETAIL UNITS HCPCS/CPT

BC

Per test/HCPCS Code Description Required for OP

DESCRIPTION: Charges for the detection and management of communication handicaps centering in whole or in part on the hearing function. STANDARD ABBREVIATION: SUBCATEGORY: AUDIOLOGY 0 - General Classification AUDIOLOGY/DX 1 ­ Diagnostic AUDIOLOGY/RX 2 ­ Treatment OTHER AUDIOL 9 - Other Audiology

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X

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048X

CARDIOLOGY

DETAIL UNITS HCPCS/CPT

BC

OP Per test/HCPCS Code Description Required for OP

DESCRIPTION: Services provided are by staff from the cardiology department of the hospital or under arrangement. Services include such procedures as: heart catherization, coronary angiography, Swan-Ganz catheterization and exercise stress test. Charges for cardiac procedures furnished in a separate unit within the hospital. Such procedures include, but are not limited to: heart catheterization, coronary angiography, Swan-Ganz catheterization and exercise stress test. SUBCATEGORY: STANDARD ABBREVIATION: 0 - General Classification CARDIOLOGY 1 - Cardiac Cath Lab CARDIAC CATH LAB 2 - Stress Test STRESS TEST 3 ­ Echocardiology ECHOCARDIOLOGY 9 - Other Cardiology OTHER CARDIOL

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X NOTE: There is a medical policy for these specific services. Refer to the website for guidelines.

http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional

BILLING & CODING GUIDELINES: Cardiac Catheterization The three major components of cardiac catheterization include: Introduction and positioning of the catheter (93501-93533) including repositioning, Injection procedures (93539-93545); imaging supervision, interpretation, and report (93555-93556). Supervision and interpretation codes related to cardiac catheterization (93555 and 93556) are used with imaging performed as part of cardiac catheterization procedures. Drug-Eluting Stents The Food and Drug Administration (FDA) approved drug-eluting stents effective April 24, 2003. This notification provides updated billing instructions for the placement of drug-eluting stents. Hospitals should report HCPCS code the stent device codes C1874-C1877, in addition to the surgical placement codes G0290 or G0291. Hospitals should make certain that the charge for G0290 and G0291 for placement of the stents does not include the stent charge. Contains Public Information Revision Date: March 31, 2009 133

HCPCS Code G0290

Long Descriptor

G0291

Transcatheter placement of a drug-eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel Transcatheter placement of a drug-eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel

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049X

AMBULATORY SURGICAL CARE

BC

DETAIL UNITS HCPCS/CPT Per HCPCS Code Description Required for OP

DESCRIPTION: Charges for ambulatory surgery, not covered by any other category. SUBCATEGORY: STANDARD ABBREVIATION: 0 - General Classification AMBULTRY SURG 9 - Other Ambulatory Surgical OTHER AMBL SURG

TYPE OF CLAIM: Outpatient BILLING & CODING GUIDELINES: To be used only with prior approval.

050X

OUTPATIENT SERVICES

DETAIL UNITS HCPCS/CPT

BC

Per service Required

DESCRIPTION: Outpatient charges for services rendered to an outpatient who is admitted as an inpatient before midnight of the day following the date of service. SUBCATEGORY: STANDARD ABBREVIATION: 0 - General Classification OUTPATIENT SVCS 9 - Other Outpatient OTHER ­ O/P SERVICES

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X BILLING & CODING GUIDELINES: Services provided the day before an admission, must be included on the inpatient claim when provided at the same facility. Revenue code 0450 or 0500 can be used for contracting facilities only.

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051X

CLINIC

DETAIL UNITS HCPCS/CPT

BC

Per Visit Required for OP

DESCRIPTION: Clinic (non-emergency/outpatient visit) charges for providing diagnostic, preventive curative, rehabilitative and education services to ambulatory patients. STANDARD ABBREVIATION: SUBCATEGORY: CLINIC 0 ­ General Classification CHRONIC PAIN CLINIC 1 ­ Chronic Pain Center DENTAL CLINIC 2 - Dental Clinic PSYCHIATRIC CLINIC 3 ­ Psychiatric Clinic OB-GYN CLINIC 4 - OB-GYN Clinic PEDIATRIC CLINIC 5 ­ Pediatric Clinic URGENT CARE CLINIC 6 - Urgent Care Clinic FAMILY CLINIC 7 - Family Practice Clinic OTHER CLINIC 9 - Other Clinic

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X BILLING & CODING GUIDELINES: Beginning November 8, 2008, the ER copay will be applied to Revenue Code 516 just as it applies to Revenue Code 450. This category should only be used to report services provided at a hospital based clinic. Revenue code 051X is used to report the technical charge associated with a physician/practitioner service. Blue Cross requires revenue code 0510 to be billed when hospitals are providing medical services and scheduling patients for clinic visits for physicians whose specialty is not available in the rural community. Providers should not use 0510 for services that do not meet the above definition. If other medical services are provided after the physician assessment, they should be billed using the appropriate revenue code (e.i 761 or 360) with the CPT code that describes the service. In order to charge for this service, there must be documentation in the medical record to support the visit. The clinic MAP is based on revenue code 0510 regardless of the CPT code billed.

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Clinic Billing Guidelines

Did physician provide the service? YES Is this a visiting physician? Is the hospital located in a rural location? Place of service- off site or on base hospital grounds On hospital grounds Billing guideline

1

NO

YES

All charges for the professional service must be reported on a CMS-1500 claim form. The hospital cannot bill a 510 for the use of the room, because the service was not provided by a visiting physician. All charges for the professional service must be reported on a CMS-1500 claim form. The hospital cannot bill a 510 for the use of the room, because the hospital is not in a rural location. The professional services must be reported on a CMS-1500 claim form. The hospital reports the TC charges on a UB04 with an E&M CPT code. Use revenue code 510. All charges would be billed on a UB04. Do not use revenue code 51X, since no physician was involved. Use revenue code 76X. All charges for the professional service must be billed on a CMS-1500. Since this service can also be provided on the hospital campus an additional charge cannot made for the use of the room. All charges for the professional service must be billed on a CMS-1500. Since this service can also be provided on the hospital campus an additional charge cannot made for the use of the room. All charges for the professional service must be billed on a CMS-1500. Since this service can also be provided on the hospital campus an additional charge cannot made for the use of the room. If the service provided is also available at the hospital, the total charge (PC/TC) must be billed on a 1500 claim form. If the service provided is only available off site, the TC can be billed on a UB04 with a revenue code other than 510. Use revenue code 76X.

2

YES

YES

NO

On hospital grounds

3

YES

YES

YES

On hospital grounds

4

NO

NO (physician did not see the patient) NO

YES

On hospital grounds

5

YES

YES

Off site

6

YES

YES

NO

Off site

7

YES

YES

YES

Off site

8

NO

NO (physician did not see the patient)

YES

Off site

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Off-Site Services: Services provided off-site the physical main hospital campus must be billed on the CMS -1500 claim form, except in those cases where that off-site location is the sole place of service for an outpatient ancillary service or as determined by BCBSKS. When hospitals provide multiple services off-site the main hospital campus, an addendum agreement to peer group pricing may be offered. Telemedicine Starting May 1, 2008, Blue Cross and Blue Shield of Kansas will provide reimbursement for originating site telemedicine services that meet established guidelines. The guidelines are: · · · Applies to outpatient claims received by BCBSKS starting May 1, 2008 that have a service date on or after April 1, 2008. Claims with dates prior to these will not be reimbursed. Like outpatient clinic visits, the telemedicine service must involve a physician's specialty that is not otherwise available in the community. Telemedicine services for primary care or care by a mid-level practitioner are not covered nor should they be billed to BCBSKS.

Billing procedures: Originating site telemedicine services meeting these guidelines should be billed to BCBSKS: · · Using the UB-04 billing format Type of bill 13X or 85X. (Telemedicine services are billable only on outpatient claims.) · With either: *Revenue code 0780 ­ telemedicine general classification; or *The revenue code center that identifies where the service was performed (i.e. 0450 = emergency room, 0510 = clinic, 0360 = operating room). · HCPCS Q3014, telehealth originating site facility fee. (This HCPCS must be reported regardless of what revenue code is used.) · Additional services provided during the telemedicine encounter (e.g. laboratory, x-rays, etc.) are separately billable. Reimbursement: Originating site telemedicine services will be reimbursed a maximum allowable payment (MAP) assigned to HCPCS Q3014. The allowance for Q3014 will be the same as the MAP for outpatient clinic visits, revenue code 0510. (See your 2008 Outpatient Maximum Allowable Payments listing for the exact amount or contact the institutional relations department). Contains Public Information Revision Date: March 31, 2009 138

052X

FREE-STANDING CLINIC

DETAIL UNITS HCPCS/CPT

BC

DESCRIPTION: Charges for the outpatient visit at a free-standing clinic. STANDARD ABBREVIATION: SUBCATEGORY: FREESTAND CLINIC 0 ­ General Classification FS-RURAL/CLINIC 1 ­ Clinic visit by member to RHC/FQHC FS-RURAL/HOME 2 ­ Home visit by RHC/FQHC FS-FAMILY PRACT 3 ­ Family Practice Clinic FR/STD FAMILY CLINIC 4 ­ Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF RURAL/SNF NF ICF MR OTHER 5- Visit by RHC/FQHC practitioner to a member in

a SNF (not a covered Part A stay) or NF or ICF MR or other residential facility

6 ­ Urgent Care Clinic 7 - RHC/FQHC Visiting Nurse Service(s) to a member's home when in a home health shortage area ­ 8 - Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g. scene of accident) 9 ­ Other Free-standing Clinic FR/STD URGENT CLINIC

OTHER FS-CLINIC

BILLING & CODING GUIDELINES: This revenue code category is not allowed for BCBSKS primary claims. Rural Health Clinic (RHC) services are billed on a CMS 1500 claim form. SECONDARY CLAIMS: Medicare rural health clinics (RHCs) submit claims on UB-04 claim form. These providers are set up with a separate contract number to allow these charges to crossover from Medicare in the UB-04 format and process. (Type of Bill = 711) When billing hardcopy secondary rural health clinic claims to Blue Cross, claims must be submitted on the same format they are submitted to Medicare.

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053X

OSTEOPATHIC SERVICES

DETAIL UNITS HCPCS/CPT

BC

Per Visit Required

DESCRIPTION: Charges for a structural evaluation of the cranium, entire cervical, dorsal and lumbar spine by a doctor of osteopathy. There is a service unique to osteopathic hospitals and cannot be accommodated in any of the existing codes. STANDARD ABBREVIATION: SUBCATEGORY: 0 - General Classification 1 ­ Osteopathic Therapy 9 - Other Osteopathic Services OSTEOPATH SVS OSTEOPATH RX OTHER OSTEOPATH

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X

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054X

AMBULANCE

DETAIL UNITS HCPCS/CPT

BC

DESCRIPTION: Charges for ambulance services necessary for the transport of the ill or injured who require medical attention at a health care facility. Charges for ambulance service, usually on an unscheduled basis to the ill and injured that require immediate medical attention. Provides subcategories that third party payers or hospitals may wish to recognize. Heart mobile is a specifically designed ambulance transport for cardiac patients. STANDARD ABBREVIATION: SUBCATEGORY: AMBULANCE 0 ­ General Classification AMBUL/SUPPLY 1 ­ Supplies AMBUL/MED TRANS 2 ­ Medical Transplant AMBUL/HEART MOB 3 ­ Heart Mobile AMBUL/OXYGEN 4 ­ Oxygen AIR AMBULANCE 5 ­ Air Ambulance AMBUL/NEONAT 6 ­ Neonatal Ambulance Services AMBUL/PHARMAS 7 ­ Pharmacy AMBUL/EKG TRANS 8 ­ EKG Transmission AMBUL/OTHER 9 ­ Other Ambulance

BILLING & CODING GUIDELINES: This revenue code category is not allowed for BCBSKS primary claims. All

ambulance services must be billed on a CMS 1500 claim form.

SECONDARY CLAIMS: Ambulance services may be submitted on a UB-04 when Medicare is the primary payer.

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055X

HOME HEALTH (HH)

DETAIL

BC

Only 0551 allowed for Blue Cross Per HCPCS Code Definition Required ­ G0154

UNITS HCPCS/CPT

DESCRIPTION: Charges for nursing services provided under the direct supervision of a home health (HH) licensed nurse. ...that must be provided under the direct supervision of a licensed nurse to assure the safety of the patient and to achieve the medically desired result. This code may be used for nursing home services, CORFS, or a service charge for home health billing. STANDARD ABBREVIATION: SUBCATEGORY: SKILLED NURSING-HH 0 ­ General Classification SKILLED NURS/VISIT 1 ­ Visit Charge SKILLED NURS/HOUR 2 ­ Hourly Charge SKILLED NURS/OTHER 9 ­ Other Skilled Nursing

TYPE OF CLAIM: Outpatient TYPE OF BILL: 32X, 33X, 34X, 81X, 82X BILLING & CODING GUIDELINES: Home health facilities should use revenue code 0551 only when billing HCPCS code G0154 (Services of skilled nurse in home health setting, each 15 minutes) Hospice Hospice facilities may bill for skilled nursing visits (including initial evaluations) using revenue code 0551. HCPCS coding is not required. REIMBURSEMENT: Reimbursement for skilled and therapeutic visits is the provider's charge up to the maximum allowable payment amount. Reimbursement for IV therapy to include teaching will be limited to the MAP for a skilled visit.

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056X

HOME HEALTH (HH) MEDICAL SOCIAL SERVICES

BC

DETAIL Only 0561 allowed for Blue Cross Per HCPCS Code Definition Required ­ G0155

UNITS HCPCS/CPT

DESCRIPTION: Home health (HH) charges for services such as counseling patients, interviewing patients, and interpreting problems of social situation rendered to patients on any basis. STANDARD ABBREVIATION: SUBCATEGORY: MED SOCIAL-HH 0 ­ General Classification MED SOC SVCS-VISIT 1 - Visit Charge MED SOC SVCS-HOUR 2 - Hourly Charge MED SOC SVCS-OTHER 9 - Other Med. Social Services

TYPE OF CLAIM: Outpatient TYPE OF BILL: 32X, 33X, 34X BILLING & CODING GUIDELINES: Home health facilities should use revenue code 0561 only when billing HCPCS code G0155 (Services of clinical social worker in home health setting, each 15 minutes) G0155 (Services of clinical social worker in a home health setting, each 15 minutes) should only be used for this revenue code category. REIMBURSEMENT: Reimbursement for skilled and therapeutic visits is the provider's charge up to the maximum allowable payment amount.

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057X

HOME HEALTH (HH) AIDE

DETAIL

BC

Only 0571 allowed by Blue Cross Per HCPCS Code Definition Required ­ G0156

UNITS HCPCS/CPT

DESCRIPTION: Home health (HH) charges for personnel that are primarily responsible for the personal care of the patient. STANDARD ABBREVIATION: SUBCATEGORY: HH AIDE 0 - General Classification HH AIDE-VISIT 1 - Visit Charge HH AIDE-HOUR 2 - Hourly Charge HH AIDE-OTHER 9 - Other Home Health Aide

TYPE OF CLAIM: Outpatient TYPE OF BILL: 32X, 33X, 34X BILLING & CODING GUIDELINES: Home health facilities should use revenue code 0571 only when billing HCPCS code G0156 (Services of clinical social worker in home health setting, each 15 minutes) G0156 (Services of home health aide in a home health setting, each 15 minutes) should only be used for this revenue code category. REIMBURSEMENT: Reimbursement for skilled and therapeutic visits is the provider's charge up to the maximum allowable payment amount.

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144

058X

HOME HEALTH (HH) ­ OTHER VISITS

DETAIL UNITS HCPCS/CPT

BC

Only 581 allowed by Blue Cross # of Services Provided Not Required

DESCRIPTION: Home health (HH) agency charges for visits other than physical therapy, occupational therapy or speech therapy-language pathology, requiring specific identification. STANDARD ABBREVIATION: SUBCATEGORY: HH-OTH VIS 0 - General Classification HH-OTH VIS/VISIT 1 - Visit Charge HH-OTH VIS/HOUR 2 - Hourly Charge HH-OTH/VIS/ASSESS 3 - Assessment HH-OTH VIS/OTHER 9 - Other Home Health Visits

TYPE OF CLAIM: Outpatient TYPE OF BILL: 32X, 33X, 34X BILLING & CODING GUIDELINES: Peripheral Blood Draws for Laboratory Services If a home health agency is asked to visit a home patient and the only scheduled service is peripheral blood draw for laboratory services, the blood draw will be handled as follows: a) This service is subject to a maximum allowable payment. b) The home health agency will only bill revenue code 0581 (Home Health/Other visit). No HCPCS code is required but if one is reported, providers should use either 36415 or S9529. c) Home health visits for peripheral blood draws must be prior authorized. d) The 25% payment reduction applies if the service is not prior authorized. e) Peripheral blood draws done in conjuction with a scheduled home health visit will not be separately billed or reimbursed. DEFINITIONS: 36415: Collection of venous blood by venipuncture S9529: Routine venipuncture for collection of specimen(s), single home bound, nursing home, or skilled nursing facility patient

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145

059X

HOME HEALTH (HH) ­ UNITS OF SERVICE

DETAIL UNITS HCPCS/CPT

BC

DESCRIPTION: Home health (HH) charges for services billed according to the units of service provided. SUBCATEGORY: STANDARD ABBREVIATION: 0 - General Classification HH-SVCS/UNIT 9 - Reserved

BILLING & CODING GUIDELINES: This revenue code is not allowed on Blue Cross primary claims.

060X

HOME HEALTH (HH) ­ OXYGEN

BC

DETAIL UNITS HCPCS/CPT

DESCRIPTION: Home health (HH) agency charges for oxygen equipment supplies or contents, excluding purchased equipment. If a beneficiary has purchased a stationary oxygen system, an oxygen concentrator or portable equipment, current revenue codes 0292 or 0293 apply. DME (other than oxygen systems) is billed under current revenue codes 0291, 0292, or 0293. STANDARD ABBREVIATION: SUBCATEGORY: O2/HOME HEALTH 0 - General Classification 1 - Oxygen ­ Stat Equip/Supply/Content O2/STAT EQUIP/SUPL/CONT 2 - Oxygen ­ Stat Equip/Supply <1 PLUM O2/STAT EQP/SUPPL <1 LPM 3 - Oxygen ­ Stat Equip/Supply >4 PLUM O2/STAT EQP/SUPPL >4 LPM 4 - Oxygen ­ Port Add-on O2/PORTABLE ADD-ON 9 - Other Oxygen O2/OTHER

BILLING & CODING GUIDELINES: This revenue code is not allowed on Blue Cross primary claims.

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146

061X

Magnetic Resonance Technology (MRT)

BC

DETAIL UNITS HCPCS/CPT Required Per test/HCPCS code Description Required for OP

DESCRIPTION: Charges for Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA). STANDARD ABBREVIATION: SUBCATEGORY: MRI 0 ­ General Classification MRI/BRAIN 1 ­ MRI-Brain/Brainstem MRI/SPINE 2 ­ MRI-Spinal Cord/Spine 3 ­ RESERVED MRI/OTHER 4 ­ MRI-Other MRA/HEAD AND NECK 5 ­ MR-Head and Neck MRA/LOWER EXTRM 6 ­ MRA-Lower Extremities 7 ­ RESERVED MRA/OTHER 8 ­ MRA-Other MRT/OTHER 9 ­ Other MRT

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X EXPERIMENTAL/INVESTIGATIONAL: NOTE: There is a medical policy for these specific services. Refer to the website for guidelines. http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institut ional/policies.htm BILLING & CODING GUIDELINES: Contrast Material High osmolar contrast materials should be billed under revenue code 0636, refer to this section for further details on coding. 74185 - Magnetic resonance angiography, abdomen, with or without contrast; use the following codes: C8900 - Magnetic resonance angiography with contrast, abdomen C8901 - Magnetic resonance angiography without contrast, abdomen C8902 - Magnetic resonance angiography without contrast followed by with contrast, abdomen 77058 - Magnetic resonance imaging, breast, without and/or with contrast; use the following codes: C8903 - Magnetic resonance imaging with contrast, breast; unilateral Contains Public Information Revision Date: March 31, 2009 147

C8904 - Magnetic resonance imaging without contrast, breast; unilateral C8905 - Magnetic resonance imaging without contrast followed by with contrast, breast; unilateral 77059 - Magnetic resonance imaging, breast, without and/or with contrast; bilateral HCPCS effective 10/01/01 C8906 - Magnetic resonance imaging with contrast, breast; bilateral C8907 - Magnetic resonance imaging without contrast, breast; bilateral C8908 - Magnetic resonance imaging without contrast followed by with contrast, breast; bilateral 71555 - Magnetic resonance angiography, chest (excluding myocardium), with or without contrast; use the following codes: C8909 - Magnetic resonance angiography with contrast, chest (excluding myocardium) C8910 - Magnetic resonance angiography without contrast, chest (excluding myocardium) C8911 - Magnetic resonance angiography without contrast followed by with contrast, chest (excluding myocardium) 73725 - Magnetic resonance angiography, lower extremity, with or without contrast; use the following codes: C8912 - Magnetic resonance angiography with contrast, lower extremity C8913 - Magnetic resonance angiography without contrast, lower extremity C8914 - Magnetic resonance angiography without contrast followed by with contrast, lower extremity

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148

062X

MEDICAL/SURGICAL SUPPLIES-EXTENSION OF 027X

BC

DETAIL UNITS HCPCS/CPT Required for 0624 Per HCPCS Description Required for OP

DESCRIPTION: Charges for supply items required for patient care. The category is an extension of 027X for reporting additional breakdown where needed. Subcode 1 is for providers that do not bill supplies used under radiology revenue codes as part of the radiology procedure charges. Subcode 2 is for providers that cannot bill supplies used for other diagnostic procedures. STANDARD ABBREVIATION: SUBCATEGORY: MED-SUR SUPL-INCDT RAD 1 - Supplies incident to radiology MED-SUR SUPL-INCDT ODX 2 - Supplies incident to other DX services SURG DRESSINGS 3 - Surgical Dressings IDE 4 - FDA Investigational Devices

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 85X BILLING & CODING GUIDELINES: Outpatient Dressings (Not Take Home) Surgical dressings applied in an outpatient department during the encounter should be billed under revenue code 0270 or 0272, without a HCPCS. Dressings furnished as part of a radiology procedure, can be billed under 0272 or bill under 0621 (Supplies incident to radiology); Dressings applied as incident to another diagnostic procedure, can be billed under 0272 or under 0622 (Supplies incident to other diagnostic services). HCPCS codes are not required under 0621 or 0622. Take Home Dressings Take home surgical dressings may be billed under 027X or 0623 (Surgical dressings). Experimental/Investigational Devices Locally underwritten Blue Cross and Blue Shield of Kansas (BCBSKS) member contracts include a general exclusion for any drug, device or medical treatment or procedure and related services that are experimental or investigational. (The definition of experimental or investigational as defined in the member contract follows).

