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Chiropractic Modalities

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• Physical Medicine and Rehabilitation

• CPT Code Description


The application of a modality that does not require direct (one-on-one) patient contact by the provider is as follows:

• 64550 Application of surface (transcutaneous) neuro stimulator

• 97012 Traction, mechanical

• 97014 Electrical stimulation (unattended)

• 97016 Vasopneumatic devices

• 97018 Paraffin bath

• 97022 Whirlpool

• 97024 Diathermy (e.g., microwave)

• 97028 Ultraviolet


Constant Attendance Modalities

The application of a modality that requires direct (one-on-one) patient contact by the provider is as follows:

97032 Electrical stimulation (manual)

97033 Iontophoresis

97034 Contrast baths

97035 Ultrasound

97036 Hubbard tank

Therapy and Acupuncture CPT code list

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Therapeutic Procedures

Physician or therapist required to have direct (one-on-one) patient contact. The therapeutic procedures, for one or more areas, each 15 minutes interval is as follows:

• 97110 Therapeutic exercises to develop strength and endurance, range of motion and flexibility

• 97112 Neuromuscular reeducation of movement, balance, coordination, kinesthetic senses, posture, and/or proprioception for sitting and/or standing activities

• 97113 Aquatic therapy with therapeutic exercises

• 97116 Gait training (includes stair climbing)

• 97124 Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

• 97140 Manual therapy techniques, one or more regions, each 15 minutes

• 97150 Therapeutic procedure(s), group (2 or more individuals)

• 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

• 97535 Self-care/home management training (e.g., ADL), each 15 minutes


Tests and Measurements (Requires direct on-on-one patient contact)

• 97750 Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes

• Orthotic Management and Prosthetic Management

• 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes

• 97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes


Acupuncture

• 97810 Without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

• 97811 Without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)

• 97813 With electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

• 97814 With electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)


Florida Blue reserves the right to change the contents of the listing in accordance with revisions to industry standards, AMA/CPT guidelines, and with normal annual fee schedule coding updates.

CPT code 10060 , 10061 With ICD code

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Coverage Indications, Limitations, and/or Medical Necessity

An abscess is a cavity containing pus surrounded by inflamed tissue. It is generally associated with pain, swelling and erythema. An abscess often requires incision and drainage to remove the purulent material in order for healing to occur.

Procedure codes 10060 and 10061 represent incision and drainage of an abscess involving the skin, subcutaneous and/or accessory structures. This includes the following types of abscess: furuncle, carbuncle, suppurative hidradenitis, an abscessed cyst, an abscessed paronychia, and/or other abscess involving the cutaneous and/or subcutaneous structures.

The use of incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures will be considered to be medically reasonable and necessary for the treatment of a symptomatic abscess (e.g. inflamed, painful, tender) involving these structures. This includes the incision and drainage of the following types of abscess:

furuncle;

carbuncle;

suppurative hidradenitis;

an abscessed cyst;

an abscessed paronychia; and/or

other abscess of cutaneous and/or subcutaneous structures.

It would not generally be expected to see incision and drainage of an abscess of the skin, subcutaneous and/or accessory structures to be repeated frequently and/or multiple times. If frequent repeated incision and drainage is required, the medical record must reflect the reason for persistent/recurrent abscess formation, as well as any measures taken to prevent reoccurrence.

CPT/HCPCS Codes

10060Drainage of skin abscess
10061Drainage of skin abscess


ICD-10 Codes that Support Medical Necessity

K13.0Diseases of lips
L02.01Cutaneous abscess of face
L02.02Furuncle of face
L02.03Carbuncle of face
L02.11Cutaneous abscess of neck
L02.12Furuncle of neck
L02.13Carbuncle of neck
L02.211Cutaneous abscess of abdominal wall
L02.212Cutaneous abscess of back [any part, except buttock]
L02.213Cutaneous abscess of chest wall
L02.214Cutaneous abscess of groin
L02.215Cutaneous abscess of perineum
L02.216Cutaneous abscess of umbilicus
L02.221Furuncle of abdominal wall
L02.222Furuncle of back [any part, except buttock]
L02.223Furuncle of chest wall
L02.224Furuncle of groin
L02.225Furuncle of perineum
L02.226Furuncle of umbilicus
L02.231Carbuncle of abdominal wall
L02.232Carbuncle of back [any part, except buttock]
L02.233Carbuncle of chest wall
L02.234Carbuncle of groin
L02.235Carbuncle of perineum
L02.236Carbuncle of umbilicus
L02.31Cutaneous abscess of buttock
L02.32Furuncle of buttock
L02.33Carbuncle of buttock
L02.411Cutaneous abscess of right axilla
L02.412Cutaneous abscess of left axilla
L02.413Cutaneous abscess of right upper limb
L02.414Cutaneous abscess of left upper limb
L02.415Cutaneous abscess of right lower limb
L02.416Cutaneous abscess of left lower limb
L02.421Furuncle of right axilla
L02.422Furuncle of left axilla
L02.423Furuncle of right upper limb
L02.424Furuncle of left upper limb
L02.425Furuncle of right lower limb
L02.426Furuncle of left lower limb
L02.431Carbuncle of right axilla
L02.432Carbuncle of left axilla
L02.433Carbuncle of right upper limb
L02.434Carbuncle of left upper limb
L02.435Carbuncle of right lower limb
L02.436Carbuncle of left lower limb
L02.511Cutaneous abscess of right hand
L02.512Cutaneous abscess of left hand
L02.521Furuncle right hand
L02.522Furuncle left hand
L02.531Carbuncle of right hand
L02.532Carbuncle of left hand
L02.611Cutaneous abscess of right foot
L02.612Cutaneous abscess of left foot
L02.619Cutaneous abscess of unspecified foot
L02.621Furuncle of right foot
L02.622Furuncle of left foot
L02.631Carbuncle of right foot
L02.632Carbuncle of left foot
L02.811Cutaneous abscess of head [any part, except face]
L02.818Cutaneous abscess of other sites
L02.821Furuncle of head [any part, except face]
L02.828Furuncle of other sites
L02.831Carbuncle of head [any part, except face]
L02.838Carbuncle of other sites
L02.91Cutaneous abscess, unspecified
L02.92Furuncle, unspecified
L02.93Carbuncle, unspecified
L03.011Cellulitis of right finger
L03.012Cellulitis of left finger
L03.019Cellulitis of unspecified finger
L03.031Cellulitis of right toe
L03.032Cellulitis of left toe
L03.039Cellulitis of unspecified toe
L03.111Cellulitis of right axilla
L03.112Cellulitis of left axilla
L03.113Cellulitis of right upper limb
L03.114Cellulitis of left upper limb
L03.115Cellulitis of right lower limb
L03.116Cellulitis of left lower limb
L03.211Cellulitis of face
L03.221Cellulitis of neck
L03.311Cellulitis of abdominal wall
L03.312Cellulitis of back [any part except buttock]
L03.313Cellulitis of chest wall
L03.314Cellulitis of groin
L03.315Cellulitis of perineum
L03.316Cellulitis of umbilicus
L03.317Cellulitis of buttock
L03.811Cellulitis of head [any part, except face]
L03.818Cellulitis of other sites
L03.90Cellulitis, unspecified
L73.2Hidradenitis suppurativa
N48.21Abscess of corpus cavernosum and penis
N48.22Cellulitis of corpus cavernosum and penis
N48.29Other inflammatory disorders of penis
N61Inflammatory disorders of breast

