Outpatient dialysis codes change

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August 1, 2003
Vol. 4, No. 30

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Outpatient dialysis codes change

Back up the coding truck! CMS has changed the codes for physician services for outpatient acute hemodialysis services, retroactive to January 1, 2003. Claims from that date on should be processed using codes 90935 and 90937. These codes were originally used only for inpatient services.

The change becomes effective Oct. 1, 2003, says CMS'Transmittal 1810, which provides changes to the Carriers Manual, Part 3 Claims Process.

Payment is bundled for all E/M services that are related to the patients' renal disease and provided on the same date as the dialysis. Use codes 90935 and 90937, and for all non-hemodialysis procedures use 90945 and 90947.

However, the following E/M services can be reported separately if they are performed on the same date as dialysis and are unrelated to the dialysis. Use modifier -25 with these services and make sure they are separately identifiable and meet any medical necessity requirements.

• 99201-99205: Office or Other Outpatient Visit for a New Patient

• 99211-99215: Office or Other Outpatient Visit for an Established Patient

• 99221-99223: Initial Hospital Care for a New or Established Patient

• 99238-99239: Hospital Discharge Day Management Services

• 99241-99245: Office or Other Outpatient Consultations, New or Established Patient

• 99251-99255: Inpatient Consultations, New or Established Patient

• 99291-99292: Critical Care Services

Your APCs Weekly Monitor is a free weekly e-zine from HCPro, publisher of Briefings on APCs, the monthly newsletter devoted entirely to managing under APCs, and the newsletter, APC Answer Letter, with answers to readers' questions about coding for APCs.

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Question: If we pre-mix a medication for a patient and it is not administered can we still bill it? Does the answer change if the patient expires, or if the patient cannot receive the medication due to clinical complications? What if the patient simply fails to show up for their scheduled outpatient visit? Finally, does it matter if the patient is an inpatient or outpatient?

Answer: If the provider premixes a medication in anticipation of a patient's visit and the patient is not seen, it cannot be billed to their payer regardless of the reason.

If the patient is in the facility (inpatient or outpatient) and the medication is mixed immediately prior to the administration and for clinical reasons it cannot be administered, it should be wasted, recorded in the patient's account and billed to the payer. The same would be true if the patient expired immediately prior to administration.

Providers typically encounter problems when medications are mixed many hours or days in advance. The fact that the medication was mixed and cannot be used for another patient does not make it billable.

Recently, a Medicare FI in Tennessee provided this information:

• The smallest vial manufactured is the medically necessary unit, not the smallest vial present in the facility.

• Facility convenience may not be a consideration in determining medical necessity. For example, if the order is for a 100 mg dose of a drug and the drug is manufactured in vials of 250 mg and 500 mg, it would be appropriate for the facility to bill for the 250 mg vial, wasting 150mg. It would not be appropriate for the facility to bill the 500mg vial, wasting 400 mg.

• The facility should reduce wastage by scheduling patients together who will need the same drug that is manufactured in larger than needed vials.

  For example, if one patient comes in requiring 200 mg of a 500 mg vial and another patient routinely comes in for a dose of 200 mg of the same drug, the facility should schedule these patients' appointments near the same time.

  With this process, the first patient will be charged for 200 mg and the second patient will be charged for 300 mg (the remaining amount in the vial). The documentation for the second patient would explain the wastage of 100 mg.) Insured patients are billed the same way.

As always, our APC experts encourage you to check with your own FI for rulings in effect in your area.

Coding and Compliance Feature Article of the Month: Use official coding guidelines for general rules, create facility-specific guidelines for consistency

Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.

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