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Experimental/Investigational Defined The following definition appears in the locally underwritten BCBSKS member contract. Experimental or Investigational refers to the status of a drug, device, medical treatment or procedure: · If the drug or device cannot be lawfully marketed without approval of the of the U.S. Food and Drug Administration and approval for marketing has not been given at the time the drug or device is furnished and the drug or device is not research-urgent as defined by the BCBSKS member contract; or If credible evidence shows that the drug, device, medical treatment or procedure is the subject of ongoing phase I, II or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis and the trials are not research-urgent as defined by the BCBSKS member contract; or If credible evidence shows that the consensus among experts regarding the drug, device, medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the standard means of treatment or diagnosis and the trials are not research-urgent as defined by the BCBSKS member contract; or If there is no credible evidence available that would support the use of the drug, device, medical treatment or procedure compared to the standard means of treatment or diagnosis.

·

·

·

The BCBSKS provider contract prohibits the provider from billing a member for experimental or investigational services unless the provider issued a written notice in advance stating that a specific service was not covered and the reason for non-coverage. (http://www.bcbsks.com/CustomerService/Forms/pdf/NoticePersonalFinancialObl igation.pdf) Providers are responsible to know if services offered at their facility are experimental or investigational. While it is not the responsibility of BCBSKS to keep providers informed of medical protocols and approvals, we may become aware of information about services through communications with providers and other medical resources. A list of experimental or investigational services can be found on the BCBSKS Web site: http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional/e xperimental.htm

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The list: · Is not all-inclusive. · Includes information that is valid at the time of update. · Is subject to change without notice. · Does not relieve the provider of their responsibility to monitor medical protocols and approvals. · Is intended only as a method to share information with providers.

Credible Evidence means only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating eligible provider or the protocol of another eligible provider providing or studying substantially the same drug, device, medical treatment or procedure; or the written informed consent used by the treating eligible provider or by another eligible provider providing or studying substantially the same drug, device, medical treatment or procedure. Providers should contact Customer Service prior to rendering the service, in order to determine coverage.

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063X

Pharmacy ­ Extension of 025X

BC

DETAIL UNITS HCPCS/CPT Required for 0634, 0635, 0636 Per HCPCS Code Description Required for OP

DESCRIPTION: Charges for medication produced, manufactured, packaged, controlled, assayed, dispensed and distributed under the direction of a licensed pharmacist. The category is an extension of 025X for reporting additional breakdown when needed. STANDARD ABBREVIATION: SUBCATEGORY: 0 ­ RESERVED (EFFECTIVE 01/01/98) DRUG/SINGLE 1 ­ Single Source Drug DRUG/MULTIPLE 2 ­ Multiple Source Drug DRUG/RESTRICT 3 ­ Restrictive Prescription DRUG/EPO<10,000 Units 4 ­ Erythropoietin (EPO)<10,000 Units DRUG/EPO>=10,000 Units 5 ­ Erythropoietin (EPO)>=10,000 Units DRUG/DETAIL CODE 6 ­ Drugs Requiring Detailed Coding (a) DRUG/SELF ADMIN 7 ­ Self-Administrable Drugs (b) NOTE: (a) Charges for drugs and biologicals (with the exception of radiopharmaceuticals, which are reported under Revenue Codes 0343 and 0344) requiring specific identifications as required by the payer. (effective 10/1/04). If HCPCS are used to describe the drug, enter the HCPCS code in Form Locator 44. The specified units of service to be reported are to be in hundreds (100) rounded to the nearest hundred (no decimal). (b)Value code A6 used in conjunction with revenue code 0637 indicates the amount included for covered charges for the ordinarily non-covered, self-administered drug insulin administered in an emergency situation to a patient in a diabetic coma (see UB04 Version 3.00 02/18/09).

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 18X, 21X, 72X, 85X NOTE: There is a medical policy for these specific services. Refer to the website for guidelines. http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional/ policies.htm BILLING & CODING GUIDELINES: Contact your BCBSKS provider consultant with the appropriate detailed information regarding a new procedure device or code to obtain a pure code and coverage guidelines for that service or item. Inpatient & Outpatient Drugs Outpatient drugs provided during the encounter are covered. This includes oral and injectable drugs. HCPCS should be used when available with revenue code 0636. If there is no pure HCPCS code, bill charge per drug under 25X. DO NOT USE J3490 (NOC code) Contains Public Information Revision Date: March 31, 2009 152

Chemotherapy Drugs/Biological Response Modifiers/Monoclonal Antibodies/Hormonal Antineoplastics Chemotherapy HCPCS for IV or IM chemotherapy agents are J9000-J9600 and should be billed with revenue code 0636. Units should reflect the amount administered according to HCPCS definition. See Appendix A for guidelines on billing chemotherapy administration. The administration of monoclonal antibodies and biological response modifier drugs are billed under chemotherapy administration codes. Oral Chemotherapy Drugs Oral chemotherapy drugs are covered and should be billed with revenue code 0636. Units should reflect the amount administered by HCPCS definition. HCPCS J8510 J8520 J8521 J8530 J8560 J8600 J8610 J8650 J8700 J8999 Description Oral busulfan Capecitabine, oral, 150 mg Capecitabine, oral, 500 mg Use J8520 Cyclophosphamide oral 25 MG Etoposide oral 50 MG Melphalan oral 2 MG Methotrexate oral 2.5 MG Nabilone oral Temozolomide Oral prescription drug chemo

Blue Cross will accept any valid HCPCS. Many of the chemotherapy injectable drugs are subject to MAP reimbursement. Refer to the Blue Cross MAP listing. Drug Administration Inpatient: Administration of a drug by the floor nurse is not separately billable on an inpatient claim. This is part of the routine nursing and the cost is included in the room and board charge. Outpatient: When billing for covered outpatient pharmacy items, the cost for administering the drug is a billable service. The charge for administration includes both the cost of the room and the nurse's time to administer the drug (administration is billed as one charge per CPT description). See Appendix A in this manual for billing instructions. The revenue code should reflect the patient type and room occupied, i.e.: ER patient - 0450, Observation - 0760, Treatment Room - 0761, Clinic Room - 0510. Refer to these sections for billing instructions for drug administration. Administration of a drug in the operating room and/or recovery room is not Contains Public Information Revision Date: March 31, 2009 153

separately billable for inpatient or outpatient claims. The drugs are separately billable. Separately Payable Drugs - Non Chemotherapy J0120-J7799 If the HCPCS is not on the claim, the facility may receive less reimbursement as Blue Cross allows additional payment for some add-on drugs. Units should be based on the HCPCS code definition. Contrast Material Inpatient: High osmolar contrast material should be billed under revenue code 0255. Low osmolar contrast material can be billed under either revenue code 0254 or 0255. Outpatient: High Osmolar Contrast Material (HOCM) Outpatient claims for high osmolar contrast material (HOCM) should be billed with revenue code 0636 and the appropriate HCPCS: Low Osmolar Contrast Material (LOCM) Outpatient claims for low osmolar contrast material (LOCM) must be billed under revenue code 0636. LOCM is a MAP'd add on service. It is very important that you bill contrast material separately with the correct HCPCS and units in order to receive additional reimbursement. LOCM is an add-on service for BCBSKS. Q9958 Q9959 Q9960 Q9961 Q9962 Q9963 Q9964 HOCM <=149 mg/ml iodine, 1ml HOCM 150-199mg/ml iodine,1ml HOCM 200-249mg/ml iodine,1ml HOCM 250-299mg/ml iodine,1ml HOCM 300-349mg/ml iodine,1ml HOCM 350-399mg/ml iodine,1ml HOCM >= 400 mg/ml iodine,1ml

Units must indicate the number of milliliters administered. The record must also reflect the amount (in milliliters (ml)) administered to the patient:

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Q9965 Q9966 Q9967 Q9951

LOW OSMOLAR CONTRAST MATERIAL, 100-199 mg/ml iodine, 1 ml LOW OSMOLAR CONTRAST MATERIAL, 200-299 mg/ml iodine, 1 ml LOW OSMOLAR CONTRAST MATERIAL, 300-399 mg/ml iodine, 1 ml LOW OSMOLAR CONTRAST MATERIAL, 400 OR GREATER MG/ML IODINE CONCENTRATION, PER ML

MRI Contrast Material A9579 Injection, gadolinium-based magnetic resonance contrast agent, per ml Q9953 Injection, iron-based magnetic resonance contrast agent, per ml Q9954 Oral magnetic resonance contrast agent, per 100 ml EPOETIN (EPO)/Darbepoetin Alfa (ARANESP) for ESRD Patients EPO is covered for the treatment of anemia for patients with chronic renal failure who are on dialysis when: · · · It's administered at the renal dialysis facility, or It is administered by a home dialysis patient or patient caregiver who is determined competent to use the drug and meets the other criteria. Erythropoietin replacement therapies, (ie. EPO/Aranesp) are separately billable drugs and are payable in addition to the composite rate reimbursement. The HCPCS for EPO for patients on dialysis performed by an ESRD provider: HCPCS HCPCS Description J0886 Injection, Epoetin alfa, 1,000 units (for ESRD on Dialysis) Injection, Epoetin alfa, 100 units (for ESRD on Dialysis) Injection, Darbepoetin alfa (Aranesp), 1 mcg (for ESRD on Dialysis)

Q4081 J0882

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The HCPCS for EPO for patients NOT on dialysis:

J0881 J0885 Darbepoetin alfa (Aranesp) 1 microgram, non-esrd Epoetin alfa (Procrit) 1000 units, non-esrd

Separate payment will not be made by BCBSKS for supplies used to administer EPO. SECONDARY CLAIMS: If Medicare is the primary payer, claims may include HCPCS A9270 with a GY modifier and Blue Cross will continue to deny payment on that line as noncovered. This code/modifier combination represents statutorily excluded services that do not have a specific HCPCS code assigned and should not be used when Blue Cross is primary.

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064X

HOME IV THERAPY SERVICES (NOT USED IN KANSAS)

BC

DETAIL UNITS HCPCS/CPT

DESCRIPTION: Charge for intravenous drug therapy services which are performed in the patient's residence. For Home IV providers, the HCPCS code must be entered for all equipment, and all types of covered therapy. STANDARD ABBREVIATION: IV THERAPY SVC SUBCATEGORY: IV THERAPY SERVICE 0 ­ General Classification NON RT NURSING/CENTRAL 1 - Non-routine Nursing, Central Line IV SITE CARE/CENTRAL 2 - IV Site Care, Central Line IV STRT/CARE/PERIPHRL 3 - IV Start/Care, Peripheral Line NONRT NURSING/PERIPHRL 4 - Non-routine Nursing, Peripheral Line TRNG PT/CAREGVR/CENTRAL 5 ­ Training Patient/Caregiver , Central Line TRNG DSBLPT/CENTRAL 6 ­ Training, Disabled Patient, Central Line TRNG/PT/CARGVR/PERIPHRL 7 ­ Training, Patient/Caregiver, Peripheral Line TRNG/DSBLPT/PERIPHRL OTHER IV THERAPY SVC 8 ­ Training, Disabled Patient, Peripheral Line 9 - Other IV Therapy Services NOTE: Units need to be reported in one hour increments. Revenue code 0642 relates to the HCPCS code.

BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims.

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065X

HOSPICE SERVICE

DETAIL UNITS HCPCS/CPT

BC

Only 0651 & 0656 allowed for Blue Cross # of hours/days Not Required

DESCRIPTION: Charges for hospice care services for a terminally ill patient electing hospice services in lieu of other medical services for their terminal condition. STANDARD ABBREVIATION: SUBCATEGORY: HOSPICE 0 ­ General Classification HOSPICE/RTN HOME 1 ­ Routine Home Care HOSPICE/CTNS HOME 2 ­ Continuous Home Care 3 ­ RESERVED 4 ­ RESERVED HOSPICE/IP RESPITE 5 ­ Inpatient Respite Care HOSPICE/IP NON-RESPITE 6 ­ General Inpatient Care (Non-respite) HOSPICE/PHYSICIAN 7 ­ Physician Services HOSPICE/R&B/NURSE FAC 8 ­ Hospice Room and BoardNursing Facility HOSPICE/OTHER 9 ­ Other Hospice

TYPE OF CLAIM: Outpatient: Revenue Code 0651 Inpatient: Revenue Code 0656 TYPE OF BILL: 81X, 82X BILLING & COVERAGE GUIDELINES: The following services are included in routine hospice coverage: Nursing care Home health aide services Social worker services Pastoral services Volunteer support Bereavement services Counseling services Dietary and nutritional counseling services All drugs, medical supplies, and equipment related to the terminal illness Speech-language therapy Occupational therapy Physical therapy Radiation therapy

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REIMBURSEMENT: Hospice providers are responsible for providing written notice to BCBSKS when their Medicare per diem rates are updated. Rates can also be sent to: Institutional Relations Department CC442D2 Blue Cross and Blue Shield of Kansas 1133 SW Topeka Blvd Topeka KS 66629-0001 FAX: (785) 290-0734 Hospice providers that have a qualified inpatient hospice facility approved by BCBSKS may receive, when applicable, an inpatient payment (110% of the Medicare inpatient hospice rate) for each day of approved inpatient hospice services.

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066X

RESPITE CARE

BC

DETAIL UNITS HCPCS/CPT DESCRIPTION: Charges non-hospice respite care. STANDARD ABBREVIATION: SUBCATEGORY: RESPITE CARE 0 -General Classification RESPITE/NURSING 1 - Hourly Charge-Nursing RESPITE/HMEAID/HMEMKE 2 - Hourly Charge/Home Health Aide/ Homemaker RESPITE/DAILY 3 - Daily Respite Charge RESPITE/OTHER 9 -Other Respite Care

BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims.

067X

OUTPATIENT SPECIAL RESIDENCE CHARGES

BC

DETAIL UNITS HCPCS/CPT

DESCRIPTION: Residence arrangements for patients requiring continuous outpatient care STANDARD ABBREVIATION: SUBCATEGORY: OP SPEC RES 0 - General Classification OP SPEC RES/HOSP OWNED 1 - Hospital Owned OP SPEC RES/CONTRACTED 2 - Contracted OP SPEC RES/OTHER 9 - Other Special Residence Charges

BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims.

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068X

TRAUMA RESPONSE

BC

DETAIL Per Activation UNITS G0390 HCPCS/CPT DESCRIPTION: Charges representing the activation of the trauma team. STANDARD ABBREVIATION: SUBCATEGORY: Trauma Level I 0- Not Used Trauma Level II 1- Level I Trauma Trauma Level III 2- Level II Trauma Trauma Level IV 3- Level III Trauma Trauma Level V 4- Level IV Trauma Trauma Other 9- Other Trauma Response Usage Notes:

1. To be used by trauma center/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving a trauma activation. 2. Revenue Category 068X is used for patients for whom a trauma activation occurred. A trauma team activation/response is a "Notification of key hospital personnel in response to triage information from prehospital caregivers in advance of the patient's arrival." 3. Revenue Category 068X is for reporting trauma activation costs only. It is an activation fee and not a replacement or a substitute for the emergency room visit fee; if trauma activation occurs, there will normally be both a 045X and 068X revenue code reported. 4. Revenue Category 068X is not limited to admitted patients. 5. Revenue Category 068X must be used in conjunction with FL 19 Type of Admission/Visit code 05 ("Trauma Center"), however FL 19 Code 05 can be used alone. Only patients for who there has been pre-hospital notification, who meet either local, state or American College of Surgeons field triage criteria, or are delivered by inter-hospital transfers, and are given the appropriate team response, can be billed the trauma activation fee charge. Patients who are "drive-by" or arrive without notification cannot be charged for activations, but can be classified as trauma under Type of Admission Code 5 for statistical and follow-up purposes. 6. Levels I, II, III or IV refer to designations by the state or local government authority or as verified by the American College of Surgeons. 7. Subcategory 9 is for sate or local authorities with levels beyond IV.

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X BILLING & CODING GUIDELINES: Beginning October 1, 2008, BCBSKS will allow trauma response charges to be billed if the facility meets the definition of a trauma center. If your facility meets the criteria of a trauma center, please notify your provider consultant. Inpatient: If trauma activation occurs, under the circumstances described by the National Uniform Billing Committee guidelines (see guidelines in Usage Notes above) that would permit reporting a charge, the hospital will bill one unit of service with revenue code 68X.

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Outpatient: If trauma activation occurs, under the circunstances described by the National Uniform Billing Committee guidelines (see guidelines in Usage Notes above) that would permit reporting a charge, the hospital will bill one unit of service with revenue code 68X and HCPCS code G0390 (Trauma response team activation associated with hospital critical care service). REIMBURSEMENT: Inpatient claims that include Revenue Code 68X with a service date of October 1, 2008 and after will be paid according to the facility agreement. For outpatient trauma activation charges with a service date of 10/1/08, payment will be made at the MAP rate for HCPCS code G0390 or according to the facility agreement.

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070X

CAST ROOM

DETAIL UNITS HCPCS/CPT

BC

DESCRIPTION: Charges for services related to the application, maintenance and removal of casts. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification CAST ROOM 9 ­ Reserved

TYPE OF CLAIM: Outpatient TYPE OF BILL: 11X, 13X, 85X BILLING & CODING GUIDELINES: Blue Cross recognizes the general classification (revenue code 0700) only.

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071X

RECOVERY ROOM

BC

DETAIL Not Required UNITS Not Required HCPCS/CPT DESCRIPTION: Room charge for patient recovery after surgery. SUBCATEGORY: STANDARD ABBREVIATION: 0 - General Classification RECOVERY ROOM 9 - Reserved

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X BILLING & CODING GUIDELINES: Equipment Equipment normally used in the recovery room area is not separately billable (i.e. oximetry, blood pressure monitors, etc). Levels of Recovery Effective October 1, 2007, hospitals should use revenue code 0710 for both the designated area recovery and for extended recovery/step-down recovery on an inpatient floor. Observation vs Recovery Complications that occur during the recovery period are conditions that may warrant observation. See revenue code 0762 for observation guidelines. Billing observation during recovery is not appropriate unless the condition qualifies under the observation guidelines, and there is a written physician order to admit to observation based on the complication that arises. Rarely would observation be billed on post surgical outpatients. Most post-operative care will fall into a recovery period, which is billed under revenue code 710. IV and Injections during Recovery Drugs provided during the recovery period are billable. However, administration charge for drugs provided during the recovery period if related to the surgery, pain, or anesthesia are not separately billable.

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072X

LABOR ROOM/DELIVERY

DETAIL UNITS HCPCS/CPT

BC

# of Days ­ 0723 is by procedure Not Required

DESCRIPTION: Charges for labor and delivery room services provided by specially trained nursing personnel to patients including prenatal care during labor, assistance during delivery, postnatal care in recovery room, and minor gynecologic procedures if they are performed in the delivery suite. STANDARD ABBREVIATION: SUBCATEGORY: DELIVERY ROOM LABOR 0 ­ General classification LABOR 1 ­ Labor DELIVERY ROOM 2 ­ Delivery Room CIRCUMCISION 3 ­ Circumcision BIRTHING CNTR 4 ­ Birthing Center OTHER/DELIV-LABOR 9 ­ Other Labor Room/Delivery

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: This revenue code represents the labor, delivery, or birthing center room charges. Facilities that have all inclusive care (i.e. rooms in which the labor, delivery and post care days all occur in one room) may consider charging an OB room rate that does not duplicate personnel fees that are included in the labor, delivery etc. Below are two recommended charge methods: Option 1 Labor, delivery and the remaining hospital post care all in the same room · Labor Rev Code 0721-includes the room, personnel, and equipment needed to monitor the labor · Delivery Rev Code 0722- includes the room, personnel and reusable equipment needed · OB room, Rev Code 0122 - which reflects the room, personnel and equipment in the room during the daily labor and delivery period. Normally this room charge would be considerably less, as most of the personnel costs occur during the labor and delivery period. The facility makes a 0122 room charge only for the labor and delivery days. On the post delivery days, the hospital charges a normal room rate using revenue code 0120. Option 2 Charge a daily rate that includes labor, delivery and post care. The OB room charge is all inclusive of the services, billed as revenue code 0112 or 0122 for each day the patient is an inpatient. Contains Public Information Revision Date: March 31, 2009 165

Fetal Monitoring Fetal monitoring is billed under revenue code 0732 using the appropriate CPT code. Additional Labor & Delivery Room Charges Additional nursing charges in the labor and/or delivery room are not separately billable.