Billing Guidelines for Dialysis center

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Dialysis Centers

Outlined below are generally accepted billing guidelines. This is intended to be illustrative and is not an all-inclusive list.

• Indicate “72X” type of bill. The third digit is based on the type of claim (interim, corrected, etc.).

• Hospital inpatient dialysis departments should bill with their hospital provider number and will be paid under the hospital agreement.

• Bill one claim per calendar month except when training is provided or when hemodialysis is performed in the same month as peritoneal dialysis.

• Do not submit claims that cross over from one month to the other. For example, service dates in January should be on one claim and service dates in February should be on another claim.

• Bill a line item date of service for each revenue code billed on the claim form.

• Revenue codes should be listed in ascending numeric order by date of service and line item billed.

• Bill a separate line item for each dialysis session performed.

• Separately billable drugs, including EPO should be line item billed. Include the line item date of service for the administration. Reimbursement will be calculated based on the units reported on the line.

• The units reported on the line for each date dialysis (codes 821, 831, 841 and 851) was performed should not exceed one.

• Height and weight should be reported for all ESRD patients.

• A8 – Weight in kilograms

• A9 – Height in centimeters

• Report modifiers, occurrence codes, and condition codes.

• Bill must include revenue codes and CPT codes for each line of service. For example, when billing hemodialysis submit revenue code 0821 with CPT code 90999.

• The training rate includes the composite rate. Therefore, the composite rate should not be billed separately for days when training was provided.

• Do not bill for hemodialysis and peritoneal dialysis composite rates on the same claim. In this situation, you must bill a claim for each type of dialysis provided within the same calendar month. Dates of service must not overlap.


Non-contracted Medicare Advantage

The following fields are required on all Medicare Advantage claims:

• A patient’s height and weight – entered in the value amount fields for value codes A8 and A9

• CBSA – must be included in the value amount field for value code 61

BILLING Guideline for home health - 0571, 0572 revenue codes

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Home Health/Home Infusion Agencies

Florida Blue defines home health care services as those services rendered to an individual in the home by health care professionals (e.g., nurses, therapists) or paraprofessionals (e.g., home health aides, physical therapy assistants) to achieve and sustain an optimum state of health and independence for that individual. For purposes of coverage, home health care is provided on a per visit basis, generally for no more than two hours at a time.

Revenue Codes Used
• Home Health Aide
o 0571
o 0572 - hourly

• If the agency does not bill on a calendar month basis, it prepares two bills. The first covers the period ending December 31 of the old year; the second, the period beginning January 1 of the New Year.


• All services must be itemized by date of service. Enter the appropriate revenue code and date for each service rendered.

• Physical therapy, speech therapy and occupational therapy services should be billed by the visit, not by the modality or hour, unless approved by Care Coordination.

• Reimbursement for visits provided by a health care professional of differing specialties is limited to one per day for each specialty, unless documented as medically necessary.

• Some plans, including BlueCard may require medical documentation for unlisted codes, such as 99600.

• Utilization of specific codes is strongly recommended to facilitate easier claims processing.


Home Health Billing Requirements for Non-Contracted Medicare Advantage

• Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X. After October 1, 2013 home health will need to bill with Type of Bill 032X.

• Bill type "322-329"

• Health Insurance Prospective Payment System (HIPPS) code

• Treatment Authorization Code

• Core-Based Statistical Area (CBSA) must be included with value amount field for a value code 61


Billing for Infusion Services for Providers NOT participating in the CareCentrix Network:

Classified drugs must be submitted with valid CPT/HCPCS codes, HCPCS quantity, NDC Code, and NDC Quantity.

• Do not bill more than seven consecutive days on any claim line.

• Bill only primary drugs and S per diem codes related to infusion when professional nursing services are provided.

• Do not bill codes that are considered inclusive in the S per diem code.

• Corrected claims; if billing for additional dates of service or additional items, not included on the original claim, a corrected claim is required.

• Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X. After October 1, 2013 home health will need to bill with Type of Bill 032X.

• Home health providers with several provider numbers should submit the provider number of the agency that provided the care. This will ensure claims are reimbursed correctly.

• Submit both revenue and CPT/HCPCS Codes. Claims submitted without both revenue and CPT/HCPCS codes or with invalid codes will be rejected at the claim or line level.

• Bill according to CPT/HCPCS definitions to determine appropriate coding, inclusive supply and item sizing. Claim lines must be split unevenly when units exceed 9999 to prevent duplicate denials.

• Do not bill more than 15 lines or 31-days of services on the same claim. If billing for services over a span of dates, bill once for that span (after span is complete) to include all services for the dates of service on one claim. Overlapping or repeating span dates causes duplicate denials.

• The home health agency should not submit a bill/claim for an inclusive period beginning in one calendar year and extending into the next calendar year.

• A separate line item should be submitted for each per diem for each date of service. To report units per diem, one unit should be billed for each line.


Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.

Billing Multiple Infusion Therapies - Revenue code 0640, 0641, 0644

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When billing home health services to Florida Blue, revenue codes and CPT/HCPCS should be reported using the most current publications. The matrix below indicates the commonly used the revenue codes to be used in billing home health/home infusion services.

• Multiple infusion therapies apply to patients who require multiple concurrent infusion treatments including, but not limited to, multiple antibiotics, hydration and chemotherapy.

• Reimbursement for multiple medications may be allowed with payment reductions, as noted per payment policy.

• The only exception to this is aerosolized AIDS drug therapy. It is the only therapy that must be billed in conjunction with another mode of home IV therapy administration. It is also the only drug therapy that, while provided as part of a multiple-therapy treatment, can be billed as a separate service.

• Use procedure code S9061 to report aerosolized AIDS drug therapy.

NOTE: Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.


