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New CMS Transmittal 557 updates drug administration

APCs Weekly Monitor, May 13, 2005

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New CMS Transmittal 557 updates drug administration

QUESTION: Do you expect any forthcoming guidance on our unanswered questions from CMS Transmittal 404 ("January OPPS Update: Changes to Coding and Payment for Drug Administration")?

ANSWER: Yes, it's here. CMS last Friday, May 6 released Transmittal 557 ("Clarifying Manual Instructions for Coding and Payment for Drug Administration under the OPPS"). This new policy updates Medicare's rules for hospital drug administration. Note that this Transmittal does not replace Transmittal 404, but clarifies and adds to it.

Go to the following Web site (www.cms.hhs.gov/manuals/pm_trans/R557CP.pdf) to read the Transmittal.

Jugna Shah, MPH, president of Nimitt Consulting in St. Paul, MN provides a recap of some of the most significant information released in this guidance, with all changes effective June 1, 2005:

1. Providers are limited to reporting a maximum of eight units of service for eight additional hours for each of the add-on infusion codes. If the infusion is greater than nine hours, you must report it with an additional add-on code.

For example, for a 12 hour infusion, report one unit of the first hour code, eight units of the add-on code, and three units of the same add-on code again on a separate line item.

2. CMS clarified the use of modifier -59, which you should report only when multiple separate encounters for the same service occur on the same day.

CMS uses the language "the same HCPCS code" instead of "the same service," but this appears to mean the same or similar service in terms of similar HCPCS codes grouping to the same APC. Shah notes that CMS has been asked to clarify whether it means the same service, or the same or similar service in terms of similar HCPCS codes grouping to the same APC (i.e., the 10 CPT chemotherapy injection codes all group to APC 116).

If you don't report modifier -59, the OCE collapses the multiple billed units into one payable unit. "The use of modifier -59 lets CMS know two things: First, that multiple separate encounters occurred on the same date of service, and second, that the same or similar service was provided," Shah says.

Though these services might group to the same APC, the use of modifier -59 lets CMS know that multiple payments should be made, subject to the unit limits provided in the table in the Transmittal.

3. CMS states that providers must bill a short duration infusion (one that lasts 15 minutes or less) using an appropriate push code (e.g. 96408, 96420, 90783, 90784). This is consistent with the guidance released for physicians. "Nursing staff may be very uncomfortable with charging an injection service when an infusion was clearly provided, despite the fact that it was of short duration," says Shah.

You can only bill the first hour infusion codes if the infusion service exceeds 15 minutes. For example, if you infuse an anti-emetic over 10 minutes, report it with CPT code 90784.

4. CMS also clarified that you cannot report the add-on infusion codes until more than 30 minutes have passed. This means that you must provide an infusion of greater than 90 minutes before you can bill any of the add-on infusion codes. For example, if a patient receives a 75 minute infusion, you can only report the first hour code.

The Transmittal contains other information and many examples that you should carefully review.

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