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073X

EKG/ECG (ELECTROCARDIOGRAM)

DETAIL UNITS HCPCS/CPT

BC

Required for OP Per HCPCS Code Description Required for OP

DESCRIPTION: Charges for operation of specialized equipment to record electromotive variations in actions of the heart muscle on an electrocardiography for diagnosis of heart ailments. STANDARD ABBREVIATION: SUBCATEGORY: EKG/ECG 0 ­ General classification HOLTER MONT 1 ­ Holter Monitor TELEMETRY 2 ­ Telemetry OTHER EKG/ECG 9 ­ Other EKG/ECG

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X MEDICAL POLICIES: Note: There are services that have specific medical policies. Refer to the following website for guidelines. http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional/p olicies.htm BILLING & CODING GUIDELINES: Telemetry/Cardiac Heart Monitoring A separate charge can be made if: · the equipment is portable · there is dedicated personnel monitoring the equipment. If the above are not applicable the telemetry equipment charge should be part of the room charge. Fetal Monitoring/OB Stress Test The standard revenue code in most cases for outpatient fetal monitoring and OB stress test is 0732. However, these services can be billed under revenue codes 072X (labor and delivery) or 076X (observation). These codes are mapped.

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074X

EEG (ELECTROENCEPHALOGRAM)

BC

DETAIL UNITS HCPCS/CPT Per HCPCS Code Description Required for OP

DESCRIPTION: Charges for operation of specialized equipment to measure impulse frequencies and differences in electrical potential in various areas of the brain to obtain data for use in diagnosing brain disorders. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification EEG 9 ­ Reserved

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X BILLING & CODING GUIDELINES: Revenue code 0740 is suggested, however, it would also be appropriate to use the code that represents where the costs occurred.

075X

GASTRO-INTESTINAL (GI) SERVICES

BC

DETAIL UNITS HCPCS/CPT Per HCPCS Code Description Required for OP

DESCRIPTION: Charges for GI procedures not performed in the operating room. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification GASTRO-INSTL SVCS 9 ­ Reserved

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X BILLING & CODING GUIDELINES: Only revenue code 0750 can be used on outpatient claims. Anesthesia for Upper and Lower GI Procedures Please refer to newsletter BC-07-09 dated March 9, 2007.

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076X

SPECIALTY ROOM ­ TREATMENT/OBSERVATION ROOM

BC

DETAIL UNITS HCPCS/CPT Required for OP 0762 - Hours Required for 0761

DESCRIPTION: Charges for the use of specialty rooms such as treatment or observation rooms. Charges for the use of a treatment room or for the room charge associated with outpatient observation services. Only 0762 should be used for observation services. Observation services are those services furnished by a hospital on the hospital's premises, including use of a bed and periodic monitoring by a hospital's nursing or other staff, which are reasonable and necessary to evaluate an outpatient's condition or determine the need for a possible admission to the hospital as an inpatient. Such services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. Most observation services do not exceed one day. Some patients, however, may require a second day of outpatient observation services. The reason for observation must be stated in the orders for observation. Payers should establish written guidelines, which identify coverage of observation services. STANDARD ABBREVIATION: SUBCATEGORY: SPECIALTY ROOM 0 ­ General Classification TREATMENT RM 1 ­ Treatment Room OBSERVATION RM 2 ­ Observation Room 9 ­ Other Treatment/Observation Room

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X BILLING & CODING GUIDELINES: This section includes instructions for the following: Observation (Revenue Code 0762) Treatment Room (Revenue Code 0761) Blood Administration Observation (Revenue Code 0762) Outpatient observation is reimbursable only under the following conditions: a. b. c. d. Observation must be physician ordered; Medical necessity for the observation must exist; The observation must be on an unscheduled basis; There is no hourly limitation for outpatient observation; however, payment will be limited to 24 hours by allowing the hospital's average semi-private room rate or charges, whichever is less. Any amount over the average semiprivate (AVSP) room rate will be a write-off to contracting hospitals;

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e. All outpatient services (including observation) provided to a patient who is admitted as an inpatient before midnight of the following day are considered to be included in the DRG for the inpatient stay and must be billed to BCBSKS as part of the inpatient claim. This applies only to outpatient services performed at the same facility where the patient is subsequently admitted; f. If the patient is not admitted as an inpatient following observation, the observation charge will be paid according to the member's contractual outpatient benefit. Report revenue code 0762 with an observation CPT (99217, 99218, 99219, 99220). These are the only CPT codes that can be used with this revenue code. Other separately billable services during observation should be coded under revenue code 0760 with the appropriate HCPCS/CPT. Observation hours should be reported on one line with the date the patient entered observation as the date of service. Therefore, facilities should use 99218 with the total hours of observation on one line.

Drug Administration in Observation When a drug is administered to an observation patient, a charge should be made for the administration of the drug. The administration charge reflects the room and the nurse's time. This should prompt facilities to evaluate the hourly charge for observation and the hourly charges for IV, or, a patient could be double charged unintentionally for the same time, room etc while in observation. For example, if you have an observation charge that is representating personnel and the room, and IV charges for the personnel and the room; this could indicate the patient is being charged twice. If the observation cost center has an observation charge that is reflective of medical monitoring only, then separate your charges for IV 's and injection. Evaluate what the patient may be billed if they were to receive 24 hours of observation and 24 hours of IV charges. It is important that hospitals review this area. For billing instruction of IV and injection services see Appendix A at the end of this manual.

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Recovery Room vs. Observation Billing observation during recovery is not appropriate unless the condition qualifies under the observation guidelines, and there is a written physician order to admit to observation based on the complication that arises. Rarely would observation be billed for post surgical outpatients. Most post-operative care will fall into a recovery period, which is billed under revenue code 71X. Treatment Room (Revenue Code 0761) Treatment Room is used to bill scheduled services with specific HCPCS that describes the service. Hospitals should set up charges based on the service provided. The CPT/HCPCS reflects the service, the charge reflects the cost of the service (room incidental supplies, room) and the revenue code (0761) indicates where the service took place. Following are services that may be provided in the treatment room. This is not all inclusive. · Evaluation and Management (E&M) If the patient is assessed and no procedure was performed, an E&M code should be used. Examples of this would be found when treating wound care patients who do not require debridement or a catheter change (See Appendix C). Documentation must support billing an E&M service. It is important that hospitals use the appropriate code to report the level of intensity. There should be written guidelines to assist facilities to distinguish between low and mid level visits. Each facility will be accountable for following its own system for assigning different levels of CPT codes. However, if a procedure or service is scheduled, an additional charge for an assessment is not separately billable. Surgical Services Any surgical procedure performed in the treatment room should be separately billed, using the appropriate CPT code. An E&M service should not be billed in addition to a planned or scheduled procedure. Administration of Drugs When a drug is administered to a scheduled patient, the revenue code assigned should be 761. The CPT will reflect the route of administration and the charge reflects the room and the nurse's time. Refer to Appendix A at the end of this manual for billing guidelines. Blood Administration Blood administration charges represent the room along with personnel costs and are billed with CPT code 36430, revenue code 0760 or 0391. Units are per visit. Blood products are billed under 038X, or 039X.

·

·

·

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077X

PREVENTIVE CARE SERVICES

BC

DETAIL UNITS HCPCS/CPT Per HCPCS Definition Required for OP

DESCRIPTION: Revenue code used to capture preventive care services established by payers (e.g. vaccination). STANDARD ABBREVIATION: SUBCATEGORY: PREVENT CARE SVCS 0 ­ General Classification VACCINE ADMIN 1 ­ Vaccine Administration 9 ­ Reserved

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X MEDICAL POLICY: Note: There are services that have specific medical policies. Refer to the following website for guidelines. http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional/p olicies.htm

BILLING & CODING GUIDELINES: Bone mineral density should be billed under revenue code 0320.

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078X

TELEMEDICINE

BC

DETAIL UNITS HCPCS/CPT DESCRIPTION: Faciltiy charges related to the use of telemedicine services. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification TELEMEDICINE 9 ­ Reserved

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X BILLING & CODING GUIDELINES: Blue Cross and Blue Shield of Kansas will provide reimbursement for originating site telemedicine services that meet established guidelines. The guidelines are: · Applicable to outpatient claims that have a service date on or after April 1, 2008. Claims with dates prior to these will not be reimbursed. · Like outpatient clinic visits, the telemedicine service must involve a physician's specialty that is not otherwise available in the community. · Telemedicine services for primary care or care by a mid-level practitioner are not covered nor should they be billed to BCBSKS. Billing procedures: · Originating site telemedicine services meeting these guidelines should be billed to BCBSKS: · Use the UB-04 billing format · Telemedicine services are billable only on outpatient claims. · Revenue code (either): - Revenue code 0780 ­ telemedicine general classification; or - The revenue code center that identifies where the service was performed · HCPCS Q3014, telehealth originating site facility fee · Additional services provided during the telemedicine encounter (e.g. laboratory, x-rays, etc.) are separately billable. REIMBURSEMENT: Originating site telemedicine services will be reimbursed a maximum allowable payment (MAP) assigned to HCPCS Q3014. The allowance for Q3014 will be the same as the MAP for outpatient clinic visits, revenue code 0510. (Refer to MAP listing) REFERENCES: March 26, 2008 Newsletter Contains Public Information Revision Date: March 31, 2009 173

079X

EXTRA-CORPOREAL SHOCK WAVE THERAPY (formally Lithotripsy)

BC

DETAIL UNITS HCPCS/CPT

Per HCPCS Code Description Required for OP

DESCRIPTION: Charges related to Extra-Corporeal Shock Wave Therapy (ESWT). SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification ESWT 9 ­ Reserved

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X MEDICAL POLICIES: Note: There are services that have specific medical policies. Refer to the following website for guidelines. http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional/p olicies.htm BILLING & CODING GUIDELINES: Providers should use the general classification (revenue code 0790) only with the appropriate CPT code when billing outpatient services. The CPT code for this service is subject to MAP.

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080X

INPATIENT RENAL DIALYSIS

BC

DETAIL UNITS HCPCS/CPT Per Session Not Required

DESCRIPTION: Charges for the use of equipment designed to remove waste when the body's own kidneys have failed. The waste may be removed from the blood (hemodialysis) or indirectly from the blood by flushing a special solution between the abdominal covering and the tissue (peritoneal dialysis) A waste removal process performed in an inpatient setting that uses an artificial kidney when the body's own kidneys have failed. The waste may be removed directly from the blood (hemodialysis) or indirectly from the blood by flushing a special solution between the abdominal covering and the tissue (peritoneal dialysis). Specific identification required for billing purposes. STANDARD ABBREVIATION: SUBCATEGORY: RENAL DIALYSIS 0 ­ General Classification DIALY/INPATIENT 1 ­ Inpatient Hemodialysis DIALY/IP/PER 2 ­ Inpatient Peritoneal (Non-CAPD) DIALY/IP/CAPD 3 ­ Inpatient Continuous Ambulatory Peritoneal DIALY/IP/CCPD Dialysis (APD) DIALY/IP/OTHER 4 ­ Inpatient Continuous Cycling Peritoneal Dialysis (CCPD) 9 ­ Other Inpatient Dialysis

TYPE OF CLAIM: Inpatient TYPE OF BILL: 11X BILLING & CODING GUIDELINES: Blue Cross requires charges for all services to be included on the inpatient claim.

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081X

ACQUISITION OF BODY COMPONENTS

BC

DETAIL UNITS HCPCS/CPT 0814 Only Not Required Not Required

DESCRIPTION: The acquisition and storage costs of body tissue, bone marrow, organs and other body components not otherwise identified, used for transplantation. STANDARD ABBREVIATION: SUBCATEGORY: ORGAN ACQUISIT 0 ­ General Classification LIVING DONOR 1 ­ Living Donor CADAVER DONOR 2 ­ Cadaver Donor UNKNOWN DONOR 3 ­ Unknown Donor UNSUCCESSFUL SEARCH 4 ­ Unsuccessful Organ Search-Donor Bank OTHER DONOR Charge* 9 ­ Other Donor Note: Living donor is a living person from whom an organ is collected and used for transplantation purposes.Cadaver is an individual pronounced dead according to medical and legal criteria, and whose organs may be harvested for transplantation. Unknown is used whenever the status of the individual source cannot be determined. Use the other category whenever the organ is non-human. Revenue code 0814 is used only when costs incurred for an organ search does not result in an eventual organ acquisition and transplantation.

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X BILLING & CODING GUIDELINES: Revenue code 0814 is to be used only when costs incurred for an organ search do not result in organ acquisition and transplantation. Units and CPT/HCPCS are not to be reported for any of the 081X revenue codes.

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082X

HEMODIALYSIS OUTPATIENT OR HOME

BC

DETAIL UNITS HCPCS/CPT X Per Session Required

DESCRIPTION: A waste removal process, performed in an outpatient or home setting, necessary when the body's own kidneys have failed. Waste is removed directly from the blood. STANDARD ABBREVIATION: SUBCATEGORY: HEMO/OP OR HOME 0 ­ General Classification HEMO/COMPOSITE 1 ­ Hemodialysis/Composite or Other Rate HEMO/HOME/SUPPL 2 ­ Home Supplies HEMO/HOME/EQUIP 3 ­ Home Equipment HEMO/HOME/100% 4 ­ Maintenance/100% HEMO/HOME/SUPSERV 5 ­ Support Services HEMO-OTHER OP 9 ­ Other OP Hemodialysis Note: Detailed revenue coding is required. Therefore, service may not be summed at the zero level.

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 72X BILLING & CODING GUIDELINES: Blue Cross requires charges for all services to be included on the dialysis facility claim. When a service is excluded from the composite rate, the service may be billed separately. However, the service must also be medically necessary, documented in the patient's medical record and have an appropriate ICD-9-CM diagnosis code (reflecting the medical reason for the test) on the claim. Uncompleted Treatments and "No-shows" Uncompleted Treatments ­ If a dialysis treatment is started (ie, a patient is connected to the machine and a dialyzer and blood lines are used) but the treatment is not completed for some unforeseen, but valid reason (eg, a medical emergency where the patient must be rushed to an emergency room) the facility is paid based on the full composite rate. This should be a rare occurrence and must be fully documented in the medical record. "No-shows" ­ If a facility sets up in preparation for a dialysis treatment, but the treatment is never started (eg, the patient never arrives) no payment is made. REIMBURSEMENT: Reimbursement for dialysis encounters are based on a composite rate which includes components similar to those identified by Medicare, including but not limited to: routine pharmacy, laboratory services and all supplies. Contains Public Information Revision Date: March 31, 2009 177

Services that are excluded from the composite rate are those services that are: · not routinely provided as part of outpatient dialysis treatment; or · tests that are provided more frequently than normal for dialysis patients. Please see revenue codes 025X (pharmacy), 0300 (laboratory) and 063X (EPO/Aranesp) for further details.

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178

083X

PERITONEAL DIALYSIS ­ OUTPATIENT OR HOME

BC

DETAIL UNITS HCPCS/CPT X Per Session Required

DESCRIPTION: Charges for a waste removal process performed in an outpatient or home setting, necessary when the body's own kidneys have failed.Waste is removed indirectly by flushing a special solution between the abdominal covering and the tissue. STANDARD ABBREVIATION: SUBCATEGORY: PERITONEAL/OP OR HOME 0 ­ General Classification PERTNL/COMPOSITE 1 ­ Peritoneal/Composite or Other Rate PERTNL/HOME/SUPPL 2 ­ Home Supplies PERTNL/HOME/EQUIP 3 ­ Home Equipment PERTNL/HOME/100% 4 ­ Maintenance/100% PERTNL/HOME/SUPSERV 5 ­ Support Services PERTNL/HOME/OTHER 9 ­ Other Outpatient Peritoneal Dialysis

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 72X, 85X BILLING & CODING GUIDELINES: Use condition code 73 in addition to revenue code 0831 when providing selftraining. Blue Cross requires charges for all services to be included on the dialysis facility claim. When a service is excluded from the composite rate, the service may be billed separately. However, the service must also be medically necessary, documented in the patient's medical record and have an appropriate ICD-9-CM diagnosis code (reflecting the medical reason for the test) on the claim. Uncompleted Treatments and "No-shows" Uncompleted Treatments ­ If a dialysis treatment is started (ie, a patient is connected to the machine and a dialyzer and blood lines are used) but the treatment is not completed for some unforeseen, but valid reason (eg, a medical emergency where the patient must be rushed to an emergency room) the facility is paid based on the full composite rate. This should be a rare occurrence and must be fully documented in the medical record. "No-shows" ­ If a facility sets up in preparation for a dialysis treatment, but the treatment is never started (eg, the patient never arrives) no payment is made.

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179

REIMBURSEMENT: Reimbursement for dialysis encounters are based on a composite rate which includes components similar to those identified by Medicare, including but not limited to: routine pharmacy, laboratory services and all supplies. Services that are excluded from the composite rate are those services that are: · not routinely provided as part of outpatient dialysis treatment; or · tests that are provided more frequently than normal for dialysis patients. Please see revenue codes 025X (pharmacy), 0300 (laboratory) and 063X (EPO/Aranesp) for further details.

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180

084X

CONTINUOUS AMBULATORY PERITONEAL DIALYSIS (CAPD) - OUTPATIENT OR HOME

BC

DETAIL UNITS HCPCS/CPT X # of Days Required

DESCRIPTION: Charges for a continuous dialysis process performed in an outpatient or home setting which uses the patient peritoneal membrane as a dialyzer. STANDARD ABBREVIATION: SUBCATEGORY: CAPD/OP OR HOME 0 ­ General Classification CAPD/COMPOSITE 1 ­ CAPD/Composite or Other Rate CAPD/HOME/SUPPL 2 ­ Home Supplies CAPD/HOME/EQUIP 3 ­ Home Equipment CAPD/HOME/100% 4 ­ Maintenance 100% CAPD/HOME/SUPSERV 5 ­ Support Services CAPD/HOME/OTHER 9 ­ Other Outpatient CAPD

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 72X, 85X BILLING & CODING GUIDELINES: Use condition code 73 in addition to revenue code 0841 when providing selftraining. Blue Cross requires charges for all services to be included on the dialysis facility claim. When a service is excluded from the composite rate, the service may be billed separately. However, the service must also be medically necessary, documented in the patient's medical record and have an appropriate ICD-9-CM diagnosis code (reflecting the medical reason for the test) on the claim. Uncompleted Treatments and "No-shows" Uncompleted Treatments ­ If a dialysis treatment is started (ie, a patient is connected to the machine and a dialyzer and blood lines are used) but the treatment is not completed for some unforeseen, but valid reason (eg, a medical emergency where the patient must be rushed to an emergency room) the facility is paid based on the full composite rate. This should be a rare occurrence and must be fully documented in the medical record. "No-shows" ­ If a facility sets up in preparation for a dialysis treatment, but the treatment is never started (eg, the patient never arrives) no payment is made.

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181

REIMBURSEMENT: Reimbursement for dialysis encounters are based on a composite rate which includes components similar to those identified by Medicare, including but not limited to: routine pharmacy, laboratory services and all supplies. Services that are excluded from the composite rate are those services that are: · not routinely provided as part of outpatient dialysis treatment; or · tests that are provided more frequently than normal for dialysis patients. Please see revenue codes 025X (pharmacy), 0300 (laboratory) and 063X (EPO/Aranesp) for further details.

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182

085X

CONTINUOUS CYCLING PERITONEAL DIALYSIS (CCPD) - OUTPATIENT OR HOME

BC

DETAIL UNITS HCPCS/CPT X # of Days Required

DESCRIPTION: Charges for a continuous dialysis process performed in an outpatient or home setting which uses a machine to make automatic exchanges at night. STANDARD ABBREVIATION: SUBCATEGORY: CCPD/OP OR HOME 0 ­ General Classification CCPD/COMPOSITE 1 ­ CCPD/Composite or Other Rate CCPD/HOME/SUPPL 2 ­ Home Supplies CCPD/HOME/EQUIP 3 ­ Home Equipment CCPD/HOME/100% 4 ­ Maintenance 100% CCPD/HOME/SUPSERV 5 ­ Support Services CCPD/HOME/OTHER 9 ­ Other Outpatient CCPD

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 72X, 85X BILLING & CODING GUIDELINES: Use condition code 73 in addition to revenue code 0841 when providing selftraining. Blue Cross requires charges for all services to be included on the outpatient claim.