Revenue Codes Used

• General Classification Home IV Therapy

o 0640

o Non-routine nursing, central line 0641

o Site Care, central line 0642

o Start/Change, peripheral line 0643

o Routine Nursing, peripheral line 0644

• Drugs

o 0250-0252

o 0630-0636

Pulmonary Function Tests CPT code Indication

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PFTs measure two components of the respiratory system: the mechanical ability of the respiratory system to move air in and out of the lungs; and the effectiveness of the respiratory system in exchanging oxygen and carbon dioxide with the atmosphere. A PFT includes three possible components:

1. Spirometry (94010, 94060, 94070)

2. Lung Volume Determination (94250, 94726, 94727 and 94728)

Lung Volume tests cannot be measured directly using Spirometry because these volumes and capacities include air that cannot be expelled from the lungs. Lung Volume is generally determined in one of four ways:

Closed circuit helium equilibration
Open circuit nitrogen washout
Whole body plethysmography
Radiologic techniques
3. Diffusion Capacity Tests (94729)

The PFT will be considered medically necessary for the following conditions:

· Preoperative evaluation of the lungs and pulmonary reserve when:

- thoracic surgery will result in loss of functional pulmonary tissue (i.e., lobectomy) or

- patients are undergoing major thoracic and/or abdominal surgery and the physician has some reason to believe the patient may have a pre-existing pulmonary limitation (e.g., long history of smoking); or

- the patient’s pulmonary function is already severely compromised by other diseases such as chronic obstructive pulmonary disease (COPD).

· Initial diagnostic workup for the purpose of differentiating between obstructive and restrictive forms of chronic pulmonary disease. Obstructive defects (e.g., emphysema, bronchitis, asthma) occur when ventilation is disturbed by an increase in airway resistance. Expiration is primarily affected.

Restrictive defects (e.g., pulmonary fibrosis, tumors, chest wall trauma) occur when ventilation is disturbed by a limitation in chest expansion. Inspiration is primarily affected.

· To assess the indications for and effect of therapy in diseases such as sarcoidosis, diffuse lupus erythematosus, and diffuse interstitial fibrosis syndrome.

· Evaluate patient’s response to a newly established bronchodilator anti-inflammatory therapy.

· To monitor the course of asthma and the patient’s response to therapy (i.e., especially to confirm home peak expiratory flow measurements).

· Evaluate patients who continue to exhibit increasing shortness of breath (SOB) after initiation of bronchodilator anti-inflammatory therapy.

· Initial evaluation for a patient that presents with new onset (within 1 month) of one or more of the following symptoms: shortness of breath, cough, dyspnea, wheezing, orthopnea, or chest pain.

· Initial diagnostic workup for a patient whose physical exam revealed one of the following: overinflation, expiratory slowing, cyanosis, chest deformity, wheezing, or unexplained crackles.

· Initial diagnostic workup for a patient with chronic cough. It is not expected that a patient would have a repeat spirometry without new symptomatology.

· Re-evaluation of a patient with or without underlying lung disease who presents with increasing SOB (from previous evaluation) or worsening cough and related qualifying factors such as abnormal breath sounds or decreasing endurance to perform Activities of Daily Living (ADL’s).

· To establish baseline values for patients being treated with pulmonary toxic regimens (e.g., Amiodarone).

· To monitor patients being treated with pulmonary toxic regimens when any new respiratory symptoms (e.g., exertional dyspnea, non-productive cough, pleuritic chest pain) may suggest the possibility of pulmonary toxicity.

· To evaluate cystic fibrosis patients with pulmonary manifestations.

It is expected that procedure code 94070 will only be performed to make an initial diagnosis of asthma.

Also, it is expected that procedure code 94060 be utilized during the initial diagnostic evaluation of a patient. Once it has been determined that a patient is sensitive to bronchodilators, repeat bronchospasm evaluation is usually not medically necessary, unless one of the following circumstances exist:

(1) a patient is exhibiting an acute exacerbation and a bronchospasm evaluation is being performed to determine if the patient will respond to bronchodilators;

(2) the initial bronchospasm evaluation was negative for bronchodilator sensivity and the patient presents with new symptoms which suggest the patient has a disease process which may respond to bronchodilators; or

(3) the initial bronchospasm evaluation was not diagnostic due to lack of patient effort. Repeat spirometries performed to evaluate patients’ response to newly established treatments, monitor the course of asthma/COPD, or evaluate patients continuing with symptomatology after initiation of treatment should be utilized with procedure code 94010.

In addition, it is not expected that a pulse oximetry (procedure code 94760 or 94761) for oxygen saturation would routinely be performed with spirometry. Pulse oximetry is considered medically necessary when the patient has a condition resulting in hypoxemia and there is a need to assess the status of a chronic respiratory condition, supplemental oxygen and/or a therapeutic regimen (e.g., acute symptoms).

Usually during an initial evaluation, there is no reason to obtain a spirometry after the administration of bronchodilators in patients who have normal spirometry, normal flow volume loop and normal airway resistance unless there is reason to believe (e.g., symptoms, exam) that a patient has underlying lung disease.

The residual volume (RV) cannot be measured by spirometry because this includes air that cannot be expelled from the lungs, and, therefore, is determined by subtracting the expiratory reserve volume (ERV) from the functional residual capacity (FRC). The FRC cannot be measured by simple spirometry either; therefore, procedure code 94726 or 94727 will be performed when the RV and FRC need to be determined.

The Maximum Voluntary Ventilation (MVV; procedure code 94200) is a determination of the liters of air that a person can breathe per minute by a maximum voluntary effort. This test measures several physiologic phenomena occurring at the same time. The results and success of this test are effort dependent, therefore, routine performance of this test is not recommended, except in cases such as: pre-operative evaluation, neuromuscular weakness, upper airway obstruction, or suspicion of Chest Bellows disease.

The Respiratory Flow Volume Loop (procedure code 94375) is used to evaluate the dynamics of both large and medium size airways. This test is more useful than the conventional spirogram. The procedure is the same for spirometry except for the addition of a maximal forced inspiration at the end of the force expiratory measures.

Pulmonary Stress Testing (94620, 94621)

The pulmonary stress testing procedures range from simple to complex. The simple procedure (Stage 1) consists of BP, ECG, and ventilation measurements at timed increments during exercise. The complex procedure includes Stage 2 and Stage 3. Stage 2 involves all of Stage 1 measurements in addition to the mixed venous CO2 tension (production) by means of rebreathing technique and O2 uptake. Stage 3 requires the following: (a) blood gas sampling and analysis, (b) an indwelling catheter is inserted into the brachial or radial artery, and (c) in addition to Stage 2 tests, measurements for cardiac output, alveolar ventilation, ratio of dead space to tidal volume, alveolar-arterial O2 tension difference, venous admixture ratio and lactate levels are determined.

