Health Information Management

HCPCS and bundling procedures

APCs Insider, March 26, 2003

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March 21, 2003
Vol. 4, No. 11

Disheartening Day

According to German researchers, the risk of heart attack is higher on what day of the week?

The answer will appear in next week's APC Weekly Monitor, or be one of the first five to e-mail the correct answer and win HCPro's own "The Official Coding Coach Play Book!" Congratulations to the many correct answers last week.

The only bone in the human body not connected to another is the HYOID, a V-shaped bone at the base of the tongue between the mandible and the voice box.

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Keith Siddel,
MBA, PhD (c),
president, CEO
HRM, Hospital Resource Management

Cheryl D'Amato,
director health information management
HSS, Inc.

Julie Downey,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,

Julia R. Palmer
Health Information Management Division of HRM

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System





Turn it on

CMS is lifting the moratorium on OPPS OCE Edit 15, service unit out of range, according to PM A-03-019.

FIs must reactivate OPPS OCE Edit 15 for claims with dates of service on or after April 1, 2003. Providers should be aware that while the edit will be back on, it will only be applied to a limited number of services, which CMS has not disclosed.

"CMS is phasing Edit 15 back in," says Jugna Shah, MPH, president of Nimitt Consulting, St. Paul, MN, but since the edit won't be applied to all services, providers won't be able to rely on OCE output to determine whether they've done something wrong or right. Therefore, providers should focus on reporting all their services accurately and completely each time.

CMS will follow up with modifications to the edit in upcoming OPPS OCE releases. CMS' goal is to eventually allow OCE Edit 15 to operate the way it was intended before it was turned off in October of 2001.

The PM A-03-019 also announces that hospitals may report Low Osmolar Contrast Media (LOCM) Procedures using HCPCS codes A4644, A4645, and A4646 for services furnished on or after April 1, 2003.

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HCPCS, bundling procedures, and edits


Our compliance auditor states that we cannot charge for IV infusion (Q0081) if the patient is receiving just the normal saline or D5W. It was our impression as ER nurses that we were to charge for this as an IV infusion. Could you clarify this for us?

Click for the expert's answer.


Know your modifiers

Question: How should we handle the HCPCS code and charge for procedures that are bundled? When we get an edit that says the procedure is bundled and we don't feel a -59 modifier is appropriate, should we delete the HCPCS code or remove the charge from the bill?

My logic is as follows: If a procedure is mutually exclusive, then we should remove the charge. If it's a component of a procedure, we should remove the HCPCS code and let the charge stay on the bill (since the procedure charge doesn't include the charges for the component procedure). We would apply this logic to all patients since we don't want to lose the reimbursement for this charge for those insurance carriers that pay us a percentage of charges.

Answer: This is a common dilemma facing providers since in some software programs the HIM department cannot see the chargemaster codes, let alone make a change to the charge.

Based upon your scenario, we are assuming that you can see the charges that are hardcoded in the CDM and that your staff can edit them.

If this is the case, we agree with your logic regarding mutually exclusive procedures and disagree with your opinion regarding components.

If a procedure is mutually exclusive, another charge encompasses the services described by the first charge. In this instance, we agree that one of the charges should be removed from the claim. Which charge should be removed should be based on research. Do not make an arbitrary determination.

If a procedure is a component of a more comprehensive procedure, we do not agree that the HCPCS code should be removed and the charge be left on the claim.

  • First of all, the claim may still edit out from the claims editing software because the revenue code may require a HCPCS code.

  • Second, many commercial payers will have the same restrictions about paying for component procedure codes and they may actually OVER pay you in the interim.

  • Thirdly, the procedure charge should reflect the full cost of the procedure. CMS relies upon claims submitted to determine what the costs of the procedures are for providers. It can't determine the cost if one procedure is charged with the HCPCS code and the other is charged without a HCPCS code.

    For this reason, the charge structure should indicate both when a procedure is performed independently and when it is performed in conjunction with a component procedure.

This can be accomplished in two ways.

1. Add the charge to the comprehensive procedure code and HCPCS code. Do not leave the charge and revenue code without the HCPCS on the claim.

2. If the procedure is always performed the same way in the same department, increase the comprehensive procedure charge in the CDM to account for the component procedure. Charge all payers consistently, including when NCCI edits occur, as in these examples.

Keith Siddel, Julie Downey, Carole Gammarino and Valerie Rinkle contributed to this week's answer.

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.



Who is responsible for coding injections and infusions at your facility?

Have you given those staff members enough training and the tools they need to do their jobs? Are you getting reimbursed the appropriate amount for the work you do?

We can help you determine the answers. Join us for a live audioconference, "Coding and Billing for Injections and Infusions: Tough Issues, Easy Answers" on Thursday, March 27 beginning at 1 p.m. Eastern.

For more information or to register, CLICK HERE, or call our customer service department at 800-650-6787. Be sure to mention source code EZ8536D.

Is your heart in your cardiology coding?

Cardiology is probably an important component on your facility's menu of patient services; it has a huge impact on the bottom line because of the high dollar volume involved.

Click here to find out more about the April 11 live audioconference, "APCs for Outpatient Cardiology Procedures: How to Correctly Code to Get the Money You Deserve." If you'd prefer, call our Customer Service Team at 800/650-6787 and mention source code EZ9066C. We're saving a seat at the audioconference table for you!

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