REIMBURSEMENT: Reimbursement for dialysis encounters are based on a composite rate which includes components similar to those identified by Medicare, including but not limited to: routine pharmacy, laboratory services and all supplies. Services that are excluded from the composite rate are those services that are: · not routinely provided as part of outpatient dialysis treatment; or · tests that are provided more frequently than normal for dialysis patients. Please see revenue codes 025X (pharmacy), 0300 (laboratory) and 063X (EPO/Aranesp) for further details.

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183

088X

MISCELLANEOUS DIALYSIS

BC

DETAIL UNITS HCPCS/CPT X Per Session Required

DESCRIPTION: Charges for dialysis services not identified elsewhere. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification DIALY/MISC 1 ­ Ultrafiltration DIALY/ULTRAFILT 2 ­ Home Dialysis Aid Visit HOME DIALYSIS AID VISIT 9 - Misc. Dialysis Other DIALY/MISC/OTHER NOTE: Ultrafiltration is the process of removing excess fluid from the blood of dialysis patients by using a dialysis machine but without the dialysate solution. The designation is only used when the procedure is not performed as part of a normal dialysis session.

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 72X, 85X BILLING & CODING GUIDELINES: When medical complications arise, it may be deemed medically necessary to provide ultrafilteration services at times other than during the dialysis session. Under these circumstances, ultrafiltation may be billed separately using revenue code 881. REIMBURSEMENT: Reimbursement for dialysis encounters are based on a composite rate which includes components similar to those identified by Medicare, including but not limited to: routine pharmacy, laboratory services and all supplies. Services that are excluded from the composite rate are those services that are: · not routinely provided as part of outpatient dialysis treatment; or · tests that are provided more frequently than normal for dialysis patients.

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090X

Required for OP DETAIL Per Visit UNITS Required for OP HCPCS/CPT Description: Charges for prevention, intervention, and treatment services in the areas of mental health, substance abuse, developmental disabilities, and sexuality. Behavorial health care services are individualized, holistic, and culturally competent and may include on-going care and support and non-traditional services. STANDARD ABBREVIATION: SUBCATEGORY: BH/TREATMENTS 0 ­ General Classification BH/ELECTRO SHOCK 1 ­ Electroshock Treatment BH/MILIEU THERAPY 2 ­ Milieu Therapy BH/PLAY THERAPY 3 - Play Therapy BH/ACTIVITY THERAPY 4 ­ Activity Therapy BH/INTENS OP PSYCH 5 - Intensive outpt -psychiatric BH/INTENS OP CHEM DEP 6 - Intensive outpt services -chemical dependency BH/Community 7 ­Community behavioral health prg (day treatment) 8 ­ Reserved for National Use 9 ­ Reserved for National Use

BEHAVIORAL HEALTH TREATMENT/SERVICES(Also see 091X, an extension of 090X)

BC

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X BILLING & CODING GUIDELINES: Partial Day and Outpatient Mental Health Services ­ See revenue code 091X SECONDARY CLAIMS: Revenue code 0907 can be accepted when the primary payer utilizes this revenue code for payment and Blue Cross is secondary.

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185

091X

BEHAVIORAL HEALTH TREATMENTS/SERVICES ­ Extension of 090x

BC

DETAIL UNITS HCPCS/CPT X Per Visit Required OP

DESCRIPTION: Charges for prevention, intervention, and treatment services in the areas of mental health, substance abuse, developmental disabilities, and sexuality. Behavorial health care services are individualized, holistic, and culturally competent and may include on-going care and support and non-traditional services. STANDARD ABBREVIATION: SUBCATEGORY: Reserved 0 ­ Reserved PSYCH/REHAB 1 ­ Rehabilitation PSYCH/PARTIAL HOSP 2 ­ Partial Hospitalization-Less Intensive BH/PARTIAL INTENSV 3 ­ Partial Hospitalization-Intensive PSYCH/INDIV RX 4 ­ Individual Therapy PSYCH/GROUP RX 5 ­ Group Therapy PSYCH/FAMILY RX 6 ­ Family Therapy PSYCH/BIOFEED 7 - Bio Feedback PSYCH/TESTING 8 ­ Testing BH/OTHER 9 ­ Other Behavioral Health Treatments NOTE: Subcategories 0912 and 0913 are designed as zero-billed revenue codes (i.e., no dollars in the amount field) to be used as a vehicle to supply program information as defined in the provider/payer contract.

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, BILLING & CODING GUIDELINES: All Blue Cross partial hospitalization services must be pre-certified. Partial Day Treatment Programs (Substance Abuse & Psychiatric) Refer to Institutional Provider Manual ­ Benefits/Exclusions for further information. In order to be eligible to participate in the "Partial-Day Treatment Program", providers must be approved by BCBSKS. Members decide whether to trade their inpatient nervous and mental health days for partial days vs. applying the partial-day services to their outpatient benefit. All partial-day patients must complete a "Partial-day Treatment Program Release Form"(http://www.bcbsks.com/CustomerService/Forms/pdf/PartialDayWaiver.pdf) If no form is signed by the member, the claim will be processed applying inpatient psychiatric benefits. Partial-day treatment programs are defined as:

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186

SUBSTANCE ABUSE PARTIAL-DAY TREATMENT DEFINITION A substance abuse partial-day treatment program must adhere to the standards outlined by the State of Kansas relating to the development and execution of an individual's treatment plan. The program must include a minimum of fifteen (15) hours per five (5) day week of structured activities geared to meet the individual client's need. Of the minimum fifteen (15) hours required per week, no less than ten (10) hours per week will be structured group, individual and/or family counseling for each client. (Group and family counseling requires the participation of the primary client.) A substance abuse partial-day program must also meet and adhere to Substance Abuse Prevention, Treatment and Recovery (SAPTR) requirements relating to the development and execution of an individual's treatment plan. PSYCHIATRIC PARTIAL-DAY TREATMENT DEFINITION A psychiatric partial-day treatment program is a planned program of mental health treatment services provided at least twice per week in four (4) or more hours at a single visit for persons who need broader programs than are possible through outpatient care, but who do not require 24-hour hospitalization. For each day of client participation, a minimum of two hours of structured group, individual and/or family counseling is required. (Group and family counseling requires the participation of the primary client.) A psychiatric partial-day program must also meet and adhere to the requirements of KDHE. The following guidelines are applicable: 1. Partial-day programs may be considered inpatient and for each day of partial-day care paid by BCBSKS, the member will have one day subtracted from his current benefit period for inpatient nervous and mental days. If more than one partial-day care charge is made for one calendar day, only one day is subtracted from the member's eligible days. Situations such as this will be reviewed by the BCBSKS medical review department or New Directions. Partial-day services do not "break" a continuous confinement for the purposes of establishing a hiatus (if applicable to the contract). Deductibles that are specifically applicable to inpatient services are not applied to partial-day psychiatric services. Deductibles that are applicable to all benefits of a member's contract (i.e. Comprehensive Major Medical) are to be applied to partial-day services. For contracts that provide inpatient nervous and mental 187

2.

3. 4.

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5. 6. 7. 8.

days beyond sixty (60) days with a payment limitation of 50% beginning with the 61st day, the 50% is not applicable to partial-day programs. Benefits paid on partial-day charges are limited to those services that would be eligible under the member's BCBSKS contract. Payment will be made to providers using special BCBSKS provider numbers assigned for partial-day programs. Pre-certification may be required for partial-day programs. New Directions is responsible for the pre-certification review process. The member decides how the benefits will be processed. They can elect to trade their inpatient days for partial-day or have the partialday service apply towards their outpatient benefits. Providers who have approved partial-day treatment programs have agreed to obtain a release form from the patient/member that designates what benefits should be utilized.

Blue Cross and Blue Shield of Kansas will be held harmless if a signed release form is not obtained by the hospital/facility. If the member chooses to trade their inpatient days for partial-day care, providers should bill as follows: Revenue Code: 0912 CPT Code: 90899 (Unlisted psychiatric service or procedure) Units: Equal the number of days the patient participated in partial-day during the the billing period. The claim should not contain any other charges and all services are bundled into the 0912 line item charge. If the member elects to trade their outpatient benefits for partial-day care, the provider: · MUST bill the individual services the patient receives under the applicable revenue code and HCPCS/CPT (e.g., revenue code 0914 with HCPCS/CPT for individual therapy, etc.) using the hospital provider number. Payment will be limited to the member's outpatient contractual benefits. Outpatient Services (non-PHP) Professional services provided by a physician, psychologist or LSCSW must be billed on a CMS 1500 claim form.

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188

Biofeedback ­ Revenue Code 0917 Most Blue Cross insurance plans do not cover autogenic biofeedback services and materials, except for urinary incontinence in adults 18 years old and older. Providers should check the member's benefits for coverage. REFERENCE: See Blue Cross Hospital Manual for guidelines on this service. BCBSKS - Customer Service - Providers - Publications - Institutional Manuals - Institutional Relations Manuals

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189

092X

OTHER DIAGNOSTIC SERVICES

BC

DETAIL UNITS HCPCS/CPT Required for OP Per Test/HCPCS Code Description Required for OP

DESCRIPTION: Charges for various diagnostic services specific to common screening for disease, illness or medical condition. STANDARD ABBREVIATION: SUBCATEGORY: OTHER DX SVCS 0 ­ General Classification PERI VASCUL LAB 1 ­ Peripheral Vascular Lab EMG 2 ­ Electromyelogram PAP SMEAR 3 ­ Pap Smear ALLERGY TEST 4 ­ Allergy Test PREG TEST 5 ­ Pregnancy Test OTHER DX SVCS 9 ­ Other Diagnostic Service

TYPE OF CLAIM: Inpatient & Outpatient TYPE OF BILL: 11X, 13X, 85X MEDICAL POLICIES: Note: There are services that have specific medical policies. Refer to the following website for guidelines.

http://www.bcbsks.com/CustomerService/Providers/MedicalPolicies/institutional/policies.h tm

BILLING & CODING GUIDELINES: Sleep Studies BCBSKS encourages sleep study facilities to become accredited through the American Academy of Sleep Medicine (AASM) and physicians to be board certified in sleep medicine. When accreditation is received, send the information to: INSTITUTIONAL RELATIONS DEPT COST CTR 442D2 BLUE CROSS AND BLUE SHIELD OF KANSAS 1133 SW TOPEKA BLVD TOPEKA KS 66629-0001 FAX: (785) 290-0734 Contracting providers receive higher reimbursement if they are accredited.

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190

Diagnoses: 347, 780.51, 780.53, 780.54, 780.56, 780.57 are subject to postpay review and require documentation of the pretest evaluation, documented review of this information before the test is performed, and interpretation of test. Professional Services require documentation of the interpretation. All other diagnoses require the information noted above and must be submitted with the claim. AASM certified labs are exempt from prepayment review but are subject to post payment review. ICD-9-CM: COVERED DIAGNOSIS 327.20 Organic sleep apnea, unspecified 327.21 Primary central sleep apnea 327.23 Obstructive sleep apnea (adult) (pediatric) 327.24 Idiopathic sleep related nonobstructive alveolar hypoventilation 327.25 Congenital central alveolar hypoventilation 327.27 Central sleep apnea in conditions classified elsewhere 347 Cataplexy and narcolepsy 770.81 Primary apnea of newborn 780.51 Insomnia with sleep apnea 780.52 Other insomnia 780.53 Hypersomnia with sleep apnea 780.54 Other hypersomnia 780.55 Disruptions of 24-hour sleep-wake cycle 780.56 Dysfunctions associated with sleep states or arousal from sleep 780.57 Other and unspecified sleep apnea If other services (i.e. laboratory, x-ray, etc.) are provided during the same outpatient encounter, providers should submit two (2) claims: one for the sleep study/polysomnography; the other claim for the other services provided during that outpatient encounter. 95806 will be denied experimental. CPT 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness

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191

95806

95807

95808 95810 95811

Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist Sleep study simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist Polysomnography; sleep staging with 1-3 additional parameters of sleep, attended by a technologist sleep staging with 4 or more additional parameters of sleep, attended by a technologist sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist

REIMBURSEMENT: Sleep study/polysomnography services will receive tiered reimbursement. Providers who obtain American Academy of Sleep Medicine accreditation will be reimbursed at the highest MAP for this service. Providers who do not have this certification will be reimbursed at the lower MAP rate. Providers who qualify for the highest level of reimbursement for either service MUST NOTIFY BCBSKS in advance of billing claims. Proof of the accreditation must be submitted in order to receive proper reimbursement. Notification should be sent to: Institutional Relations, cc 442D2 Blue Cross and Blue Shield of Kansas 1133 SW Topeka Blvd Topeka KS 66629-0001 FAX: (785) 290-0734

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192

093X

DETAIL UNITS HCPCS/CPT DESCRIPTION: Medical rehabilitation services as contracted with a payer and/or certified by the State. Services may include physical therapy, occupational therapy, and speech therapy. SUBCATEGORY: STANDARD ABBREVIATION: 1 ­ Half Day HALF DAY 2 ­ Full Day FULL DAY Note: The subcategories of 093X are designed as zero-billed revenue codes (i.e. no dollars in the amount field) to be used as a vehicle to supply program information as defined in the provider/payer contract. Therefore, zero would be reported in FL47 and the number of hours provided would be reported in FL46. The specific rehabilitation services would be reported under the applicable revenue codes as normal.

MEDICAL REHABILITATION DAY PROGRAM

BC

BILLING & CODING GUIDELINES: These codes are valid, but should not be used on BCBSKS primary claim.

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193

094X

OTHER THERAPEUTIC SERVICES (Also see 095X an extension of 094X)

BC

DETAIL UNITS HCPCS/CPT Required Per Visit Required

DESCRIPTION: Charges for other therapeutic services not otherwise categorized. STANDARD ABBREVIATION: SUBCATEGORY: OTHER RX SVCS 0 ­ General Classification RECREATION RX 1 ­ Recreational Therapy EDUC/TRAINING 2 ­ Education/Training (includes diabetic related dietary therapy CARDIAC Rehab 3 ­ Cardiac Rehabilitation DRUG Rehab 4 ­ Drug Rehabilitation ALCOHOL Rehab 5 ­ Alcohol Rehabilitation CMPLX MED EQUIP ­ ROUT 6 ­ Complex Medical Equipment ­ Routine CMPLX MED EQUIP ­ ANC 7 ­ Complex Medical Equipment ­ Ancillary PULMONARY REHAB 8 ­ Pulmonary Rehabilitation (eff 10-1-07) ADDITIONAL RX SVS 9 ­ Other Therapeutic Services

TYPE OF CLAIM: Outpatient TYPE OF BILL: 13X, 85X BILLING & CODING GUIDELINES: This section includes instructions for the following: Patient Education Diabetic Education Medical Nutritional Therapy Pulmonary Rehabilitation Cardiac Rehabilitation Patient Education Diet instruction/patient education is not a covered service except as listed in the following pages. The patient should be given a Notice of Personal Financial Obligation form when a non-covered service will be provided. Diabetic Education This service is not separately billable when provided to inpatients. It is considered a routine cost. Institutional providers can be reimbursed by BCBSKS for diabetic education if they have either: · a program certified by the American Diabetes Association; or · employ a certified diabetic educator (CDE).

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194

When the provider employs a CDE, BCBSKS will reimburse for the services of the educator as well as the services of their dietitian. The dietitian does not need to be a certified diabetic educator themselves but must be part of a program offered by an institutional provider that employees a CDE. REVENUE CODE: 0942 - education/training HCPCS: G0108 - diabetes outpatient self-management training services, individual session, per 30 minutes G0109 - diabetes outpatient self-management training services, group session, per individual, per 30 minutes UNITS: Report 1 unit for each 30 minute session of participation. If a diabetic education session is greater than 30 minutes but less than 60 minutes, BCBSKS suggests that providers round the units as follows: less than 40 minutes = 1 unit 40 minutes or more = 2 units Claims for BCBSKS members who participate in diabetic education for greater than 5 hours will be subject to post payment review. DIAGNOSIS CODE: BCBSKS looks for the presence of a diabetes diagnosis code in the primary diagnosis code field on the claim. If the diabetes code is not in the primary field, benefits will not be allowed. NOTIFY BCBSKS OF YOUR DIABETIC EDUCATION PROGRAM If you have not already done so, you need to notify BCBSKS if you have either a program that is certified by the American Diabetes Association or if you have an employee that is certified by the National Certification Board for Diabetic Educators. Send this information (including copies of the certifications) to: INSTITUTIONAL RELATIONS CC 442D2 BLUE CROSS AND BLUE SHIELD OF KANSAS 1133 SW TOPEKA BLVD TOPEKA KS 66629-0001 or FAX to (785) 290-0734 REIMBURSEMENT: Diabetic education services provided by eligible providers will be reimbursed at the maximum allowable payment (MAP) for each unit of service.

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195

SPECIAL PLAN INSTRUCTIONS: State Of Kansas ­ Does allow for nutritional education. Providers should use: S9452 ­ Nutrition classes, nonphysician provider, per session S9470 ­ Nutritional counseling

Medical Nutritional Therapy (MNT) See Blue Cross Newsletter 03-08 The locally developed and marketed Blue Cross and Blue Shield of Kansas (BCBSKS) member contracts do not include benefits for medical nutritional therapy (MNT). The traditional BCBSKS member contract includes a benefit for diabetic education, which likely, includes nutritional guidance. Diabetic education services meeting the guidelines as outlined in the above section are billed with HCPCS G0108 or G0109. MNT billed with CPT/HCPCS 97802, 97803, 97804, G0270 or G0271 (or any other assigned code) is not reimbursable by BCBSKS. We will be monitoring all claims and will recoup any money paid out inappropriately. Pulmonary Rehabilitation Providers must be pre-approved before billing these services. Outpatient pulmonary rehab service must be billed with revenue code 0419 or 0948 and HCPCS S9473 (Pulmonary rehabilitation program, non-physician provider, per diem). A global program charge is not separately billable on an inpatient claim. Blue Cross and Blue Shield of Kansas offer coverage for pulmonary rehabilitation programs. Actual coverage is determined by the individual member's contract. A pulmonary rehabilitation program must be approved by BCBSKS before benefits are available. To request approval, submit a detailed program description which supports program criteria compliance. The description must include: · program schedule ­ date/times · services and equipment available · staffing · physician availability · patient assessment · charge structure

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196

We must also receive a signed attestation certifying the facility's understanding and compliance with the criteria. While the initial program approval will be based upon the program description and attestation, follow-up review will be conducted during routine visits to your facility by our provider consultants or as the result of review activity conducted by our medical review department. · · · programs will normally be considered approved the first of the month `following' receipt of the attestation and supporting documents. members will receive eligible benefits for pulmonary rehabilitation programs that BEGIN ON OR AFTER THE PROGRAM APPROVAL DATE reimbursement by BCBSKS will be based on a maximum allowable payment (MAP) for each day of client participation. It will be necessary to submit your charge structure to us for review. Your daily charge should be inclusive of all services except as outlined in "lll. Other Diagnostic Services" as indicated in the criteria. hospitals with approved pulmonary rehabilitation programs will report the charges in the UB-04/837I claim format with revenue code 0419, other respiratory services, or 0948* - pulmonary rehab. BCBSKS requires HCPCS S9473 to report pulmonary rehabilitation services. The units field should indicate the number of days the client participated during the billing period. These billing instructions are only applicable to hospitals who have `approved' programs. DO NOT USE G0237-G0239 WHEN BILLING OUTPATIENT PULMONARY REHABILITATION TO BLUE CROSS!!!! Cardiac Rehabilitation Blue Cross and Blue Shield of Kansas offer coverage for cardiac rehabilitation programs. Actual coverage is determined by the individual member's contract. A cardiac rehabilitation program must be approved by BCBSKS before benefits are available. To request approval, submit a detailed program description which supports program criteria compliance. The description must include: - program schedule (date/times) - services and equipment available - staffing - physician availability - patient assessment - charge structure We must also receive a signed attestation certifying the facility's understanding and compliance with the criteria. The initial program approval will be based upon the program description and attestation. Follow-up review will be conducted during routine visits to your facility by our provider consultant or as the result of review activity conducted by our medical review department. Programs will normally be considered approved the first of the month following receipt of the Contains Public Information Revision Date: March 31, 2009 197

·

attestation and supporting documents unless deficiencies are noted. If deficiencies are noted, the effective date will be the first of the month after BCBSKS receives documentation that the deficiencies no longer exist. CONTACT: INSTITUTIONAL RELATIONS DEPT, CC 442D2 BLUE CROSS AND BLUE SHIELD OF KANSAS 1133 SW TOPEKA BLVD TOPEKA KS 66629-0001 PHONE: (785) 291-8692 FAX: (785) 290-0734 BLUE CROSS - BLUE SHIELD COVERAGE REQUIREMENT FOR APPROVED CARDIAC REHABILITATION PROGRAMS I. DEFINITION: Cardiac rehabilitation programs are for cardiac patients and are provided in specialized, freestanding cardiac rehabilitation clinics or in `outpatient' departments of acute care hospitals. REQUIREMENTS FOR COVERAGE A. Cardiac rehabilitation programs will be considered reasonable and necessary for only patients with a clear medical need, who are referred by their attending physician and: 1. have a documented diagnosis of acute myocardial infarction within the preceding 12 months; or 2. have had coronary artery bypass surgery; and/or 3. have stable angina pectoris; or 4. have had either a percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary angioplasty (PCA); or 5. have had heart transplantation or cardiac valve surgery (by individual consideration only). *** Before performing Cardiac Rehab for patients who have had cardiac valve surgery, provides should submit a written pre-determination. B. Cardiac rehabilitation programs are subject to the following conditions: 1. the facility meets the definition of a hospital outpatient department or a physician-directed clinic (i.e.: a physician is on the premises, available to perform medical duties at all times the facility is open); for BLUE CROSS AND BLUE SHIELD ONLY, the program may be conducted at a location other than the 198

II.