Exercise testing is done to evaluate functional capacity and to assess the severity and type of impairment of existing as well as undiagnosed conditions. The Pulmonary Stress Test will be considered medically necessary for the following conditions:

· To determine whether the patient’s exercise intolerance is related to pulmonary disease, cardiac disease, or due to lack of conditioning or poor effort.

· Initial diagnostic workup when symptoms (generally dyspnea) are out of proportion to findings on static function (spirometry, lung volume, diffusion capacity).

· Detection of interstitial lung disease (fibrosis) or exercise-induced broncho-spasm which are only manifested by exercise.

· Evaluate patient’s response to a newly established pulmonary treatment regimen.

The majority of clinical problems can be assessed during the simple procedures included in Stage 1, and should be completed before more complex tests are performed. Abnormal results indicate that more precise information is required through more complex Stage 2 protocols. If Stage 3 protocols are implemented, arterial blood analysis is necessary. In 75% of patients, Stage 1 is sufficient. Oxygen titration can be done during graded exercise to determine the oxygen needs for improving exercise tolerance and increased functional capacity.

Absolute contraindications to exercise testing include:

· Acute febrile illness

· Pulmonary edema

· Systolic BP > 250mm Hg

· Diastolic BP > 120mm Hg

· Acute asthma attack

· Unstable angina

· Acute Myocarditis

Lung Compliance (94750)

Lung compliance measures the elastic recoil or stiffness of the lungs. It is more invasive than other PFTs, because the patient is required to swallow an esophageal balloon.

Compliance studies are performed only when all other PFTs give equivocal results, or the results require confirmation by additional data.

Lab CPT codes list which can be performed by CLIA certified providers

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Providers with a CLIA certificate may conduct the following laboratory tests in their offices:

Description Codes Description Codes

Urinalysis 81000- 81003

Crystal Identification 89060

Glucose 82947- 82948

ESR 85651, 85652

Prothrombin time 85610

BM Aspiration 85097

Tuberculosis Intra-Dermal Skin Test 86580

Platelet 85007

Urine Pregnancy Test 81025

Bilirubin Direct 82248

Tissue Exam (KOH) Prep 87220

Bilirubin Total 82247

Wet Mounts 87177, 87210

Hemoglobin Glycated 83036

FOBT (Hemocult) 82270

Blood Smear 85060

Strep Test Group A 87070, 87880

Molecular Cytogenetics Chromosomal 88273


CBC 85025- 85048

Molecular Cytogenetics Interphase 88274

BUN, Creatinine 82565

Special Stains Group I 88312

Potassium 84132

Special Stains Group II 88313

Hemoglobin 85018

Clinical Pathology Consultation Limited 80500

Semen Analysis 89300 - 89320

Clinical Pathology Consultation Comprehensive 80502

Sperm Evaluation 89329

Lead Testing 83655

Cervical Mucus Penetration Test 89330

Rapid Flu Test 87804

PFT CPT 94010, 94750, 94250, 94200. 94060 AND 94010

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CPT/HCPCS Codes

Group 1 Codes
94010Breathing capacity test
94060Evaluation of wheezing
94070Evaluation of wheezing
94150Vital capacity test
94200Lung function test (MBC/MVV)
94250Expired gas collection
94375Respiratory flow volume loop
94620Pulmonary stress test/simple
94621Pulm stress test/complex
94726Pulm funct tst plethysmograp
94727Pulm function test by gas
94728Pulm funct test oscillometry
94729Co/membane diffuse capacity
94750Pulmonary compliance study

Group 2 Paragraph


Part B
Group 2 Codes
94750Pulmonary compliance study
94729Co/membane diffuse capacity
94728Pulm funct test oscillometry
94727Pulm function test by gas
94726Pulm funct tst plethysmograp
94621Pulm stress test/complex
94620Pulmonary stress test/simple
94375Respiratory flow volume loop
94250Expired gas collection
94200Lung function test (MBC/MVV)
94070Evaluation of wheezing
94060Evaluation of wheezing
94010Breathing capacity test


