Health Information Management

Q/A: Payment for items in OPPS Addendum B

APCs Insider, April 20, 2012

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Q: Why is our MAC denying payment for certain items that have a payment amount listed in OPPS Addendum B? We reported the correct number of units, the correct HCPCS code, and the provider documented providing the item to the patient. Why didn’t we receive payment for it?

A: You don’t specify the item or items involved, so it is unclear whether a National Coverage Determination or Local Coverage Determination is affecting the claims processing. Addendum B describes the payment status for items, tests, procedures, and services provided under OPPS and the payment amount if applicable under OPPS.

Addendum B doesn’t address the medical necessity of an item, test, procedure, or service. Payment decisions are based on medical necessity, which trumps a payable status indicator.

Transmittal 2418 reminds hospitals:

The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by the Medicare program, but indicates only how the product, procedure, or service may be paid if covered by the program. Fiscal Intermediaries (FIs)/Medicare Administrative Contractors (MACs) determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, FIs/MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.



Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Most Popular