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provider's if the program otherwise meets the coverage criteria and the services are billed by the responsible provider; 2. the facility has available for immediate use all the necessary cardiopulmonary emergency diagnostic and therapeutic life-saving equipment accepted by the medical community as medically necessary (e.g.: oxygen, cardiopulmonary resuscitation equipment, defibrillator, etc.); the program is conducted in an area set aside for the exclusive use of the program while it is in session; the program is staffed by personnel necessary to conduct the program safely and effectively, who are trained in both basic and advanced life-support techniques and in exercise therapy for coronary artery disease. Services of non-physician personnel must be furnished under the direct supervision of a physician. Direct supervision means that a physician must be in the exercise program area and immediately available for an emergency at all times when the exercise program is conducted. It does not require that a physician be physically present in the exercise room itself but must be at a location to be considered immediately available and accessible to the patient exercise area. A physician located in an office across the hall from the exercise room who is available at all times for an emergency would meet this requirement. A physician located in a building other than that containing the exercise room does not meet this requirement. the non-physician personnel are employees of either the physician, hospital, or clinic conducting the programs and their services are "incident to a physician's professional services."

3. 4.

5.

C.

Diagnostic Testing - Stress Testing - The patient must be evaluated for suitability to participate. A valuable diagnostic test for this purpose is the stress test. The program need not necessarily include a stress test, but may accept one performed by the patient's attending physician. Stress testing performed in the outpatient department of a hospital or in a physician-directed clinic may be covered when reasonable and necessary for one or more of the following: 1. 2. evaluation of chest pain, especially atypical chest pain; development of exercise prescriptions for patients with known cardiac disease; 199

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3.

pre and post operative evaluation of patients undergoing coronary artery bypass procedures.

D.

ECG Rhythm Strips - ECG rhythm strips and other ECG monitoring constitute an important and necessary procedure which should be performed periodically while a cardiac patient is engaged in a physician-controlled exercise program (refer to Section III.E. for utilization screens).

III. OTHER DIAGNOSTIC AND THERAPEUTIC SERVICES: Diagnostic and therapeutic services `other' than stress testing and ECG monitoring may be provided if the usual coverage requirements are met as outlined in Section I and II. Other such services may include: A. PSYCHOTHERAPY AND PSYCHOLOGICAL TESTING - Although not all cardiac rehabilitation patients would require this type testing, where a patient has a diagnosed mental, psychoneurotic, or personality disorder, psychotherapy provided by a psychiatrist or psychologist incident to a physician's professional service may be covered if the patient shows appropriate symptoms of excessive anxiety or fear associated with the cardiac disease (for Blue Shield, the patient must have the psychiatric rider). B. PHYSICAL AND OCCUPATIONAL THERAPY - Physical and occupational therapy would not be covered unless there is a diagnosed non-cardiac condition requiring such services (i.e.: patient is recuperating from an acute phase of heart disease, such as a stroke, and would require this type of physical/occupational therapy). C. PATIENT EDUCATION SERVICES - Programs providing health education lectures or counseling, in which patients and/or family members are given information regarding diet, nutrition and sexual activity, are not considered reasonable and necessary as `separately' identifiable services when provided as a part of a cardiac rehabilitation exercise program. These services are considered included in the overall scope of the program. In addition, room and board for the patient and/or family members is also non-covered. D. DURATION OF THE PROGRAM - For BCBSKS beneficiaries, services provided in connection with a cardiac rehabilitation exercise program may be considered reasonable and necessary for up to 36 sessions, usually 3 sessions a week in a single 12-week period. Coverage for continued participation in cardiac exercise programs beyond 12 weeks would be allowed only on a case-by-case basis with exit criteria taken into consideration. For Blue Cross insureds, services provided in connection with a cardiac rehabilitation exercise program may be considered reasonable and necessary for up to 18 sessions, usually 3 sessions a week in a single 6-week period. Coverage

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for continued participation would be allowed only on a case-by-case basis with exit criteria taken into consideration. Although firm exit criteria for terminating the therapeutic outpatient exercise treatment and rehabilitation program have not been established, the following guidelines have been identified as acceptable: - the patient has achieved a stable level of exercise tolerance without ischemia or dysrhythmia; - symptoms of angina or dyspnea are stable at the patient's maximum exercise level; - patient's `resting' blood pressure and heart rate are within normal limits; or - the stress test is not `positive' during exercise. (A `positive test' in this context implies an ECG with a functional depression of 2mm or more associated with slowly rising, horizontal, or down sloping ST segment.) E. UTILIZATION SCREENS Group 1 Services At least one Group 1 service must be performed during each cardiac rehabilitation visit. Group 1 services include: - continuous ECG telemetric monitoring during exercise; - ECG rhythm strip with interpretation and physician's revision of exercise prescription; and - limited examination for physician follow-up to adjust medication or other treatment change. Group 2 Services New patient comprehensive evaluation, including history, physical and preparation of initial exercise prescription. Allow one at the beginning of the program if not already performed by the patient's attending physician, or if that performed by the patient's attending physician is not acceptable to the program's director. ECG stress test (treadmill or bicycle ergometer) with physician monitoring and report. Blue Cross allows one at the program start and completion. For more information regarding cardiac rehabilitation can be found in Chapter 8 of the Institutional Provider Manual: http://www.bcbsks.com/CustomerService/Providers/Publications/institution al/manuals/institutional_rel_manual.htm

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Cardiac Rehabilitation ­ Billing Guidelines · Revenue Code 0943 · HCPCS codes: 93797 - Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) 93798 - Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring (per session) · Separately billable services should be billed under the appropriate revenue code. · The initial evaluation is not a separately billable service. The cost of the evaluation should be considered when setting up the per visit rate.

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095X

DETAIL Per Visit UNITS Required HCPCS/CPT DESCRIPTION: Charges for other therapeutic services not otherwise categorized. STANDARD ABBREVIATION: SUBCATEGORY: 0 ­ Reserved ATHLETIC TRAINING 1 ­ Athletic Training KINESIOTHERAPY 2 ­ Kinesiotherapy

OTHER THERAPEUTIC SERVICES (EXTENSION OF 094X)

BC

BILLING & CODING GUIDELINES: These codes are valid, but should not be used on BCBSKS primary claim.

096X

PROFESSIONAL FEES (ALSO SEE 097X AND 098X)

BC

DETAIL UNITS HCPCS/CPT

DESCRIPTION: Charges for medical professionals that the institutional health care provider along with the third party payer require the professional fee component to be billed on the UB-04. SUBCATEGORY: STANDARD ABBREVIATION: 0 ­ General Classification PRO FEE 1 ­ Psychiatric PRO FEE/PSYCH 2 ­ Ophthalmology PRO FEE/EYE 3 ­ Anesthesiologist (MD) PRO FEE/ANEST MD 4 ­ Anesthetist (CRNA) PRO FEE/ANEST CRNA 9 ­ Other Professional Fees PRO FEE/OTHER

TYPE OF CLAIM: Outpatient BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims. These codes must be filed on a CMS 1500 claim form to Blue Shield as they represent professional services. SECONDARY CLAIMS: Blue Cross will allow these revenue codes on claims when Medicare is primary (CAH Method II-OP only). These revenue codes are considered professional services and must be billed on a CMS 1500 claim form. Type of bill = 85X.

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097X

DETAIL UNITS HCPCS/CPT DESCRIPTION: Charges for medical professionals that the institutional health care provider along with the third party payer require the professional fee component to be billed on the UB-04. STANDARD ABBREVIATION: SUBCATEGORY: PRO FEE/LAB 1 ­ Laboratory PRO FEE/RAD/DX 2 ­ Radiology ­ Diagnostic PRO FEE/RAD/DX 3 ­ Radiology ­ Therapeutic PRO FEE/NUC MED 4 ­ Radiology - Nuclear PRO FEE/OR 5 ­ Operating Room PRO FEE/RESPIR 6 ­ Respiratory Therapy PRO FEE/PHYSI 7 ­ Physical Therapy PRO FEE/OCCUPA 8 ­ Occupational Therapy PRO FEE/SPEECH 9 ­ Speech Pathology

PROFESSIONAL FEES (EXTENSION OF 096X)

BC

TYPE OF CLAIM: Outpatient BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims. These codes must be filed on a CMS 1500 claim form to Blue Shield as they represent professional services. SECONDARY CLAIMS: Blue Cross will allow these revenue codes on claims when Medicare is primary (CAH Method II-OP only). These revenue codes are considered professional services and must be billed on a CMS 1500 claim form. Type of bill = 85X.

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098X

DETAIL UNITS HCPCS/CPT DESCRIPTION: Charges for medical professionals that the institutional health care provider along with the third party payer require the professional fee component to be billed on the UB-04. STANDARD ABBREVIATION: SUBCATEGORY: PRO FEE/ER 1 ­ Emergency Room Services PRO FEE/OUTPT 2 ­ Outpatient Services PRO FEE/CLINIC 3 ­ Clinic PRO FEE/SOC SVC 4 ­ Medical Social Services PRO FEE/EKG 5 ­ EKG PRO FEE/EEG 6 ­ EEG PRO FEE/HOS VIS 7 ­ Hospital Visit PRO FEE/CONSULT 8 ­ Consultation PRO FEE/PVT NURSE 9 ­ Private Duty Nurse

PROFESSIONAL FEES (EXTENSION OF 096X AND 097X)

BC

TYPE OF CLAIM: Outpatient BILLING & CODING GUIDELINES: This revenue code is not allowed for BCBSKS primary claims. These codes must be filed on a CMS 1500 claim form to Blue Shield as they represent professional services. SECONDARY CLAIMS: Blue Cross will allow these revenue codes on claims when Medicare is primary (CAH Method II-OP only). These revenue codes are considered professional services and must be billed on a CMS 1500 claim form. Type of bill = 85X.

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099X

PATIENT CONVENIENCE ITEMS

BC

DETAIL UNITS HCPCS/CPT

DESCRIPTION: Charges for items that are generally considered by the third party payers to be strictly convenience items and, as such, are not covered by many health plans. STANDARD ABBREVIATION: SUBCATEGORY: PT CONVENIENCE 0 ­ General Classification CAFETERIA 1 ­ Cafeteria/Guest Tray LINEN 2 ­ Private Linen Service TELEPHONE 3 ­ Telephone/Telecom TV/RADIO 4 - TV/Radio NONPT ROOM RENT 5 - Non-patient Room Rentals LATE DISCHARGE 6 - Late Discharge ADM KITS 7 ­ Admission Kits BARBER/BEAUTY 8 ­ Beauty Shop/Barber PT CONV/OTHER 9 ­ Other Patient Convenience Items

BILLING & CODING GUIDELINES: All charges must be reported as non-covered except revenue code 0996. Patient convenience items are not covered and should be billed under revenue code 0990. Charges should be filed as non-covered. These services are billable to the patient. Examples of patient convenience items are listed under revenue code 027X.

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100X

BEHAVIORAL HEALTH ACCOMMODATIONS

BC

DETAIL UNITS HCPCS/CPT

DESCRIPTION: Charges for Behavioral health. STANDARD ABBREVIATION: SUBCATEGORY: BH R&B RES/CHEM 0 - General Classification BH R&B RES/PSYCH 1 - Residential treatment ­ psychiatric BH R&B RES/CHEM DEP 2- Residential treatment ­ chemical dependency BH R&B SUP LIVING 3 - Supervised Living BH R&B HALFWAY HOUSE 4 ­ Halfway house BH R&B GROUP HOME 5 ­ Group home

BILLING & CODING GUIDELINES: These codes are valid, but should not be used on a BCBSKS primary claim.

210X

ALTERNATIVE THERAPY SERVICES

BC

DETAIL UNITS HCPCS/CPT

STANDARD ABBREVIATION:

DESCRIPTION: . SUBCATEGORY: 0 ­ General Classification 1 ­ Acupuncture 2- Acupressure 3 ­ Massage 4 ­ Reflexology 5 - Biofeedback 6 ­ Hypnosis 9 ­ Other Alternative Therapy Services

BILLING & CODING GUIDELINES: These codes are valid, but should not be used on a BCBSKS primary claim.

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310X

ADULT CARE

DETAIL UNITS HCPCS/CPT

BC

DESCRIPTION: SUBCATEGORY: 0 ­ Not Used 1 ­ Adult Day care, medical and Social - hourly 2 ­ Adult Day Care, social ­ hourly 3 ­ Adult Day Care, medical and social ­ daily 4 ­ Adult Day Care social ­ daily 5 ­ Adult foster care ­ daily 9 ­ Other adult care

STANDARD ABBREVIATION:

BILLING & CODING GUIDELINES: These codes are valid, but should not be used on a BCBSKS primary claim.

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APPENDIX A

IV INFUSION AND INJECTION BILLING

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In this section are billing guidelines for drug administration. Revenue codes Billing Instructions for Drug Administration Separately Reportable Services Separate Reporting of Drugs Provided Intravenous or Intra-arterial Push Multiple Infusions Initial Subsequent/Concurrent Hierarchy Catheter and Port Declotting Documentation Non-Chemotherapy Drug Administration Codes for 2009 Billing Instructions for the Administration of Non-Chemotherapy Drugs Hydration Additional hours Antibiotic injections Chemotherapy Drug Administration Codes for 2009 Billing Instructions for the Administration of Chemotherapy Drugs List of biological response modifiers, monoclonal antibodies, hormonal antineoplastics,chemotherapy drugs Reporting separate codes Reporting non-chemotherapy Administration Blue Cross Case Examples FAQs

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Revenue Codes Use the revenue code that describes where the services were performed. 0450 - ER 0510 - Clinic 0761 - Treatment Room (scheduled patients) 0760 - Observation 0331, 0332, 0335 - Chemotherapy Administration Billing Instructions for Drug Administrations Reference material AMA 2009 CPT code book CPT instructions have been added: When these codes are reported by the facility, the following instructions apply. 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. This hierarchy does not apply to physician reporting. Separately Reportable According to the CPT code book, the following services are included in the drug administration code and are not separately billable: Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes and supplies Separate Reporting of Drugs Provided Report both the specific service as well as code(s) for the specific substance(s) or drug(s) provided. The fluid used to administer the drug(s) is considered incidental hydration and is not separately reportable. Intravenous or Intra-arterial Push is defined as: a) an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient; or b) an infusion of 15 minutes or less. Multiple Administrations When multiple drugs are administered, report the service(s) and the specific substance/drug for each administration. When administering more than one (1) infusion, injection or combinations; only one 'initial' administration code should be reported unless the standard protocol requires two separate IV sites.

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Initial The 'initial' code should be the code that best describes the primary or key reason for the encounter/visit and should always be reported regardless of the order in which the infusions/injections occur. Subsequent or Concurrent 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 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. Concurrent indicates two administrations are occurring at the same time at the same site. Sequential indicates the injections, infusions or pushes are occurring one after the other. Hierarchy The initial CPT code that should be reported according to the 2009 CPT facility hierarchy guidelines: #1 - Chemotherapy services #2 - Therapeutic, diagnostic, prophylactic services #3 - Hydraction Secondly: #1 Infusion #2 Push #3 Injection Documenting Drug Administration Hospital staff must clearly document the start and end time for each IV. Hospitals are to report CPT codes that describe the actual time over which the infusion is administered to the patient for time-specific drug administration codes (Hospitals should not include in their reporting the time that may elapse between establishment of vascular access and initiation of the infusion.) In order to appropriately bill for infusion services, the name of the drug, strength of the drug, method of administration and the time must be documented. If an IVPB therapeutic drug is performed, but no time is documented, the provider may only bill for administering an IV push. If IV hydration is provided and there are no notes to support any length of time, no service may be reported. Documentation in the record is required for all charges billed. If the nurse's notes indicate that an IV is infusing, and there are times documented, the time furnished will support a charge. For example: The nurse may note the hydration solution was started at 8:00. Additional notes show at 10:00 the IV is still infusing however, there are no Contains Public Information Revision Date: March 31, 2009 212

further notes regarding the infusion. Charges can only be billed from 8:00 to 10:00. If the only documentation is that a bag was hung, then an administration charge cannot be made. (An IV push code cannot be used since hydration is not a considered a therapeutic, prophylactic or diagnostic substance.)

Non-chemotherapy Drug Administration codes for 2009 96360 ­ Intravenous infusion, hydration; initial 31 minutes to 1 hour 96361 ­ each additional hour (List separately in addition to code for primary procedure) 96365 ­ Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial up to 1 hour 96366 each additional hour (List separately in addition to code for primary procedure) 96367 additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) 96368 additional concurrent infusion (List separately in addition to code for primary procedure) 96369 - Subcutaneous infusion for therapy or phophylaxis (specify substance or drug); initial, up to one hour, including pump set-up and establishment of subcutaneous infusion site(s) 96370 each additional hour (List separately in addition to code for primary procedure) 96371 additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure) 96372 - Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 96373 intra-arterial 96374 96375 intravenous push, single or initial substance/drug each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) 96376 each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure) NOTE: Do not report for a push performed within 30 minutes of a reported push of the same substance or durg) 96379 ­ Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or Infusion

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Billing Instructions for Non-Chemotherapy Drug Administration Hydration Codes 96360-96361 are intended to be used to report a hydration IV infusion consisting of a pre-packaged fluid and electrolytes (e.g. normal saline, D5- ½ normal saline. When fluids are used to administer the drug(s), the administration of the fluid is considered incidental hydration and is NOT separately billable. Catheter and Port Declotting Users are instructed to report 36593 for catheter or port declotting. Additional Hours The additional hour(s), beyond the first hour of sequential infusion as well as the second and subsequent hours for infusion services can be reported only after more than 30 minutes has passed from the end of a previously billed hour. 1st hour 16-90 minutes 2nd hour 91-150 minutes 3rd hour 151-210 minutes Antibiotic Injections Use 96372 to report an injection of an antibiotic. If the antibiotic is given as an IV infusion, use the appropriate code as defined in the infusion instructions.