Group 1 Codes
B44.81Allergic bronchopulmonary aspergillosis
C33Malignant neoplasm of trachea
C34.00Malignant neoplasm of unspecified main bronchus
C34.01Malignant neoplasm of right main bronchus
C34.02Malignant neoplasm of left main bronchus
C34.10Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11Malignant neoplasm of upper lobe, right bronchus or lung
C34.12Malignant neoplasm of upper lobe, left bronchus or lung
C34.2Malignant neoplasm of middle lobe, bronchus or lung
C34.30Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31Malignant neoplasm of lower lobe, right bronchus or lung
C34.32Malignant neoplasm of lower lobe, left bronchus or lung
C34.80Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82Malignant neoplasm of overlapping sites of left bronchus and lung
C34.90Malignant neoplasm of unspecified part of unspecified bronchus or lung
C34.91Malignant neoplasm of unspecified part of right bronchus or lung
C34.92Malignant neoplasm of unspecified part of left bronchus or lung
C78.00Secondary malignant neoplasm of unspecified lung
C78.01Secondary malignant neoplasm of right lung
C78.02Secondary malignant neoplasm of left lung
C78.30Secondary malignant neoplasm of unspecified respiratory organ
C78.39Secondary malignant neoplasm of other respiratory organs
D14.2Benign neoplasm of trachea
D14.30Benign neoplasm of unspecified bronchus and lung
D14.31Benign neoplasm of right bronchus and lung
D14.32Benign neoplasm of left bronchus and lung
D57.01Hb-SS disease with acute chest syndrome
D57.211Sickle-cell/Hb-C disease with acute chest syndrome
D57.411Sickle-cell thalassemia with acute chest syndrome
D57.811Other sickle-cell disorders with acute chest syndrome
D86.0Sarcoidosis of lung
D86.1Sarcoidosis of lymph nodes
D86.2Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.3Sarcoidosis of skin
D86.81Sarcoid meningitis
D86.82Multiple cranial nerve palsies in sarcoidosis
D86.83Sarcoid iridocyclitis
D86.84Sarcoid pyelonephritis
D86.85Sarcoid myocarditis
D86.86Sarcoid arthropathy
D86.87Sarcoid myositis
D86.89Sarcoidosis of other sites
D86.9Sarcoidosis, unspecified
E84.0Cystic fibrosis with pulmonary manifestations
E84.19Cystic fibrosis with other intestinal manifestations
G02Meningitis in other infectious and parasitic diseases classified elsewhere
G47.30Sleep apnea, unspecified
I26.01Septic pulmonary embolism with acute cor pulmonale
I26.02Saddle embolus of pulmonary artery with acute cor pulmonale
I26.09Other pulmonary embolism with acute cor pulmonale
I26.90Septic pulmonary embolism without acute cor pulmonale
I26.92Saddle embolus of pulmonary artery without acute cor pulmonale
I26.99Other pulmonary embolism without acute cor pulmonale
J17Pneumonia in diseases classified elsewhere
J18.8Other pneumonia, unspecified organism
J18.9Pneumonia, unspecified organism
J20.0Acute bronchitis due to Mycoplasma pneumoniae
J20.1Acute bronchitis due to Hemophilus influenzae
J20.2Acute bronchitis due to streptococcus
J20.3Acute bronchitis due to coxsackievirus
J20.4Acute bronchitis due to parainfluenza virus
J20.5Acute bronchitis due to respiratory syncytial virus
J20.6Acute bronchitis due to rhinovirus
J20.7Acute bronchitis due to echovirus
J20.8Acute bronchitis due to other specified organisms
J20.9Acute bronchitis, unspecified
J21.0Acute bronchiolitis due to respiratory syncytial virus
J21.1Acute bronchiolitis due to human metapneumovirus
J21.8Acute bronchiolitis due to other specified organisms
J21.9Acute bronchiolitis, unspecified
J22Unspecified acute lower respiratory infection
J39.8Other specified diseases of upper respiratory tract
J40Bronchitis, not specified as acute or chronic
J41.0Simple chronic bronchitis
J41.1Mucopurulent chronic bronchitis
J41.8Mixed simple and mucopurulent chronic bronchitis
J42Unspecified chronic bronchitis
J43.0Unilateral pulmonary emphysema [MacLeod's syndrome]
J43.1Panlobular emphysema
J43.2Centrilobular emphysema
J43.8Other emphysema
J43.9Emphysema, unspecified
J44.0Chronic obstructive pulmonary disease with acute lower respiratory infection
J44.1Chronic obstructive pulmonary disease with (acute) exacerbation
J44.9Chronic obstructive pulmonary disease, unspecified
J45.20Mild intermittent asthma, uncomplicated
J45.21Mild intermittent asthma with (acute) exacerbation
J45.22Mild intermittent asthma with status asthmaticus
J45.30Mild persistent asthma, uncomplicated
J45.31Mild persistent asthma with (acute) exacerbation
J45.32Mild persistent asthma with status asthmaticus
J45.40Moderate persistent asthma, uncomplicated
J45.41Moderate persistent asthma with (acute) exacerbation
J45.42Moderate persistent asthma with status asthmaticus
J45.50Severe persistent asthma, uncomplicated
J45.51Severe persistent asthma with (acute) exacerbation
J45.52Severe persistent asthma with status asthmaticus
J45.901Unspecified asthma with (acute) exacerbation
J45.902Unspecified asthma with status asthmaticus
J45.909Unspecified asthma, uncomplicated
J45.990Exercise induced bronchospasm
J45.991Cough variant asthma
J45.998Other asthma
J47.0Bronchiectasis with acute lower respiratory infection
J47.1Bronchiectasis with (acute) exacerbation
J47.9Bronchiectasis, uncomplicated
J60Coalworker's pneumoconiosis
J61Pneumoconiosis due to asbestos and other mineral fibers
J62.0Pneumoconiosis due to talc dust
J62.8Pneumoconiosis due to other dust containing silica
J63.0Aluminosis (of lung)
J63.1Bauxite fibrosis (of lung)
J63.2Berylliosis
J63.3Graphite fibrosis (of lung)
J63.4Siderosis
J63.5Stannosis
J63.6Pneumoconiosis due to other specified inorganic dusts
J64Unspecified pneumoconiosis
J65Pneumoconiosis associated with tuberculosis
J66.0Byssinosis
J66.1Flax-dressers' disease
J66.2Cannabinosis
J66.8Airway disease due to other specific organic dusts
J67.0Farmer's lung
J67.1Bagassosis
J67.2Bird fancier's lung
J67.3Suberosis
J67.4Maltworker's lung
J67.5Mushroom-worker's lung
J67.6Maple-bark-stripper's lung
J67.7Air conditioner and humidifier lung
J67.8Hypersensitivity pneumonitis due to other organic dusts
J67.9Hypersensitivity pneumonitis due to unspecified organic dust
J68.4Chronic respiratory conditions due to chemicals, gases, fumes and vapors
J68.8Other respiratory conditions due to chemicals, gases, fumes and vapors
J68.9Unspecified respiratory condition due to chemicals, gases, fumes and vapors
J70.0Acute pulmonary manifestations due to radiation
J70.1Chronic and other pulmonary manifestations due to radiation
J70.2Acute drug-induced interstitial lung disorders
J70.3Chronic drug-induced interstitial lung disorders
J70.4Drug-induced interstitial lung disorders, unspecified
J70.5Respiratory conditions due to smoke inhalation
J70.8Respiratory conditions due to other specified external agents
J70.9Respiratory conditions due to unspecified external agent
J80Acute respiratory distress syndrome
J81.0Acute pulmonary edema
J82Pulmonary eosinophilia, not elsewhere classified
J84.01Alveolar proteinosis
J84.02Pulmonary alveolar microlithiasis
J84.09Other alveolar and parieto-alveolar conditions
J84.10Pulmonary fibrosis, unspecified
J84.111Idiopathic interstitial pneumonia, not otherwise specified
J84.112Idiopathic pulmonary fibrosis
J84.113Idiopathic non-specific interstitial pneumonitis
J84.114Acute interstitial pneumonitis
J84.115Respiratory bronchiolitis interstitial lung disease
J84.116Cryptogenic organizing pneumonia
J84.117Desquamative interstitial pneumonia
J84.17Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
J84.2Lymphoid interstitial pneumonia
J84.81Lymphangioleiomyomatosis
J84.82Adult pulmonary Langerhans cell histiocytosis
J84.89Other specified interstitial pulmonary diseases
J84.9Interstitial pulmonary disease, unspecified
J95.1Acute pulmonary insufficiency following thoracic surgery
J95.2Acute pulmonary insufficiency following nonthoracic surgery
J95.3Chronic pulmonary insufficiency following surgery
J95.821Acute postprocedural respiratory failure
J95.822Acute and chronic postprocedural respiratory failure
J95.84Transfusion-related acute lung injury (TRALI)
J96.00Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.01Acute respiratory failure with hypoxia
J96.02Acute respiratory failure with hypercapnia
J96.10Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.11Chronic respiratory failure with hypoxia
J96.12Chronic respiratory failure with hypercapnia
J96.20Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.21Acute and chronic respiratory failure with hypoxia
J96.22Acute and chronic respiratory failure with hypercapnia
J96.90Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia
J96.91Respiratory failure, unspecified with hypoxia
J96.92Respiratory failure, unspecified with hypercapnia
J98.01Acute bronchospasm
J98.09Other diseases of bronchus, not elsewhere classified
J98.11Atelectasis
J98.19Other pulmonary collapse
J98.2Interstitial emphysema
J98.3Compensatory emphysema
J98.4Other disorders of lung
J98.6Disorders of diaphragm
J98.8Other specified respiratory disorders
J99Respiratory disorders in diseases classified elsewhere
M31.0Hypersensitivity angiitis
M32.13Lung involvement in systemic lupus erythematosus
M33.01Juvenile dermatopolymyositis with respiratory involvement
M33.11Other dermatopolymyositis with respiratory involvement
M33.21Polymyositis with respiratory involvement
M33.91Dermatopolymyositis, unspecified with respiratory involvement
M34.81Systemic sclerosis with lung involvement
M35.02Sicca syndrome with lung involvement
R04.2Hemoptysis
R04.89Hemorrhage from other sites in respiratory passages
R04.9Hemorrhage from respiratory passages, unspecified
R05Cough
R06.00Dyspnea, unspecified
R06.01Orthopnea
R06.02Shortness of breath
R06.09Other forms of dyspnea
R06.2Wheezing
R06.3Periodic breathing
R06.81Apnea, not elsewhere classified
R06.82Tachypnea, not elsewhere classified
R06.83Snoring
R06.89Other abnormalities of breathing
R09.2Respiratory arrest
R91.1Solitary pulmonary nodule
R91.8Other nonspecific abnormal finding of lung field
Z01.811Encounter for preprocedural respiratory examination
Z51.81Encounter for therapeutic drug level monitoring

