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Note from Hugh

Medicare Weekly Update, February 12, 2008

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As previously reported in the January 2 Medicare Weekly Update, CMS recently issued a frequently asked question (ID 8813) in which CMS stated:

"Exclusion of CCI edits for critical care or other services under the OPPS does not imply that reporting the affected code pairs under the OPPS is appropriate. Hospitals should follow the CPT code descriptors and guidance, and utilize any additional CMS guidance, in reporting services."

Although not entirely clear, this language seems to suggest that CMS is now taking the position that hospitals may not separately bill for services identified by the CPT Manual as included in critical care services when the additional services were provided in conjunction with critical care services. This is very controversial because it seems to represent a fundamental change in CMS policy with regard to the application of the CPT critical care bundling guidelines to hospitals.

On the January 31 call, CMS addressed this issue once again, stating that "the absence of a CCI [correct coding initiative] edit does not mean that code pairs are appropriate for reporting" and that "it would be inappropriate to separately report a service which CPT or CMS guidance specifically indicates is included in the base code." With respect to critical care services in particular, CMS stated that it is "inappropriate to separately report those services that the CPT guidelines specifically indicate are included in the reporting of the critical care code."

Where does this statement leave hospitals? It appears that CMS's position is that hospitals must follow all CPT bundling guidelines, even in the absence of any applicable CCI edits, unless CMS guidance specifically states that a particular CPT guideline is not applicable to hospitals.

Issues 2: Billing for administration of Erythropoiesis Stimulating Agents (ESAs)

In response to a question from a caller, CMS stated that when there are two more ESA administrations during the same month for the same patient, the most recent hematocrit or hemoglobin levels must be reported "per administration." The CMS representative went on to say that this means that "you cannot use a monthly bill for multiple administrations." However, the CMS representative also stated that CMS "[does] not have complete resolution on how this will work."

If CMS requires each ESA administration to be billed separately, this could have a significant operational effect on those hospitals that bill monthly for outpatient oncology services.

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