Health Information Management

Q/A: Addendum B as the basis for coverage

APCs Insider, January 4, 2013

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Q: In the 2013 OPPS Addendum B, when we look up a specific CPT® code, it shows status indicator T with national payment.  Does this mean it is a covered procedure and CMS will pay for it?  

A: CMS Transmittal 2611, January 2013 Update of the Hospital OPPS regarding coverage states:
 
 
 
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.
                                                           
Refer to you MAC and Local Coverage Determinations to determine coverage of procedures, tests, and services where applicable. Do not use Addendum B as the basis for coverage under the OPPS program.
 
Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



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