Inpatient Care in SNF - Revenue code 0191 - 0194

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Type of bill (211-214)

Revenue code (0191-0194, 0199)

• Level 1 (Revenue Code 0191)

• Level 2 (Revenue Code 0192)

• Level 3 (Revenue Code 0193)

• Level 4 (Revenue Code 0194)

• Level 5 (Revenue Code 0199)

• All per diem rates will include, but may not be limited to the following services:

• Semi-private room

• Meals (including special dietary requirements)

• Skilled nursing care

• Case management

• Medication and pharmacy supplies

• Routine laboratory

• Routine radiology (except when excluded based on the terms of the agreement)

• Nutrition services (including enteral feedings)

• Administration of medications including intramuscular and intravenous services

• Medical supplies

• Discharge planning

• DME (excluding specialized/high cost DME*)

• Quality assessment and improvement programming

• Occupational, physical and speech therapy


All codes billed other than the per diem revenue codes (0191-0194, 0199) will be denied as included in the per diems rates. If the referenced per diem revenue codes are not submitted on the claim, the claim will be denied. Exceptions include outliers, instances where Blue Plan coverage is secondary to Medicare and other specific instances defined in the member’s contract.

Participating SNFs can coordinate select medications with one of the pharmacy providers that are part of the SNF select medication program. These pharmacy providers will bill and be reimbursed directly for these services. Please refer to the Skilled Nursing Facility Select Medication Program section program details. Any services not included in the per diem rate should be delivered and billed by participating providers outside the SNF. Contact Care Coordination for a list of participating providers for these services.

*Certain DME may be considered Custom DME due to its modification for use by a particular member. The term Custom DME shall mean equipment that is significantly altered or uniquely manufactured to meet the specific needs of an individual member according to the description and orders a physician or licensed practitioner whose license permits such practitioner to order Custom DME.

CPT CODE 99183 AND G0277 - COVERAGE AND ICD code

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Coverage Indications, Limitations, and/or Medical Necessity


Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere (atm) pressure. Either a mono-place chamber pressurized with pure O2 or a larger multi-place chamber pressurized with compressed air where the patient receives pure O2 by mask, head tent, or endotracheal tube may be used.

Hyperbaric Oxygen Therapy serves four primary functions:

It increases the concentration of dissolved oxygen in the blood, which augments oxygenation to all parts of the body; and
It replaces inert gas in the bloodstream with oxygen, which is then metabolized by the body; and
It may stimulate the formation of a collagen matrix and angiogenesis; and
It acts as a bactericide for certain susceptible bacteria.

Developed as treatment for decompression illness, this modality is an established therapy for treating medical disorders such as carbon monoxide poisoning, gas gangrene, acute decompression illness and air embolism. HBO is also considered acceptable as adjunctive therapy in the treatment of sequelae of acute vascular compromise and in the management of some disorders that are refractory to standard medical and surgical care or the result of radiation injury.

Covered Conditions: 

Program reimbursement for HBO therapy is limited to the following conditions:

Acute carbon monoxide intoxication,
Decompression illness,
Gas embolism,
Gas gangrene,
Acute traumatic peripheral ischemia. HBO therapy is a valuable adjunctive treatment to be used in combination with accepted standard therapeutic measures when loss of function, limb, or life is threatened.
Crush injuries and suturing of severed limbs. As in the previous conditions, HBO therapy would be an adjunctive treatment when loss of function, limb, or life is threatened.
Progressive necrotizing infections (necrotizing fasciitis),
Acute peripheral arterial insufficiency,
Preparation and preservation of compromised skin grafts (not for primary management of wounds),
Chronic refractory osteomyelitis, unresponsive to conventional medical and surgical management,
Osteoradionecrosis as an adjunct to conventional treatment,
Soft tissue radionecrosis as an adjunct to conventional treatment,
Cyanide poisoning,
Actinomycosis, only as an adjunct to conventional therapy when the disease process is refractory to antibiotics and surgical treatment,
Diabetic wounds of the lower extremities in patients who meet the following three criteria:

a.Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
b.Patient has a wound classified as Wagner grade III or higher; and
c.Patient has failed an adequate course of standard wound therapy.


The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 –days of treatment with standard wound therapy and must be used in addition to standard wound care. Standard wound care in patients with diabetic wounds includes: assessment of a patient’s vascular status and correction of any vascular problems in the affected limb if possible, optimization of nutritional status, optimization of glucose control, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, appropriate off-loading, and necessary treatment to resolve any infection that might be present. Failure to respond to standard wound care occurs when there are no measurable signs of healing for at least 30 consecutive days. Wounds must be evaluated at least every 30 days during administration of HBO therapy. Continued treatment with HBO therapy is not covered if measurable signs of healing have not been demonstrated within any 30-day period of treatment.