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Chemtherapy Drug Administration Codes for 2008 96401 - Chemotherapy administration, subcutaneous or intramuscular; non-hormonal antineoplastic 96402 - Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic 96405 - Chemotherapy administration; intralesional, up to and including 7 lesions 96406 - Chemotherapy administration; intralesional, more than 7 lesions 96409 - Chemotherapy administration; intravenous, push technique, single or initial substance/drug 96411 - Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) 96413 - Chemotherapy administration, intravenous technique; up to 1 hour, single or initial substance/drug 96415 - Chemotherapy administration, intravenous technique; each additional hour, 1 ­ 8 hours 96416 ­ Chemotherapy administration, intravenous technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump. (See 96521-96523 for refilling & maintenance of a portable pump) 96417 - Chemotherapy administration, intravenous technique; each additional sequential infusion (different substance or drug), up to 1 hour (List separately in addition to code for primary procedure) Use 96417 in conjunction with 96413. Report only once per sequential infusion. Report 96415 for additional hour(s) of sequential infusion. 96420 - Chemotherapy administration, intra-arterial; push technique 96422 - Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour 96423 - Chemotherapy administration, intra-arterial; infusion technique, each additional hour (List separately in addition to code for primary procedure). Use 96423 in conjuction with 96422. Report 96423 for infusion intervals of greater than 30 minutes beyond 1-hour increments) 96425 - Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours) requiring use of portable or implantable pump 96440 - Chemotherapy administration into pleural cavity, requiring and including thoracentesis 96445 - Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis 96450 - Chemotherapy administration, into CNS (e.g., intrathecal), requiring and including spinal puncture 96521 - Refilling and maintenance of portable pump 96522 - Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) 96523- Irrigation of implanted venous access device for drug delivery systems. Do not report if any other services are provided on the same day. 96542 - Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents 96549 ­ Unlisted chemotherapy procedure

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Billing Administration of Chemotherapy Drugs 2009 AMA CPT Section notes for Chemotherapy administration codes 96401-96549: These codes apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g., cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers. The list below classifies some of the drugs that fall into the description above. THIS LIST IS NOT ALL INCLUSIVE AND WILL NOT BE MAINTAINED BY BLUE CROSS AND BLUE SHIELD OF KANSAS. Providers should keep documentation that demonstrates chemotherapy administration codes can be used with specific drugs. When administering one of the drugs on the list below, providers will bill the applicable administration codes (96401-96549) Biological Response Modifiers, Monoclonal Antibodies, Hormonal Antineoplastics,Chemotherapy Drugs

Bio Response Modifiers J0128 J0129 J0215 J1440 J1441 J1566 J2355 J2425 J2505 J2820 J7511 J7516 J7525 J9015 J9031 J9213 J9214 J9215 Q3025 Hormonal Antineoplastics J0970 J1000 J1380 J1390 J1410 J1435 J3315 J9165 J9202 J9217 Aberelix 10 mg Abatacept 10mg (Orencia) Alefacept 0.5 mg Filgrastim 300 mcg Filgrastim 480 mcg Immune Globulin IV, LYOPHILIZED E.G. POWD) Oprelvekin 5 mg Palifermin 50 mcg Pegfilgrastim 6 mg Sargramostim 50 mcg Antithymocyte globulin rabbit 25 mg Cyclosporin parenteral 250 mg Tacrolimus 5 mg Aldesleukin/single use vial Bcg live intravesical per instillation Interferon alfa-2a 3 million units Interferon alfa-2b 1 million units Interferon alfa-n3 250,000 IU Interferon beta 1-a 11 mcg IM Estradiol valerate, up to 40 mg Depo-estradiol cypionate up to 5 mg Estradiol valerate 10 mg Estradiol valerate 20 mg Estrogen conjugate 25 mg Estrone 1 mg Triptorelin pamoate 3.75 mg Diethylstilbestrol 250 mg Goserelin acetate implant per 3.6 mg Leuprolide acetate suspension 7.5 mg

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J9219 J9225 J9395 Monoclonal Antibodies J0130 J0480 J1162 J1745 J2357 J2503 J7513 J9010 J9035 J9041 J9055 J9310 Chemotherapy Drugs J9000 J9001 J9017 J9020 J9025 J9027 J9040 J9045 J9050 J9060 J9062 J9065 J9070 J9080 J9090 J9091 J9092 J9093 J9094 J9095 J9096 J9097 J9098 J9100 J9110 J9120 J9130 J9140 J9150 J9151

Leuprolide acetate implant 65 mg Histrelin implant, 50 mg Fulvestrant 25 mg Abciximab 10 mg Basiliximab 20 mg Digoxin immune fab (ovine) per vial Infliximab 10 mg Omalizumab 5 mg Pegaptanib sodium 0.3 mg Dacililzumab, parenteral 25 mg Alemtuzumab 10 mg Bevacizumab 10 mg Bortezomib 0.1 mg Cetuximab 10 mg Rituximab 100 mg Doxorubicin HCI 10 mg Doxorubicin HCI liposome 10 mg Arsenic trioxide 1 mg Asparaginase 10,000 units Azacitidine 1 mg Clofarabine 1 mg Bleomycin sulfate 15 units Carboplatin 50 mg Carmustine 100 mg Cisplatin 10 mg Cisplatin 50 mg Cladribine 1 mg Cyclophosphamide 100 mg Cyclophosphamide 200 mg Cyclophosphamide 500 mg Cyclophosphamide 1 g Cyclophosphamide 2 g Cyclophosphamide lyophilized 100 mg Cyclophosphamide lyophilized 200 mg Cyclophosphamide lyophilized 500 mg Cyclophosphamide lyophilized 1 g Cyclophosphamide lyophilized 2 g Cytarabine liposome 10 mg Cytarabine 100 mg Cytarabine 500 mg Dactinomycin 0.5 mg Dacarbazine 100 mg Dacarbazine 200 mg Daunorubicin HCI 10 mg Daunorubicin citrate, liposomal 10 mg

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J9160 J9170 J9178 J9181 J9185 J9190 J9200 J9201 J9206 J9208 J9211 J9230 J9245 J9250 J9260 J9263 J9265 J9266 J9268 J9270 J9280 J9290 J2921 J9293 J9300 J9305 J9320 J9340 J9350 J9357 J9360 J9370 J9375 J9380 J9390 J9600

Denileukin diftitox 300 mcg Docetaxel 20 mg Epirubicin HCI 2 mg Etoposide 10 mg Fludarabine phosphate 50 mg Fluorouracil 500 mg Floxuridine 500 mg Gemcitabine HCI 200 mg Irinotecan 20 mg Ifosamide 1 g Idarubicin HCI 5 mg Mechlorethamine HCI 10 mg Melphalan HCI 50 mg Methotrexate 5 mg Methotrexate 50 mg Oxaliplatin 0.5 mg Paclitaxel 30 mg Pegaspargase single dose vial Pentostatin 10 mg Plicamycin 2.5 mg Mitomycin 5 mg Mitomycin 20 mg Mitomycin 40 mg Mitoxantrone HCI 5 mg Gemtuzumab ozogamicin 5 mg Pemetrexed 10 mg Streptozocin 1 g Thiotepa 15 mg Topotecan 4 mg Valrubicin 200 mg Vinblastine sulfate 1 mg Vincristine sulfate 1 mg Vincristine sulfate 2 mg Vincristine sulfate 5 mg Vinorelbine tartrate 10 mg Porfimir sodium 75 mg

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Reporting of Separate Codes Report separate codes for each parenteral method of administration employed when chemotherapy is administered by different techniques. Reporting Non-Chemotherapy Administration Codes The administration of medications (e.g., antibiotics, steroidal agents, antiemetics, narcotics, analgesics) administered independently or sequentially as supportive management of chemotherapy administration should be separately reported using 96360, 96361, 96365, 96379 as appropriate. * Note 96360/96361- cannot be reported separately when administered concurrently.

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Blue Cross Reimbursement If the code is indicated as a MAP'd code, the rate will be provided on your facility MAP'd list. If the code is an add-on code, the line item is always paid at the MAP'd rate. If the code is subject to a unit limitation, the number of units listed will be reimbursed for the service.

Blue Cross MAP Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y N N Y N Y Y Y Y Y Y Y Y N N N N N N N N Add-on BC unit limit 1 1 1 1 1 1

Code 96360 93661 96365 96366 96367 96368 96369 96370 96371 96372 96373 96374 96375 96376 96379 96401 96402 96405 96406 96409 96411 96413 96415 96416 96417 96420 96422 96423 96425 96440 96445 96450 96521 96522 96523 96542 96549

Description Hydration iv infusion, init Hydrate iv infusion, add-on Ther/proph/diag iv inf, init Ther/proph/dg iv inf, add-on Tx/proph/dg addl seq iv inf Ther/diag concurrent inf Ther/proph sq inf Ther/proph sq inf Ther/proph sq inf Ther/proph/diag inj, sc/im Ther/proph/diag inj, ia Ther/proph/diag inj, iv push Ther/proph/diag inj add-on Ther/proph/diag inj Ther/prop/diag inj/inf proc Chemo, anti-neopl, sq/im Chemo hormon antineopl sq/im Chemo intralesional, up to 7 Chemo intralesional over 7 Chemo, iv push, sngl drug Chemo, iv push, addl drug Chemo, iv infusion, 1 hr Chemo, iv infusion, addl hr Chemo prolong infuse w/pump Chemo iv infus each addl seq Chemo, ia, push technique Chemo ia infusion up to 1 hr Chemo ia infuse each addl hr Chemotherapy, infusion method Chemotherapy, intracavitary Chemotherapy, intracavitary Chemotherapy, into CNS Refill/maint, portable pump Refill/maint pump/resvr syst Irrig drug delivery device Chemotherapy injection Chemotherapy, unspecified

Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y

Y Y Y Y Y Y Y Y Y

1 1 1 1 1 1

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CASE EXAMPLES

In each of these examples below, the CPT coding instructions applies to the drug administration(s) only. Providers should be aware to also code other services as well as the specific drugs separately. Example 1 Multiple Infusions, Therapeutic An initial therapeutic infusion (IV piggyback) was given for one hour and a subsequent infusion (IV piggyback) for different non-chemotherapy drugs (one hour) on the same day:

CPT coding 96365- 1 unit 96367- 1 unit

Service IV infusion therapeutic, initial, up to one hour IV infusion therapeutic, sequential, up to one hour

Example 2 Multiple Infusion, Therapeutic 2 hours (10 a.m. to 12 p.m.) of subcutaneous infusion was administered for pain medication, then one hour of hydration was administered: Service CPT coding 96369- 1 unit Subcutaneous infusion initial up to 1 hour 96370- 1 unit Subcutaneous infusion each additional hour 96371- 1 units IV hydration each additional hour According to the hierarchy guidelines: - Only one initial code - Therapeutic/prophylactic/diagnostic is primary over hydration

Example 3 Multiple Infusion-Therapeutic and Push Patient receives an IV therapeutic drug infusion (1 hour) and an IV push for a different nonchemotherapy drug on the same day. CPT coding Service 96365 - 1 unit Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour (First drug/first hour) 96375 ­ 1 unit Therapeutic, prophylactic or diagnostic injection; each additional sequential intravenous push of a new substance/drug When multiple infusions, injections or combinations are administered, only one initial code can be reported. According to the hierarchy guidelines: - Only one initial code - both drugs were therapeutic - Infusions are primary over a push

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Example 4 Multiple Infusion, Therapeutic and Hydration Hydration therapy was provided from 1:00p.m. - 2:15 p.m. IV Piggyback of an antibiotic was provided from 2:16 p.m. - 3:25 p.m. CPT coding 96365 ­ 1 unit 96361 ­ 1 unit Service Intravenous infusion, for therapy, prophylaxis, or Diagnosis; initial, up to 1 hour Intravenous infusion, hydration, each additional hour

When multiple infusions, injections or combinations are administered, only one initial code can be reported. According to the hierarchy guidelines: - Only one initial code - Therapeutic is primary over hydration Example 5 Multiple Infusion Therapeutic IV Push, IM Injection IVPB therapeutic drug provided for 2 hours. Two IV push administrations were performed. Both were the same drug, one at 12:00 and one at 1:00. The patient also received an IM injection. CPT coding 96365 ­ 1 unit 96366 ­ 1unit 96375 ­ 1 unit 96376­ 1 unit 96372 ­ 1 unit Service Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) Each additional hour Therapeutic, prophylactic or diagnostic injection (specify) substance or drug); each additional sequential intravenous push of a new substance/drug Each additional sequential IV push of the same substance/drug Therapeutic, prophylactic or diagnostic injection (specify) substance or drug); subcutaneous or intramuscular

When multiple infusions, injections or combinations are administered, only one initial code can be reported. According to the hierarchy guidelines: - Only one initial code - all drugs were Therapeutic/prophylactic - Infusions are primary over a push - Push is primary over IM - The additional push can be billed since documentation supports 30 muinutes elapsed between each IV push administration.

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Example 6 Multiple infusion/injections Therapeutic Hydration and Chemotherapy IV hydration 45 minutes Intramuscular injection IV Piggyback antiemectic 95 minutes Chemotherapy IV infusion 50 minutes CPT coding Service Chemotherapy administration; intravenous technique; up to 1 hour, single or 96413 ­ 1 unit initial substance/drug

96367 ­ 1 unit

Intravenous infusion, for therapy, prophylaxis, or diagnosis; sequential IV, up to 1 hour 96366­ 1 unit Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) Each additional hour 96361 ­ 1unit Intravenous infusion, hydration, Each additional hour 96372 ­ 1 unit Therapeutic, prophylactic or diagnostic injection (specify) substance or drug); subcutaneous or intramuscular The hierarchy would be selected as follows: 1. Chemotherapy will be selected as the initial code-96413 2. Antiemetic IV infusion is next using 96367as sequential IV for the first hour 3. The additional hour would be reported with 96366 4. Hydration would be reported as 96361 5. IM injection would be reported as 96372

Example 7 Multiple Push and Injection IV push of a therapeutic drug #1 x 1. IV push of a therapeutic drug #2 x 2. The time for each states 10:00 and 10:15 Subcutaneous injection x 1 CPT coding Service 96374 ­ 1 unit Therapeutic, prophylactic or diagnostic injection (specify) substance or drug) intravenous push, single or initial substance/drug 96375 ­ 1 unit 96372 ­ 1 unit Therapeutic, prophylactic or diagnostic injection (specify) substance or drug); each additional sequential intravenous push of a new substance/drug Therapeutic, prophylactic or diagnostic injection (specify) substance or drug); subcutaneous or intramuscular Push is primary over SQ injections IM The additional sequential IV push of the same substance/drug cannot be billed since documentation supports 30 muinutes did not elapse between each IV push administration.

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Example 8 Multiple Infusion Therapeutic Concurrent IV Piggyback of a therapeutic drug 1:00 pm to 4:00 pm IV Piggyback of a different drug 1:00 pm to 3:00 pm CPT coding Service 96365 ­ 1 unit Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour 96366 ­ 2 units Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) Each additional hour 96368 ­ 1 unit Concurrent infusion

Example 9 Infusion Therapeutic Normal saline (hydration fluid) was infused with an antibiotic. The antibiotic was added to the saline. The infusion lasted 2 hours and 15 minutes CPT coding Service 96365 ­ 1 unit Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour 96366 ­ 1unit Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug) Each additional hour Normal saline was used as a vehicle for the antibiotic infusion. Therefore the hydration is incidental. If the normal saline was provided concurrently with a non-chemotherapeutic, diagnostic, or chemotherapeutic agent, the hydration infusion is incidental and not separately reportable. If the antibiotic was delivered IV push, and the saline was a vehicle for the antibiotic, again the hydration 96360 is not separately billable, only the IV push would be billed. Example 10 Multiple IV push Chemotherapy How do I bill for a chemotherapy drug that was administered via IV push twice during an encounter? CPT coding Service 96409 ­ 1 unit Chemotherapy administration, intravenous, push technique, single or initial substance/drug 96411 ­ 1 unit Chemotherapy administration, intravenous, push technique, each additional substance/drug(List separately in addition to code for primary procedure)

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Example 11 Multiple Infusion Chemotherapy Sequential How do we bill if we infuse 2 chemotherapy drugs sequentially? The first drug took 2 hours, the second drug took 4 hours for a total of 6 hours. How should this be billed? CPT coding Service 96413 ­ 1 unit Chemotherapy administration; intravenous technique; up to 1 hour, single or initial substance/drug 96417 ­ 1 unit Chemotherapy administration; intravenous technique each additional sequential infusion (different substance or drug, up to 1 hour) List separately in addition to code for primary procedure 96415 ­ 4 units Chemotherapy administration; intravenous technique each additional hour

Example 12 Multiple Chemotherapy IV push and SQ Drugs commonly considered to fall under the category of hormonal antineoplastics include leuprolide acetate and goserelin acetate. If a patient receives one of these subcutaneous, then receives a different chemotherapy agent IV push, how is this billed? CPT coding Service 96409 ­ 1 unit 96402 ­ 1 unit Chemotherapy administration, intravenous, push technique, single or initial substance/drug Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic

Example 13 Multiple Infusions Chemotherapy, Therapeutic and hydration All drugs were administered during different times, not concurrently. Hydration services 47 minutes Zofran IVPB (therapeutic) 45 minutes IVPB 5-FU (chemotherapy) 50 minutes Service CPT coding 96413- 1 unit 96361- 1 unit 96365- 1 unit · · · · 5 FU Hydration Zofran

96413 is chosen for the initial since the chemotherapy was the primary service provided. The hydration and therapeutic drugs were sequential. 96361 is chosen because the CPT instructions state to use 96361 to identify hydration if provided as a secondary or subsequent service after a different initial service is provided. We used 96413 as the initial service. 96365 is chosen because CPT instructions state to use 96365, 96367, 96375 to identify therapeutic, prophylactic, or diagnostic drug infusion or injection, if provided as a secondary or subsequent service in association with 96413. Each drug would also be billed under revenue code 25X, or 636 as appropriate.

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Questions and Answers (Q&As) Infusions started outside the Hospital Q1. If the ambulance starts an IV during transport and continues upon arrival at the hospital, how does the ambulance and hospital charge for the IV administration? A1. Hospitals may receive BCBSKS beneficiaries for outpatient services who are in the process of receiving an infusion at their time of arrival at the hospital (e.g. a patient who arrives via ambulance with an ongoing intravenous infusion initiated by paramedics during transport). Hospitals are reminded to bill for all services provided using the HCPCS code(s) that most accurately describe the service(s) they provided. This includes hospitals reporting an initial hour of infusion, even if the hospital did not initiate the infusion, and additional HCPCS codes for additional or sequential infusion services if needed.

IV Documentation/Time Q1. If an IV infiltrates in the middle of an infusion, there will be two start/stop times. Which set of start/stop times is used to determine the time of the infusion? A1. For documentation purposes, both the start (start time before and after the IV infiltrates) and stop times (stop times when IV infiltrates and at the conclusion of the infusion) should be recorded. When billing an infusion administration service, the provider should add up the total time the IV was infusing (excluding the time between the infiltrate and the restart) to determine the appropriate code(s). For example, an IV begins infusing at 9:00 a.m. At 10:00 a.m. the site infiltrates and the IV infusion is restarted at 10:30 a.m. The IV continues to infuse until 12:30 p.m. The total time of this infusion would be 3 hours (1 hour from 9:00 a.m. to 10:00 a.m. plus the 2 hours after the IV infusion is restarted (10:30 a.m. to 12:30 p.m.). The facility would not bill for the 30 minutes from when the IV infiltrated to when it was restarted. (1/2006) Q2. In our medication administration and clinical pharmacy process, the IV piggyback medications have an administration time noted on the bag and all of our IV medications are administered via a pump so the infusion time is very prescriptive and controlled. Will this meet the documentation requirement if the nurse notes on the Medication Administration Record (MAR) the actual start time and that the MAR notes the prescribed rate (i.e. "infuse over 30 minutes")? Hospitals are to report codes according to CPT instructions. CPT instructions are to use the actual time over which the infusion is administered to the member for time-specific drug administration codes. This would indicate hospitals should not include their reporting time that may elapse between establishment of vascular access and initiation of the infusion. 226

A2.

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It is BCBSKS' interpretation that the actual infusion start and stop times should be documented. CPT ASSISTANT November 2005 states: Initial IV infusion codes 96360, 96365, 96413 are reported for initial infusion which is greater than 15 minutes up to 1 hour. CPT codes 96361, 96366, 96415 may be used to report infusions that are at least 30 minutes beyond the initial hour. Q3. A3. For an injection that takes one minute, is the start/stop time still required? CPT instructions state that the actual time is required only when the infusion time is a factor in the CPT descriptor. If a patient is receiving an IV infusion for hydration and the stop time is not documented in the record, how should that be coded? If the medical record clearly indicates that IV fluids were initiated and infusing (e.g. nurses notes indicate bag is infusing), then it would be appropriate to submit CPT code 96360 (Intravenous infusion, hydration, initial) It would not be appropriate to bill this service using CPT code 96374 (Therapeutic, prophylactic or diagnostic injection (specify substance or drug) intravenous push, single or initial substance/drug). IV/INJECTIONS DURING SURGERY AND/OR RECOVERY Q1. If an IV is started during a surgical procedure (in the OR) and continues into the post-recovery area, when would it be appropriate to start billing for the IV infusion? A1. In general, payment for the outpatient procedure includes both post-procedure recovery services and associated pain management treatments. Therefore, once the patient leaves the regular recovery room and enters an extended recovery unit, it is not appropriate to bill for the IV infusion. If a problem occurs, not related to the surgery, anesthesia or pain management, administration of IV's and Injections are separately billable. Q2. If a patient in a recovery area requires an injection (e.g. IV push, intramuscular (IM), subcutaneous (SQ), etc.) can the administration be billed separately (along with the drug)? See Answer 1 above. The administration of the drug cannot be billed separately.

Q4.

A4.

A2.

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IV PUMPS Q1. Is an IVAC infusion pump considered a portable pump with regards to refilling and maintenance of a portable pump (HCPCS 96521)? A1. IVAC is a brand name for pumps that range from simple to complex. HCPCS code 96521 is used for refilling and maintenance of a portable pump. CPT code 96521 will not be appropriate in all situations when a pump is used for infusions. Is it appropriate to separately bill for an IV medication pump? At this time there is no indication that the use of an IV medication pump is not separately billable.

Q2. A2.

SEQUENTIAL/CONCURRENT IV Q1. Could you explain the difference between concurrent and sequential? A2. A concurrent infusion is an add-on process (CPT code 96368). CPT Assistant June 2007 defines a concurrent infusion as one in which multiple infusions are provided through the same intravenous line or when two distinct infusions are given in two separate lumens in a multilumen catheter IV site. A sequential infusion (CPT code 96367) means that the drug is administered before or after the initial drug service. If an IV infusion is started with one type of fluid and then changed to a different type of fluid, would this be considered sequential? A sequential infusion is considered to be an infusion of a different drug administered immediately following the initial infusion. {Reference November 2005 AMA's "CPT Assistant"} Can concurrent infusions be charged for more than once? According to the CPT codebook, 96368 may only be billed once per encounter.

Q2.

A2.

Q3. A3.

IV's Spanning Two Days Q1. If there is a patient encounter that extends beyond midnight, will the system edit if an initial drug administration code is billed for the first day and an "add-on" code is submitted for the second day? A1. According to the November 2005 CPT Assistant, only one initial drug administration code should be reported unless protocol requires that two separate IV sites must be utilized. Hospitals should use IV coding based on an encounter/episode.

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For example if a patient is in ER on 1/1/07, and IV hydration is started at 10:00 p.m. and continues until 1/2/07 at 2:00a.m., how is this reflected on the claim? 96360 1 unit 010107 96361 1 unit 010107 96361 2 units 010207 IV Start/IV Flush Declotting Q1. If IV access is obtained but nothing is administered through this access, is this separately billable? If so, how would it be coded? A1. If there is a suspected medical need for IV access but it is not used to administer drugs, then it would be appropriate to bill for the IV start under CPT code 36000 (Introduction of needle or intracatheter, vein). An example of a suspected medical need would be a patient that presents to the emergency room with a condition that could indicate IV access would be indicated. To merely start an IV as a standard protocol would not justify billing separately for the IV start. The cost of the saline flush, tubing, etc. would be content of the service and therefore the costs should be included in the charge for the IV start. Q2. If IV access (36000) is the only service provided, can we bill a low level E&M (evaluation & management) service? An E&M code can only be billed if the hospital provides a significant, separately identifiable evaluation. This must be documented in the medical record. It states that at the conclusion of treatment a flush is not separately billable. What about a flush at the beginning of the infusion? According to the CPT guidelines, services leading up to and concluding the infusion have been included in the primary infusion service code and are not separately billable. These services will include starting the IV and monitoring the patient post infusion. Therefore, it is BCBSKS' interpretation an IV flush prior to an infusion would not be separately billable. Q4. Is an IV flush considered a chargeable item when used for a PIC line or portacath? CPT code 96523 should be billed.

A2.

Q3.

A3.

A4.

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Q5.

There is information in the literature about the declotting code 36550. This code seems much more of an extensive service than what is performed for monthly portacath maintenance encounter. Is there another code that would be more appropriate to use for portacath maintenance? The CPT code 36593 pertains to the declotting and not the monthly maintenance of a port. BCBSKS recommends CPT code 96523. Please refer to question 15 (above) for more details regarding CPT code 96523.

A5.

IV Fluids with Wound Care Q1. How does one bill when IV fluids are used for wound cleansing? A1. Wound cleansing is considered a part of the wound care treatment and would be billed under the appropriate wound care code.

Multiple IVs Q1. Is it appropriate to submit multiple units when multiple chemotherapy IV push injections are administered during a hospital outpatient encounter? A1. BCBSKS encourages hospitals to always refer to CPT coding guidelines. CPT code 96411 does not indicate that each additional substance/drug must be a NEW substance or drug. If a chemo drug was administered twice via IV push, then 96409 would be billed with one unit, and 96411 would be billed with one unit X 2. If a patient has 4 piggyback IVs of all therapeutic medications (i.e. patient is not being treated for hydration) and these medications are infusing through the same IV line, how should these services be billed? CPT code 96365 for the initial start of the therapeutic drug CPT code 96368 would be billed for the concurrent infusion CPT code 96366 would be billed based on the additional hours of infusion. If a patient comes in and receives and IV infusion of three therapeutic medications (piggyback) that infuse over 2 hours. The patient then leaves the facility and returns later that day for another IV infusion of the same three medications (infused over 2 hours); leaves the facility and returns a third time for the same IV infusion, how would this situation be billed? The coding would be as follows: 96365 (Intravenous infusion, for therapeutic, prophylaxis or diagnostic (specify substance or drug); initial up to 1 hour) 96366 (Intravenous infusion, for therapeutic, prophylaxis or diagnostic each additional hour. For a 2 hour infusion, this code would be billed with 1 unit.

Q2.

A2.

Q3.

A3.

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When the patient returns for the second (and subsequent infusions), these would be new encounters. Therefore, it would be appropriate to bill the 96365 and 96366 with modifier 59. Q4. If a patient receives two IV pushes for the same therapeutic drug, how should the second IV push be coded? Only one unit of 96374 can be billed when two pushes of the same drug are administered. If a patient is in for Adriamycin (chemotherapy drug) IV over 45 minutes, followed by Cytoxan (chemotherapy drug) IV over 30 minutes, is it appropriate to bill with CPT code 96413 or should the facility use CPT codes 96413 and 96417? The hospital would submit these two drug administrations using CPT codes 96413 and 96417.

A4.

Q5.

A5.

Medical Necessity Q1. Is there a requirement for medical necessity for infusions and injections? A1. Medical necessity is required for ANY service that is billed to BCBSKS.

Multiple Visits Q1. A facility has a wound care clinic in our facility. If the patient is seen in wound care for a dressing change on the same day they are seen at the hospital for infusion therapy, would it be appropriate to charge an E&M charge for the wound care visit? A1. The wound care evaluation is a separate and distinct service and therefore is separately billable.

IV Contrast Q1. Is it appropriate to separately bill for an IV infusion of contrast during a radiological procedure (e.g. CT scan)? A1. Injections or infusions inherent to another procedure (e.g. CT scan) are not separately billable. The contrast media used (e.g. low osmolar contrast material (LOCM)); however, is separately billable (revenue code 0636).

Chemotherapy/Monoclonal Drugs Q1. A patient comes to the facility and receives Campath subcutaneously. This drug is classified as a monoclonal antibody. What is the proper code that should be used? Contains Public Information Revision Date: March 31, 2009 231

A1.

According to the CPT codebook: "Chemotherapy administration codes 9640196549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g. cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents and other biologic response modifiers." Therefore, it would be appropriate to code 96401 for the subcutaneous administration of the monoclonal antibody. Is it appropriate to charge monoclonal antibodies as a chemotherapy administration or as a therapeutic/prophylactic/diagnostic administration? According to the CPT codebook: "Chemotherapy administration codes 9640196549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of noncancer diagnoses (e.g. cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents and other biologic response modifiers." Therefore, for monoclonal antibodies, providers should use the appropriate chemotherapy administration codes.

Q2.

A2.

Rabies Immune Globulin (90375) Q1. How do you code/charge for the administration of rabies immune globulin (90375). A1. The full dose should be infiltrated around the wound(s) and any remaining volume should be administered IM at an anatomical site distant from rabies vaccine administration. Infiltrate means that the one syringe is administered several times around the wound. Therefore bill 96372 with one unit.

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Appendix B Blue Cross 2009 Add-On Codes and Descriptions

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Blue Cross 2009 Add-on Codes The following codes receive separate line item payment on outpatient claims, for most facilities. For verification of your facility reimbursement, check your MAP listing. These codes must reflect a charge on the line item. Codes with time, dosage or minutes must reflect units according to the code description.

A4641 A4642 A9500 A9502 A9503 A9504 A9505 A9507 A9508 A9510 A9546 A9550 A9556 A9557 A9558 A9560 A9561 A9562 A9563 A9564 A9580 A9605 A9700 C8900 C8901 C8902 C8903 C8904 C8905 C8906 C8907 C8908 C8909 C8910 C8911 C8912 C8913 C8914 C8918 RADIOPHARMACEUTICAL, DIAGNOSTIC, NOT OTHERWISE CLASSIFIED INDIUM IN-111 SATUMOMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 TECHNETIUM TC-99M APCITIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE INDIUM IN-111 CAPROMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO IODINE I-131 IOBENGUANE SULFATE, DIAGNOSTIC, PER 0.5 MILLICURIE TECHNETIUM TC-99M DISOFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 COBALT CO-57/58, CYANOCOBALAMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 TECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY DOSE, UP GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE TECHNETIUM TC-99M BICISATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY TECHNETIUM TC-99M OXIDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 SODIUM PHOSPHATE P-32, THERAPEUTIC, PER MILLICURIE CHROMIC PHOSPHATE P-32 SUSPENSION, THERAPEUTIC, PER MILLICURIE SODIUM FLUORIDE F-18, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES SAMARIUM SM-153 LEXIDRONAMM, THERAPEUTIC, PER 50 MILLICURIES SUPPLY OF INJECTABLE CONTRAST MATERIAL FOR USE IN ECHOCARDIOGRAPHY, MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, ABDOMEN MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, ABDOMEN MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; UNILATERAL MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; UNILATERAL MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH MAGNETIC RESONANCE IMAGING WITH CONTRAST, BREAST; BILATERAL MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST, BREAST; BILATERAL MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST FOLLOWED BY WITH MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, CHEST (EXCLUDING MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, CHEST (EXCLUDING MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, LOWER EXTREMITY MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, LOWER EXTREMITY MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH MAGNETIC RESONANCE ANGIOGRAPHY WITH CONTRAST, PELVIS

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C8919 C8920 C8921 C8922 C8923 C8924 C8925 C8926 C8927 C8928 C8929

C8930

C9247 G0166 G0202 G0204 G0206 G0219 G0235 G0237 G0238 G0239 G0252 G0259 G0260 G0268 J0133 J0150 J0152 J0170 J0295 J0330 J0636 J0640 J0690 J0694 J0696 J0881

MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST, PELVIS MAGNETIC RESONANCE ANGIOGRAPHY WITHOUT CONTRAST FOLLOWED BY WITH TRANSTHORACIC ECHOCARDIOGRAPHY WITH OR WITHOUT CONTRAST TRANSTHORACIC ECHOCARDIOGRAPHY WITH OR WITHOUT CONTRAST TRANSTHORACIC ECHOCARDIOGRAPHY WITH OR WITHOUT CONTRAST TRANSTHORACIC ECHOCARDIOGRAPHY WITH OR WITHOUT CONTRAST TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH OR WITHOUT CONTRAST TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH OR WITHOUT CONTRAST TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) WITH OR WITHOUT CONTRAST TRANSTHORACIC ECHOCARDIOGRAPHY WITH OR WITHOUT CONTRAST TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES MMODE RECORDING, WHEN PERFORMED, COMPLETE, WITH SPECTRAL DOPPLER ECHOCARDIOGRAPHY, AND WITH COLOR FLOW DOPPLER ECHOCARDIOGRAPHY TRANSTHORACIC ECHOCARDIOGRAPHY, WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES MMODE RECORDING, WHEN PERFORMED, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT; INCLUDING PERFORMANCE OF CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, WITH PHYSICIAN SUPERVISION IOBENGUANE, I-123, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES EXTERNAL COUNTERPULSATION, PER TREATMENT SESSION SCREENING MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, ALL DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, BILATERAL, DIAGNOSTIC MAMMOGRAPHY, PRODUCING DIRECT DIGITAL IMAGE, UNILATERAL, PET IMAGING WHOLE BODY; MELANOMA FOR NON-COVERED INDICATIONS PET IMAGING, ANY SITE, NOT OTHERWISE SPECIFIED THERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR ENDURANCE OF THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION, OTHER THAN THERAPEUTIC PROCEDURES TO IMPROVE RESPIRATORY FUNCTION OR INCREASE PET IMAGING, FULL AND PARTIAL-RING PET SCANNERS ONLY, FOR INITIAL INJECTION PROCEDURE FOR SACROILIAC JOINT; ARTHROGRAPY INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, REMOVAL OF IMPACTED CERUMEN (ONE OR BOTH EARS) BY PHYSICIAN ON SAME INJECTION, ACYCLOVIR, 5 MG INJECTION, ADENOSINE FOR THERAPEUTIC USE, 6 MG (NOT TO BE USED TO INJECTION, ADENOSINE FOR DIAGNOSTIC USE, 30 MG (NOT TO BE USED TO INJECTION, ADRENALIN, EPINEPHRINE, UP TO 1 ML AMPULE INJECTION, AMPICILLIN SODIUM/SULBACTAM SODIUM, PER 1.5 GM INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO 20 MG INJECTION, CALCITRIOL, 0.1 MCG INJECTION, LEUCOVORIN CALCIUM, PER 50 MG INJECTION, CEFAZOLIN SODIUM, 500 MG INJECTION, CEFOXITIN SODIUM, 1 GM INJECTION, CEFTRIAXONE SODIUM, PER 250 MG INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE)

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J0882 J0885 J0886 J1020 J1030 J1040 J1100 J1170 J1200 J1245 J1260 J1265 J1327 J1440 J1441 J1459 J1561 J1566 J1568 J1569 J1572 J1580 J1626 J1642 J1644 J1650 J1745 J1756 J1790 J1885 J1950 J1956 J2001 J2060 J2175 J2180 J2250 J2270 J2275 J2300 J2355 J2405 J2430 J2469

INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS) INJECTION, EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS INJECTION, EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS) INJECTION, METHYLPREDNISOLONE ACETATE, 20 MG INJECTION, METHYLPREDNISOLONE ACETATE, 40 MG INJECTION, METHYLPREDNISOLONE ACETATE, 80 MG INJECTION, DEXAMETHASONE SODIUM PHOSPHATE, 1MG INJECTION, HYDROMORPHONE, UP TO 4 MG INJECTION, DIPHENHYDRAMINE HCL, UP TO 50 MG INJECTION, DIPYRIDAMOLE, PER 10 MG INJECTION, DOLASETRON MESYLATE, 10 MG INJECTION, DOPAMINE HCL, 40 MG INJECTION, EPTIFIBATIDE, 5 MG INJECTION, FILGRASTIM (G-CSF), 300 MCG INJECTION, FILGRASTIM (G-CSF), 480 MCG

INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G. LIQUID), 500 MG

INJECTION, IMMUNE GLOBULIN, (GAMUNEX), INTRAVENOUS, NON-LYOPHILIZED INJECTION, IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), INJECTION, IMMUNE GLOBULIN, (OCTAGAM), INTRAVENOUS, NON-LYOPHILIZED INJECTION, IMMUNE GLOBULIN, (GAMMAGARD LIQUID), INTRAVENOUS INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, NONLYOPHILIZED (E.G. LIQUID), 500 MG INJECTION, GARAMYCIN, GENTAMICIN, UP TO 80 MG INJECTION, GRANISETRON HYDROCHLORIDE, 100 MCG INJECTION, HEPARIN SODIUM, (HEPARIN LOCK FLUSH), PER 10 UNITS INJECTION, HEPARIN SODIUM, PER 1000 UNITS INJECTION, ENOXAPARIN SODIUM, 10 MG INJECTION INFLIXIMAB, 10 MG INJECTION, IRON SUCROSE, 1 MG INJECTION, DROPERIDOL, UP TO 5 MG INJECTION, KETOROLAC TROMETHAMINE, PER 15 MG INJECTION, LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), PER 3.75 MG INJECTION, LEVOFLOXACIN, 250 MG INJECTION, LIDOCAINE HCL FOR INTRAVENOUS INFUSION, 10 MG INJECTION, LORAZEPAM, 2 MG INJECTION, MEPERIDINE HYDROCHLORIDE, PER 100 MG INJECTION, MEPERIDINE AND PROMETHAZINE HCL, UP TO 50 MG INJECTION, MIDAZOLAM HYDROCHLORIDE, PER 1 MG INJECTION, MORPHINE SULFATE, UP TO 10 MG INJECTION, MORPHINE SULFATE (PRESERVATIVE-FREE STERILE SOLUTION), PER INJECTION, NALBUPHINE HYDROCHLORIDE, PER 10 MG INJECTION, OPRELVEKIN, 5 MG INJECTION, ONDANSETRON HYDROCHLORIDE, PER 1 MG INJECTION, PAMIDRONATE DISODIUM, PER 30 MG INJECTION, PALONOSETRON HCL, 25 MCG

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INJECTION, PARICALCITOL, 1 MCG INJECTION, PEGFILGRASTIM, 6 MG INJECTION, PROMETHAZINE HCL, UP TO 50 MG INJECTION, NEOSTIGMINE METHYLSULFATE, UP TO 0.5 MG INJECTION, METOCLOPRAMIDE HCL, UP TO 10 MG INJECTION, RANITIDINE HYDROCHLORIDE, 25 MG INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.) INJECTION, THO(D) IMMUNE GLOBULIN (HUMAN), (RHOPHYLAC), INTRAMUSCULAR INJECTION, SARGRAMOSTIM (GM-CSF), 50 MCG INJECTION, RETEPLASE, 18.1 MG INJECTION, STREPTOKINASE, PER 250,000 IU INJECTION, ALTEPLASE RECOMBINANT, 1 MG INJECTION, FENTANYL CITRATE, 0.1 MG INJECTION, TREPROSTINIL, 1 MG INJECTION, TRIAMCINOLONE ACETONIDE, NOT OTHERWISE SPECIFIED, 10 MG INJECTION, VANCOMYCIN HCL, 500 MG INJECTION, HYDROXYZINE HCL, UP TO 25 MG INJECTION, VITAMIN B-12 CYANOCOBALAMIN, UP TO 1000 MCG INJECTION, PHYTONADIONE (VITAMIN K), PER 1 MG INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ INJECTION, ZOLEDRONIC ACID, 1 MG INJECTION, ZOLEDRONIC ACID (RECLAST) 1 MG INFUSION, NORMAL SALINE SOLUTION , 1000 CC INFUSION, NORMAL SALINE SOLUTION, STERILE (500 ML=1 UNIT) 5% DEXTROSE/NORMAL SALINE (500 ML = 1 UNIT) INFUSION, NORMAL SALINE SOLUTION , 250 CC 5% DEXTROSE/WATER (500 ML = 1 UNIT) RINGERS LACTATE INFUSION, UP TO 1000 CC DERMAL AND EPIDERMAN, (SUBSTITUTE) TISSUE OF HUMAN ORIGIN, WITH OR DERMAN (SUBSTITUTE) TISSUE OF HUMAN HORIGIN, INJECTABLE, WITH OR GLYCOPYRROLATE, INHALATION SOLUTION, COMPOUNDED PRODUCT, ADMIN INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 MG INJECTION, ALDESLEUKIN, PER SINGLE USE VIAL INJECTION, ASPARAGINASE, 10,000 UNITS BCG (INTRAVESICAL) PER INSTILLATION INJECTION, BEVACIZUMAB, 10 MG INJECTION, BLEOMYCIN SULFATE, 15 UNITS INJECTION, CARBOPLATIN, 50 MG INJECTION, CETUXIMAB, 10 MG CISPLATIN, POWDER OR S0LUTION, PER 10 MG CISPLATIN, 50 MG CYCLOPHOSPHAMIDE, 100 MG CYCLOPHOSPHAMIDE, LYOPHILIZED, 100 MG CYCLOPHOSPHAMIDE, LYOPHILIZED, 1.0 GRAM INJECTION, CYTARABINE, 100 MG

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INJECTION, DACTINOMYCIN, 0.5 MG DACARBAZINE, 100 MG INJECTION, DOCETAXEL, 20 MG INJECTION, ETOPOSIDE, 10 MG INJECTION, FLUOROURACIL, 500 MG INJECTION, GEMCITABINE HYDROCHLORIDE, 200 MG GOSERELIN ACETATE IMPLANT, PER 3.6 MG INJECTION, IRINOTECAN, 20 MG INJECTION, MESNA, 200 MG INJECTION, INTERFERON, ALFA-2B, RECOMBINANT, 1 MILLION UNITS LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG LEUPROLIDE ACETATE, PER 1 MG INJECTION, OXALIPLATIN, 0.5 MG INJECTION, PACLITAXEL, 30 MG INJECTION, PLICAMYCIN, 2.5 MG MITOMYCIN, 5 MG INJECTION, MITOXANTRONE HYDROCHLORIDE, PER 5 MG INJECTION, RITUXIMAB, 100 MG INJECTION, STREPTOZOCIN, 1 GRAM INJECTION, TOPOTECAN, 4 MG INJECTION, TRASTUZUMAB, 10 MG INJECTION, VINBLASTINE SULFATE, 1 MG VINCRISTINE SULFATE, 1 MG VINCRISTINE SULFATE, 2 MG INJECTION, VINORELBINE TARTRATE, 10 MG INFUSION THERAPY, USING OTHER THAN CHEMOTHERAPEUTIC DRUGS, PER VISIT CHEMOTHERAPY ADMINISTRATION BY OTHER THAN INFUSION TECHNIQUE ONLY (E.G. CHEMOTHERAPY ADMINISTRATION BY INFUSION TECHNIQUE ONLY, PER VISIT CHEMOTHERAPY ADMINISTRATION BY BOTH INFUSION TECHNIQUE AND OTHER TELEHEALTH ORIGINATING SITE FACILITY FEE ORAL MAGNETIC RESONANCE CONTRAST AGENT, PER 100 ML LOW OSMOLAR CONTRAST MATERIAL, 100-199 MG/ML IODINE CONCENTRATE LOW OSMOLAR CONTRAST MATERIAL, 200-299 MG/ML IODINE CONCENTRATE LOW OSMOLAR CONTRAST MATERIAL 300-300 MG/ML IODINE CONCENTRATE HOSPITALIST SERVICES (LIST SEPARATELY IN ADDITION TO CODE FOR MAGNETIC SOURCE IMAGING MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY (MRCP) TOPOGRAPHIC BRAIN MAPPING MAGNETIC RESONANCE IMAGING (MRI), LOW-FIELD SCINTIMAMMOGRAPHY (RADIOIMMUNOSCINTIGRAPHY OF THE BREAST), FLUORINE-18 FLUORODEOXYGLUCOSE (F-18 FDG) IMAGING USING DUAL-HEAD ELECTRON BEAM COMPUTED TOMOGRAPHY (ALSO KNOWN AS ULTRAFAST CT, CINE VERTEBRAL AXIAL DECOMPRESSION, PER SESSION

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SPEECH THERAPY REEVALUATION ADMINISTRATION OF ORAL, INTRAMUSCULAR AND/OR SUBCUTANEOUS MEDICATION DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH DEBRIDEMENT; SKIN, PARTIAL THICKNESS DEBRIDEMENT; SKIN, FULL THICKNESS DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND BONE DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, INITIAL OR INJECTION PROCEDURE ONLY FOR MAMMARY DUCTOGRAM OR GALACTOGRAM PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; IMAGE GUIDED PLACEMENT, METALLIC LOCALIZATION CLIP, PERCUTANEOUS, INJECTION OF SINUS TRACT; THERAPEUTIC (SEPARATE PROCEDURE) INJECTION OF SINUS TRACT; DIAGNOSTIC (SINOGRAM) INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS (E.G., INJECTION(S); SINGLE TENDON ORIGIN/INSERTION INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), ONE OR TWO INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), THREE OR MORE INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA INJECTION PROCEDURE FOR SACROILIAC JOINT, ARTHROGRAPHY AND/OR INJECTION PROCEDURE FOR KNEE ARTHROGRAPHY INJECTION PROCEDURE FOR ANKLE ARTHROGRAPHY APPLICATION; SHOULDER TO HAND (LONG ARM) APPLICATION; ELBOW TO FINGER (SHORT ARM) APPLICATION; HAND AND LOWER FOREARM (GAUNTLET) APPLICATION, CAST; FINGER (E.G., CONTRACTURE) APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); DYNAMIC APPLICATION OF FINGER SPLINT; STATIC APPLICATION OF FINGER SPLINT; DYNAMIC STRAPPING; SHOULDER (E.G., VELPEAU) STRAPPING; ELBOW OR WRIST STRAPPING; HAND OR FINGER APPLICATION OF LONG LEG CAST (THIGH TO TOES);