Limitations

Topical Application of Oxygen

This method of administering oxygen does not meet the definition of HBO therapy as stated above, as its clinical efficacy has not been established. Therefore, Medicare considers the topical application of oxygen not reasonable and necessary. Medicare reimbursement will be limited to therapy that is administered in a chamber (including single or multi-place units)


CPT/HCPCS Codes

99183Hyperbaric oxygen therapy
G0277Hbot, full body chamber, 30m

Covered ICD-10 diagnoses codes may be downloaded at:
https://www.cms.gov/Medicare/Coverage/DeterminationProcess/downloads/CR9252.zip, choose the spreadsheet 20.29 HBO Therapy.

Revenue code list with description

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The following chart identifies revenue codes that require a specific CPT/HCPCS code in field 44 of the UB-04.

Revenue Code        Description           CPT/HCPCS Code

0300 - 0309        Laboratory – Clinical Diagnostic      Code for lab procedure performed

0310 - 0319      Laboratory - Pathology     Code for pathology procedure performed

0320 - 0329           Radiology - Diagnostic      Code for radiology procedure performed

0333                Radiology - Therapeutic   Code for therapeutic radiology procedure performed

0340 - 0349            Nuclear Medicine        Code for nuclear medicine procedure performed

0350 - 0359          CT Scan          Code for CT scan performed

0360 - 0369       Operating Room Services     Code for surgery procedure performed

0400 - 0409       Other Imaging Services     Code for imaging services, such as, mammography, ultrasound, PET, etc.

0450 - 0459         Emergency Room             Code for visit or surgery procedure performed

0460 - 0469              Pulmonary Function        Code for pulmonary function procedure performed

0471                   Audiology                  Code for audiology service performed

Urgent Care Centers CPT code list

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Urgent Care Centers (UCCs0 are the delivery of ambulatory care in a facility dedicated to unscheduled, walk-in care outside a hospital emergency department.

Billing Requirements

• Place of service "11" or "20"

• UCCs are reimbursed based on the following E/M CPT codes per the provider’s agreement:

o Level 1

° 99201

° 99202

° 99211

° 99212

o Level 2

° 99203

° 99213

o Level 3

° 99204

° 99205

° 99214

° 99215

• UCCs should itemize all services rendered to the member, including the E/M code.

• To ensure appropriate reimbursement when rendering additional services (i.e., sutures, basic diagnostics, imaging and laboratory tests), the modifier 25 should be applied to the appropriate E/M code.

CPT CODE G0296, G0297 COVERAGE and payment Guide

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Health Care Common Procedure Coding System (HCPCS) Codes

Effective for claims with dates of service on and after February 5, 2015, the following HCPCS codes are used for lung cancer screening with LDCT:


** G0296 – Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan (service is for eligibility determination and shared decision making)


** G0297 – Low dose CT scan (LDCT) for lung cancer screening


In addition to the HCPCS code, these services must be billed with ICD-10 diagnosis code Z87.891 (personal history of tobacco use/personal history of nicotine dependence), ICD-9 diagnosis code V15.82.


NOTE: Contractors shall apply contractor-pricing to claims containing HCPCS G0296 and G0297 with dates of service February 5, 2015, through December 31, 2015. 

CMS reviewed the evidence for lung cancer screening with low dose computed tomography (LDCT) and determined that the criteria listed above were met, enabling CMS to cover this “additional preventive service” under Medicare Part B.

CMS issued NCD 210.14 on August 21, 2105, that provides for Medicare coverage of screening  for lung cancer with LDCT. Effective for claims with dates of service on and after February 5, 2015, Medicare beneficiaries must meet all of the following criteria:

** Be 55–77 years of age;
** Be asymptomatic (no signs or symptoms of lung cancer);
** Have a tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 pack = 20 cigarettes);
** Be a current smoker or one who has quit smoking within the last 15 years; and,
** Receive a written order for lung cancer screening with LDCT that meets the requirements described in the NCD.

Written orders for lung cancer LDCT screenings must be appropriately documented in the beneficiary’s medical record, and must contain the following information:

** Date of birth;
** Actual pack–year smoking history (number);
** Current smoking status, and for former smokers, the number of years since quitting smoking;
** A statement that the beneficiary is asymptomatic (no signs or symptoms of lung cancer); and,
** The National Provider Identifier (NPI) of the ordering practitioner.


Counseling and Shared Decision-Making Visit

Before the first lung cancer LDCT screening occurs, the beneficiary must receive a written order for LDCT lung cancer screening during a lung cancer screening counseling and shared decision-making visit that includes the following elements and is appropriately documented in the beneficiary’s medical records:

** Must be furnished by a physician (as defined in section 1861(r)(1) of the Act) or qualified non-physician practitioner (meaning a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) as defined in section1861(aa)(5) of the Act); and

** Must include all of the following elements:

o Determination of beneficiary eligibility including age, absence of signs or symptoms of lung cancer, a specific calculation of cigarette smoking pack-years; and if a former smoker, the number of years since quitting;

o Shared decision-making, including the use of one or more decision aids, to include benefits and harms of screening, follow-up diagnostic testing, over-diagnosis, false  positive rate, and total radiation exposure;

o Counseling on the importance of adherence to annual lung cancer LDCT screening, impact of co-morbidities, and ability or willingness to undergo diagnosis and treatment;

o Counseling on the importance of maintaining cigarette smoking abstinence if former smoker; or the importance of smoking cessation if current smoker and, if appropriate, furnishing of information about tobacco cessation interventions; and,

o If appropriate, the furnishing of a written order for lung cancer screening with LDCT. Written orders for subsequent annual LDCT screens may be furnished during any appropriate
visit with a physician or qualified non-physician practitioner (PA, NP, or CNS)

Billing Guide for partial hospitalization

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Partial Hospitalization

• Submit partial hospitalization services with the following revenue codes:

• 0912, 0913 or 0915

o If a separate contract for the hospital and psych DPU are in effect, submit partial hospitalization services and inpatient services on separate UB-04 claim forms.

• Florida Blue considers partial hospitalization to be an outpatient service.

• Partial hospitalization for psychiatric or substance abuse admissions is calculated as follows:

o Partial Days (including beginning and ending dates) x Per Diem.

DRG

DRGs are statistically meaningful medical groupings used for the purpose of categorization and reimbursement of hospital services.
• DRGs allow for more uniform billing based upon the member’s diagnosis and procedures, age, sex, and discharge status.

• Reimbursement for DRG cases is based on discharge date.

• Exception: A newly established participating provider, under a DRG contract, will have the first year of claims reimbursed based on the admission date of the inpatient claim.

• Deaths and transfers are reimbursed based on the assigned DRG and payment hierarchy logic. There are no special reimbursement arrangements applicable to deaths and transfers.

• A list of DRGs, along with length of stay trim points and relative weights, is contained in your hospital’s Agreement.


Outlier Cases

Outlier cases are exceptions to typical inpatient DRG cases. Refer to your Agreement for which outlier method applies.
There are three types of outlier cases but not limited to:

• Low length of stay outlier - Low Length is a case in which the member stays in the hospital fewer days than the low length of stay trim point.

• High length of stay outlier - High Length is a case in which the member stays in the hospital a greater number of days than the high length of stay trim point.

• High charge outlier- High charge is a case in which total covered charges exceed the high charge threshold.

DRG Hierarchy and calculation of allowed amount

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DRG Hierarchy for a Standard Base Agreement


Each inpatient case for a DRG contract is evaluated using the following payment hierarchy:

• Low Stay Outlier

• High Charge/High Stay Outlier

• DRG Value Inlier

Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step. For example, if a case meets the qualification as a low stay case and a high charge case, it will be reimbursed based on the low stay allowance.

Note: The hierarchy for a hospital that provides tertiary services is different from the hierarchy list above.

Calculating the Inpatient Allowed Amount

Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied.

Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.

DRG Examples

The following examples illustrate the various methods for determining the allowed amount for inpatient admissions.


Use the following “case” for the calculations:

• DRG = DRG 202 Bronchitis and Asthma, with complication or major complication

• Conversion Price = $3,000

• Low (Length of Stay) Trim Point = 2 days*

• High (Length of Stay) Trim Point = 12 days*

• Contracted Negotiated Low Stay Per Diem = $750

• Contracted Negotiated High Stay Per Diem = $800

• Relative Weight = 0.8446

• DRG Value = $2,534 (Conversion Price x Relative Weight)

*Trim point is a numerical value that represents the minimum (in the case of the low trim point) and the maximum (in the case of the high trim point) number of days for which payment will be made at the DRG value for hospital services. Length of Stay Examples

Per Diem agreement and allowed amount calculation

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Per Diem

Per Diem is a per day negotiated rate which represents an allowance that includes all services for that day.

Per Diem agreements reimburse based on the admission date of the member.

The following terminology is used when referring to per diem contracts:

• Inliers- Inpatient cases reimbursed based on room and board per diem rates

• Outliers- Inpatient cases reimbursed as a DRG carve-out or based on catastrophic reimbursement.


Per Diem Hierarchy for a Standard Base Agreement

Each inpatient case in a per diem contract is evaluated using the following payment hierarchy:

• Implant Carve-out - Typically reimbursed in addition to inliers and outliers

• Catastrophic - Outlier

• DRG Carve-outs as case rate with additional day per diem - Outlier

• Per Diem Rates - Inlier

Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step.


Calculating the Inpatient Allowed Amount

Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied. Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.


Per Diem Examples

Per Diem payment rate is based on room and board revenue codes (e.g., med/surg, ICU, psychiatric) ranging from 110-219. The following examples illustrate the per diem methods for determining payment for inpatient admissions. Per Diem Examples

What is Present on Admission Indicator Reporting ?

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A Present on Admission (POA) Indicator is used to identify whether a primary or secondary condition was present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission.

For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions known as, Hospital Acquired Conditions (HACs), are present at the time of admission. The case will be reimbursed as though the secondary diagnosis were not present. Critical Access Hospitals (CAHs), Long-term Care Hospitals (LTCHs), Cancer Hospitals, Children's Inpatient Facilities, Inpatient Psychiatric Hospitals, Inpatient Rehabilitation Facilities, and Veterans Administration/Department of Defense Hospitals are exempt from this payment provision.


The Florida Blue Present on Admission (POA) Indicator requirement applies to both Inpatient Prospective Payment Systems (IPPS) and Non-IPPS Hospitals. A POA indicator should be submitted with all primary and secondary diagnoses codes, regardless of whether the condition is considered a Hospital Acquired Condition (HAC) or not.

If an indicator of “Y” or “W” is submitted with a HAC condition, the major complicating condition or complicating condition (MCC/CC) is included in DRG grouping logic. HAC conditions submitted with an “N” or a “U” will be excluded from DRG grouping impacts. The “U” indicator is subject to specific guidelines with regard to the patient status code before it is excluded from the DRG grouping
process.

Present of Admission (POA) Indicator list on UB 04

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The table below outlines the payment implications for each of the different POA Indicator reporting options.


POA Indicator Options and Definitions Code  Description


Y    Diagnosis was present at time of inpatient admission. Florida Blue will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator

N   Diagnosis was not present at time of inpatient admission. Florida Blue will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator.

U  Documentation insufficient to determine if the condition was present at the time of inpatient admission. Florida Blue will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator.

W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Florida Blue will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.

1 Unreported/Not used. Exempt from POA reporting. This code was the equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. For 5010 reporting, the 1 is no longer valid because POAs are no longer reported in a separate string.

What is Clinical trials and well child care

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Clinical Trials

CMS has specific billing requirements for Clinical Trials. For clinical trials other than IDE A and B devices and Clinical Evidence Development, traditional Medicare A or B will pay primary, waiving any deductible. To ensure claims are processed correctly, it is extremely important that claims are billed according to CMS guidelines. Additional Electronic Billing requirements can be obtained in the Availity Companion Guide.

• All claims must be billed with V700.7 (ICD9) or Z00.6 (ICD10) in the first or second diagnosis position

• Each claim submitted must include the clinical trial number

• Outpatient claims must contain an appropriate modifier

• Q1 on each line to denote routine service

• Q0 on each line billed for investigational services

• Electronic claims billed for IDE A or B devices must have an LX in REF01, loop 2300 and Clinical Trial claims must have P4 in REF01, loop 2300

• Clinical Trial Claims (other than IDE and Clinical Evidence Development) must be submitted to traditional Medicare first, then submitted to the Medicare Advantage plan with the Medicare EOB


Well-Child Care

Well-child care refers to physician-provided preventive health care services for children. The well-child benefit applies to an insured dependent child under BlueOptions, BlueChoice or Traditional products.

Well-child services include:

• The first newborn examination in the hospital by a physician other than the delivering obstetrician or anesthesiologist

• Periodic examinations to monitor the normal growth and development of a child

• Specified immunizations (see chart)

• Specified laboratory tests (see chart)

Well-child services are not subject to a calendar-year deductible and are reimbursed at the contracted percentage of the allowed amount.

Note: Florida Blue HMO (Health Options, Inc.) product, uses the USPSTF guidelines for preventive care and the recommended childhood immunization schedule published and updated annually by the Centers for Disease Control and Prevention.


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