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APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY APPLICATION OF LONG LEG CAST BRACE APPLICATION OF CYLINDER CAST (THIGH TO ANKLE) APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR ADDING WALKER TO PREVIOUSLY APPLIED CAST APPLICATION OF RIGID TOTAL CONTACT LEG CAST APPLICATION OF CLUBFOOT CAST WITH MOLDING OR MANIPULATION, LONG OR APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) STRAPPING; HIP STRAPPING; KNEE STRAPPING; ANKLE AND/OR FOOT STRAPPING; TOES STRAPPING; UNNA BOOT DENIS-BROWNE SPLINT STRAPPING REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST REMOVAL OR BIVALVING; SHOULDER OR HIP SPICA, MINERVA, OR RISSER REMOVAL OR BIVALVING; TURNBUCKLE JACKET INJECTION INTO TURBINATE(S), THERAPEUTIC BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS NEEDLE THORACENTESIS, PUNCTURE OF PLEURAL CAVITY FOR ASPIRATION THORACENTESIS WITH INSERTION OF TUBE, INCLUDES WATER SEAL (EG, INTRODUCTION OF NEEDLE OR INTRACATHETER, VEIN INJECTION PROCEDURES (E.G., THROMBIN) FOR PERCUTANEOUS TREATMENT OF INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING INTRODUCTION INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (E.G., SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE INTRODUCTION OF CATHETER, RIGHT HEART OR MAIN PULMONARY ARTERY INTRODUCTION OF NEEDLE OR INTRACATHETER, CAROTID OR VERTEBRAL ARTERY INTRODUCTION OF NEEDLE OR INTRACATHETER; RETROGRADE BRACHIAL ARTERY INTRODUCTION OF NEEDLE OR INTRACATHETER; EXTREMITY ARTERY INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT CREATED INTRODUCTION OF NEEDLE OR INTRACATHETER, AORTIC, TRANSLUMBAR INTRODUCTION OF CATHETER, AORTA SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER

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SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR VENIPUNCTURE, AGE 3 YEARS OR OLDER, NECESSITATING PHYSICIAN'S SKILL COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY INJECTION PROCEDURE AND PLACEMENT OF CHAIN FOR CONTRAST AND/ OR CHAIN INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION INSERTION OF NON-INDWELLING BLADDER CATHETER (E.G., STRAIGHT INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE (E.G., INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (E.G., MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR AMNIOCENTESIS; DIAGNOSTIC FETAL CONTRACTION STRESS TEST FETAL NON-STRESS TEST FETAL SCALP BLOOD SAMPLING FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (E.G., ALCOHOL, PHENOL, ICED INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (E.G., ALCOHOL, PHENOL, ICED INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (E.G., ALCOHOL, PHENOL, ICED INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED TOMOGRAPHY, INJECTION, SINGLE (NOT VIA INDWELLING CATHETER), NOT INCLUDING INJECTION, SINGLE (NOT VIA INDWELLING CATHETER), NOT INCLUDING INJECTION, INCLUDING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INJECTION, INCLUDING CATHETER PLACEMENT, CONTINUOUS INFUSION OR MYELOGRAPHY, POSTERIOR FOSSA, RADIOLOGICAL SUPERVISION AND MAGNETIC RESONANCE (E.G., PROTON) IMAGING, TEMPOROMANDIBULAR JOINT(S) COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S)

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COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ORBIT, FACE, AND NECK; WITH MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ORBIT, FACE, AND NECK; MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), MAGNETIC RESONANCE (E.G., PROTON) IMAGING, BRAIN (INCLUDING BRAIN MAGNETIC RESONANCE (E.G., PROTON) IMAGING, BRAIN (INCLUDING BRAIN MAGNETIC RESONANCE (E.G., PROTON) IMAGING, BRAIN (INCLUDING BRAIN MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING TEST MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; REQUIRING MAGNETIC RESONANCE (E.G., PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM MAGNETIC RESONANCE (E.G., PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM MAGNETIC RESONANCE (E.G., PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITH CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, FOLLOWED BY MAGNETIC RESONANCE (E.G., PROTON) IMAGING, CHEST (E.G., FOR EVALUATION OF MAGNETIC RESONANCE (E.G., PROTON) IMAGING, CHEST (E.G., FOR EVALUATION OF MAGNETIC RESONANCE (E.G., PROTON) IMAGING, CHEST (E.G., FOR EVALUATION OF MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING MYOCARDIUM), WITH OR COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL, COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITH CONTRAST MATERIAL COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL, COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITH CONTRAST MATERIAL COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS,

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MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, SPINAL CANAL AND CONTENTS, MAGNETIC RESONANCE ANGIOGRAPHY, SPINAL CANAL AND CONTENTS, WITH OR COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY MAGNETIC RESONANCE (E.G., PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MAGNETIC RESONANCE (E.G., PROTON) IMAGING, PELVIS; WITH CONTRAST MAGNETIC RESONANCE (E.G., PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT CONTRAST MYELOGRAPHY, CERVICAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, THORACIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL SUPERVISION AND INTERP MYELOGRAPHY, TWO OR MORE REGIONS (E.G., LUMBAR/THORACIC, COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN MAGNETIC RESONANCE (E.G., PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN MAGNETIC RESONANCE (E.G., PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ANY JOINT OF UPPER MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ANY JOINT OF UPPER MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ANY JOINT OF UPPER MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR WITHOUT COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, MAGNETIC RESONANCE (E.G., PROTON) IMAGING, LOWER EXTREMITY OTHER THAN MAGNETIC RESONANCE (E.G., PROTON) IMAGING, LOWER EXTREMITY OTHER THAN MAGNETIC RESONANCE (E.G., PROTON) IMAGING, LOWER EXTREMITY OTHER THAN MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ANY JOINT OF LOWER MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ANY JOINT OF LOWER MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ANY JOINT OF LOWER MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ABDOMEN; WITH CONTRAST MAGNETIC RESONANCE (E.G., PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST CARDIAC MAGENTIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION CARDIAC MAGENTIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION

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CARDIAC MAGENTIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION CARDIAC MAGENTIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND ANGIOGRAPHY, CERVICOCEREBRAL, CATHETER, INCLUDING VESSEL ORIGIN, ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION AND ANGIOGRAPHY, EXTERNAL CAROTID, UNILATERAL, SELECTIVE, RADIOLOGICAL ANGIOGRAPHY, EXTERNAL CAROTID, BILATERAL, SELECTIVE, RADIOLOGICAL ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL, RADIOLOGICAL SUPERVISION ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL, RADIOLOGICAL SUPERVISION ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL, RADIOLOGICAL SUPERVISION ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL, RADIOLOGICAL SUPERVISION ANGIOGRAPHY, VERTEBRAL, CERVICAL, AND/OR INTRACRANIAL, RADIOLOGICAL INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL XERORADIOGRAPHY COMPUTED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY MAGNETIC RESONANCE SPECTROSCOPY UNLISTED COMPUTED TOMOGRAPHY PROCEDURE (E.G., DIAGNOSTIC, UNLISTED MAGNETIC RESONANCE PROCEDURE (E.G., DIAGNOSTIC, UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE ECHOENCEPHALOGRAPHY, REAL TIME WITH IMAGE DOCUMENTATION (GRAY SCALE) OPHTHALMIC ULTRASOUND, DIAGNOSTIC; QUANTITATIVE A-SCAN ONLY OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN (WITH OR WITHOUT OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; ANTERIOR SEGMENT OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CORNEAL PACHYMETRY, OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (E.G., THYROID, PARATHYROID, ULTRASOUND, CHEST (INCLUDES MEDIASTINUM), REAL TIME WITH IMAGE ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), REAL TIME WITH IMAGE ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE ULTRASOUND, RETROPERITONEAL (E.G., RENAL, AORTA, NODES), REAL TIME WITH ULTRASOUND, RETROPERITONEAL (E.G., RENAL, AORTA, NODES), B-SCAN AND/OR ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH ULTRASOUND, SPINAL CANAL AND CONTENTS ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION,

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76811 76812 76815 76816 76817 76818 76819 76825 76826 76827 76828 76830 76831 76856 76857 76870 76872 76873 76880 76885 76886 76930 76932 76936 76937 76940 76941 76942 76945 76946 76948 76950 76965 76970 76975 76977 76998 76999 77011 77012 77014 77021 77022

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR CONTINUOUS WAVE DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE ULTRASOUND, TRANSVAGINAL SALINE INFUSION SONOHYSTEROGRAPHY (SIS), INCLUDING COLOR FLOW ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE ULTRASOUND, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE ULTRASOUND, SCROTUM AND CONTENTS ULTRASOUND, TRANSRECTAL ULTRASOUND, TRANSRECTAL PROSTATE VOLUME STUDY FOR BRACHYTHERAPY ULTRASOUND, EXTREMITY, NONVASCULAR, REAL TIME WITH IMAGE ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS, IMAGING SUPERVISION AND ULTRASONIC GUIDANCE FOR ENDOMYOCARDIAL BIOPSY, IMAGING SUPERVISION ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDOANEURYSM OR ARTERIOVENOUS FISTULAE ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND ULTRASOUND GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL TISSUE ULTRASONIC GUIDANCE FOR INTRAUTERINE FETAL TRANSFUSION OR ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (E.G., BIOPSY, ASPIRATION, ULTRASONIC GUIDANCE FOR CHORIONIC VILLUS SAMPLING, IMAGING ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, IMAGING SUPERVISION AND ULTRASONIC GUIDANCE FOR ASPIRATION OF OVA, IMAGING SUPERVISION AND ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION ULTRASOUND STUDY FOLLOW-UP (SPECIFY) GASTROINTESTINAL ENDOSCOPIC ULTRASOUND, SUPERVISION AND ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL ULTRASONIC GUIDANCE, INTRAOPERATIVE UNLISTED ULTRASOUND PROCEDURE (E.G., DIAGNOSTIC, INTERVENTIONAL) COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (E.G., BIOPSY, COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (E.G., FOR BIOPSY, MAGNETIC RESONANCE GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL

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77055 77056 77057 77058 77059 77078 77079 77080 77081 77083 77084 78350 78351 78459 78464 78465 78478 78480 78491 78492 78608 78609 78811 78812 78813 78814 78815 78816 90655 90656 90723 90747 91055 92506 92507 92508 92977 92978 93303 93304 93307

MAMMOGRAPHY; UNILATERAL MAMMOGRAPHY; BILATERAL SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF EACH BREAST) MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; DUAL-ENERGY X-RAY ABSORPTIOMETRY (DEXA), BONE DENSITY STUDY, 1 OR MORE DUAL-ENERGY X-RAY ABSORPTIOMETRY (DEXA), BONE DENSITY STUDY, 1 OR MORE RADIOGRAPHIC ABSORPTIOMETRY (E.G., PHOTODENSITOMETRY, RADIOGRAMMETRY), MAGNETIC RESONANCE (E.G., PROTON) IMAGING, BONE MARROW BLOOD SUPPLY BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; SINGLE BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; DUAL MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), SINGLE STUDY MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), MULTIPLE STUDIES MYOCARDIAL PERFUSION STUDY WITH WALL MOTION, QUALITATIVE OR MYOCARDIAL PERFUSION STUDY WITH EJECTION FRACTION (LIST SEPARATELY IN MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); PERFUSION TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); LIMITED AREA (E.G., TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); SKULL BASE TO TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); WHOLE BODY TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, WHEN INFLUENZA VIRUS VACCINE, SPLIT VIRUS, PRESERVATIVE FREE, WHEN DIPHTHERIA, TETANUS TOXOIDS, ACELLULAR PERTUSSIS VACCINE, HEPATITIS HEPATITIS B VACCINE, DIALYSIS OR IMMUNOSUPPRESSED PATIENT DOSAGE (4 GASTRIC INTUBATION, WASHINGS, AND PREPARING SLIDES FOR CYTOLOGY EVALUATION OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/ OR TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/ OR AUDITORY TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/ OR AUDITORY THROMBOLYSIS, CORONARY; BY INTRAVENOUS INFUSION INTRAVASCULAR ULTRASOUND (CORONARY VESSEL OR GRAFT) DURING DIAGNOSTIC TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION

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93308 93312 93313 93314 93315 93316 93317 93318 93320 93321 93325 93350 93571 93572 93875 93880 93882 93886 93888 93922 93923 93924 93925 93926 93930 93931 93970 93971 93975 93976 93978 93979 93980 93981

ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE DOCUMENTATION ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE DOCUMENTATION ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE DOCUMENTATION TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC ANOMALIES; ECHOCARDIOGRAPHY, TRANSESOPHAGEAL (TEE) FOR MONITORING PURPOSES, DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS WAVE WITH DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST SEPARATELY ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE DOCUMENTATION INTRAVASCULAR DOPPLER VELOCITY AND/OR PRESSURE DERIVED CORONARY FLOW INTRAVASCULAR DOPPLER VELOCITY AND/OR PRESSURE DERIVED CORONARY FLOW NON-INVASIVE PHYSIOLOGIC STUDIES OF EXTRACRANIAL ARTERIES, COMPLETE DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY DUPLEX SCAN OF EXTRACRANIAL ARTERIES; UNILATERAL OR LIMITED STUDY TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; COMPLETE TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; LIMITED NON-INVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY NON-INVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY NON-INVASIVE PHYSIOLOGIC STUDIES OF LOWER EXTREMITY ARTERIES, AT REST DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS;

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93990 95930 96360 96361 96365 96366 96367 96369 96370 96371 96372 96373 96374 96375 96376 96401 96402 96409 96413 96415 96416 96417 96420 96422 96423 96425 97001 97002 97003 97004 97005 97006 97010 97012 97014 97016 97018 97022 97024 97026 97028 97032 97033 97034

DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, BODY VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL NERVOUS SYSTEM, INTRAVENOUS INFUSION, HYDRATION; INITIAL, UP TO 1 HOUR INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBCUTANEOUS INFUSION FOR THEAPY OR PHOPHYLAXIS (SPECIFY SUBSTANCE) SUBCUTANEOUS INFUSION FOR THEAPY OR PHOPHYLAXIS (SPECIFY SUBTANCE) SUBCUTANEOUS INFUSION FOR THEAPY OR PHOPHYLAXIS (SPECIFY SUBSTANCE) THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL CHEMOTHERAPY ADMINISTRATION; INTRAVENOUS, PUSH TECHNIQUE, SINGLE OR CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; UP TO 1 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; EACH CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; EACH CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; PUSH TECHNIQUE CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION TECHNIQUE, UP CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION TECHNIQUE, EACH CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION TECHNIQUE, PHYSICAL THERAPY EVALUATION PHYSICAL THERAPY RE-EVALUATION OCCUPATIONAL THERAPY EVALUATION OCCUPATIONAL THERAPY RE-EVALUATION ATHLETIC TRAINING EVALUATION ATHLETIC TRAINING RE-EVALUATION APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HOT OR COLD PACKS APPLICATION OF A MODALITY TO ONE OR MORE AREAS; TRACTION, MECHANICAL APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL APPLICATION OF A MODALITY TO ONE OR MORE AREAS; VASOPNEUMATIC DEVICES APPLICATION OF A MODALITY TO ONE OR MORE AREAS; PARAFFIN BATH APPLICATION OF A MODALITY TO ONE OR MORE AREAS; WHIRLPOOL APPLICATION OF A MODALITY TO ONE OR MORE AREAS; DIATHERMY (E.G., APPLICATION OF A MODALITY TO ONE OR MORE AREAS; INFRARED APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRAVIOLET APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL APPLICATION OF A MODALITY TO ONE OR MORE AREAS; IONTOPHORESIS, EACH APPLICATION OF A MODALITY TO ONE OR MORE AREAS; CONTRAST BATHS, EACH

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97035 97036 97039 97110 97112 97113 97116 97124 97140 97530 97533 97545 97750 97761 97799 99201 99202 99203 99204 99205 99211 99212 99213 99214 99215

APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRASOUND, EACH 15 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HUBBARD TANK, EACH 15 UNLISTED MODALITY (SPECIFY TYPE AND TIME IF CONSTANT ATTENDANCE) THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; AQUATIC THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; GAIT THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; MASSAGE, MANUAL THERAPY TECHNIQUES (E.G., MOBILIZATION/ MANIPULATION, MANUAL THERAPEUTIC ACTIVITIES, DIRECT (ONE ON ONE) PATIENT CONTACT BY THE SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND WORK HARDENING/CONDITIONING; INITIAL 2 HOURS PHYSICAL PERFORMANCE TEST OR MEASUREMENT (E.G., MUSCULOSKELETAL, PROSTHETIC TRAINING, UPPER AND/OR LOWER EXTREMITY(S), EACH 15 MINUTES UNLISTED PHYSICAL MEDICINE/REHABILITATION SERVICE OR PROCEDURE OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF

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APPENDIX C Wound Care

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Debridement and Wound Care Outpatient Hospitals should not bill for an E&M service along with the wound care service unless a significant, separately identifiable E&M service was also provided to the patient during the same encounter. BCBSKS considers payment for nonselective wound care (97602) to always be included in payment for selective wound care (97597/ 97598) or negative pressure wound therapy (97605 / 97606) if both services are provided in the same anatomic site in one encounter. Therefore, hospitals should not bill for both services when nonselective wound care or negative pressure wound therapy at the same anatomic site in a single encounter. Hospitals may have established wound care E&M assessment codes that are billed when patients do not receive a debridement (CPT 11000-11044) or a wound care code 9759797606. This type of service is usually charged when the wound is assessed and dressings are changed without debridement or other billable wound care services provided. As noted above, an E&M should not be billed if 11000-11044 or 94597-97606 are also billed. If wound care services do not involve debridement, the facility can develop wound care E&M codes. The facility must establish criteria for billing E&M services. Wound care may be provided in physical therapy (PT) (Revenue code 0421), or for scheduled outpatients this may be done in a treatment room (Revenue code 0761). For facilities with a wound care clinic- only use revenue code 051X if a physician is involved in the clinic area, otherwise use 0760 or 0761. The following page is an example of wound care criteria that could be used in establishing documentation and billing guidelines. CPT codes 99201-99205 and 99211-99215 are subject to MAP reimbursement. Surgical debridement codes that fall into the debridement section of CPT are also MAP'd. Before a facility determines to bill wound care services as a series account, there should be consideration given to the CPT codes that will be used on the claim and whether those codes are paid at the claim level or the line level as is indicated in the MAP listing. It may be necessary to file each date of service separately to assure proper reimbursement on these accounts. Inpatient Charges for non rountiene debridement and wound care provided by a physician or nurse practioner at the bedside should be billed on a CMS 1500 claim form. There would be no facility charge billable for the care. Contains Public Information Revision Date: March 31, 2009 251

Wound Care CPT Codes 97597 Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area greater than 20 square centimeters Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, and abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters Negative pressure wound therapy (e.g., vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters

97598

97602

97605

97606

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New Patient

Est. Patient

E&M Level

Interventions

Description

99201

99211

Low

Wound care management, no procedure or no HBO ­ up to 10 sq. cm. Usually 510 minutes nursing time. Wound care management, no procedure or no HBO ­ up to 11-25 sq. cm. Usually 15-20 minutes nursing time. Wound care management, no procedure or no HBO­ 26-50 sq. cm. Usually 2535 minutes nursing time. Wound care management, no procedure or no HBO ­ 51-75 sq. cm. Usually 4060 minutes nursing time. Wound care management, no procedure or no HBO ­ 76 sq. cm. or greater. Usually >60 minutes nursing time.

Includes cleansing, assessment, measurement, phot index, and/or dressing of wound. Includes steristrips patch, butterflies. Note: For multiple wounds, add the total size of all w

99202

99212

Low

Includes cleansing, assessment, measurement, phot index, and/or dressing of wound. Includes steristrips patch, butterflies. Note: For multiple wounds, add the total size of all w

99203

99213

Mid

Includes cleansing, assessment, measurement, phot index, and/or dressing of wound. Includes steristrips patch, butterflies. Note: For multiple wounds, add the total size of all wo

99204

99214

High

Includes cleansing, assessment, measurement, phot index, and/or dressing of wound. Includes steristrips patch, butterflies. Note: For multiple wounds, add the total size of all wo

99205

99215

High

Includes cleansing, assessment, measurement, phot index, and/or dressing of wound. Includes steristrips patch, butterflies. Note: For multiple wounds, add the total size of all wo

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Information

REVENUE

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