NEW DIAGNOSIS CODES

The final addendum providing complete information on changes to the diagnosis part of ICD-9-CM

Diagnosis

Code     Description

237.73   Schwannomatosis

237.79*     Other neurofibromatosis

275.01   Hereditary hemochromatosis

275.02   Hemochromatosis due to repeated red blood cell transfusions

275.03   Other hemochromatosis

275.09   Other disorders of iron metabolism

276.61   Transfusion associated circulatory overload

276.69   Other fluid overload

278.03   Obesity hypoventilation syndrome

287.41   Posttransfusion purpura

287.49   Other secondary thrombocytopenia

315.35*     Childhood onset fluency disorder

447.70   Aortic ectasia, unspecified site

447.71   Thoracic aortic ectasia

447.72   Abdominal aortic ectasia

447.73   Thoracoabdominal aortic ectasia

488.01*     Influenza due to identified avian influenza virus with pneumonia

488.02*     Influenza due to identified avian influenza virus with other respiratory

manifestations

Critical care cpt codes and additionas CPT should not billable

Critical care cpt codes and additionas CPT should not billable

PROCEDURE CODES NOT BILLABLE IN ADDITION TO CRITICAL CARE (99291 &

99292): Medicaid

FROM TO                FROM TO           FROM TO               FROM    TO

31500 31500              43752 43752          92265 92275          95925 95937

36000 36440              51100 51100           92280 92287          99090 99091

36468 36479 5           1701 51702            92950 93299           99170 99199

36510 36510              62270 62270          93303 93352          99460 99463

36555 36555              71010 71020          93561 93562

  

36591 36591              82800 82820           93668 93799

36600 36680             91105 91105           93875 94799

• Procedure codes 99291, 99292, 99466 and 99467 may be billed by the physician providing the care of the critically ill or injured patient in place of service 41, Ambulance, if care is personally rendered by the physician providing the care of the critically ill or injured patient.

When to use CRITICAL CARE SERVICES (CODES 99291-99292)

Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 99292)

CRITICAL CARE SERVICES (CODES 99291-99292)

 Use of Critical Care Codes

Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.

Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition. 

Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present. 

Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care. Consult the American Medical Association (AMA) CPT Manual for the applicable codes and guidance for critical care services provided to neonates, infants and children.

Critical Care - Full Attention of Physician and teaching physician

Critical Care Documentation – Full Attention of Physician 

Since critical care is a time-based service, the physician ’ s critical care note(s) must document the total time spent evaluating, managing and providing critical care services to a critically ill or injured patient. Critical care time may be continuous or intermittent in aggregated time increments. Time spent performing separately billable procedures/services cannot be used to support critical care time. 

The time spent providing critical care services must be spent at the immediate bedside or elsewhere on the floor or unit as long as the physician is immediately available to the patient. Therefore, the physician cannot provide services to any other patient during the same period of time. 

Teaching Physician 

In the teaching environment, the teaching physician must be present for the entire period of time for which the claim is submitted. Time spent teaching may not be counted towards critical care time. The teaching physician, in addition, cannot bill for time spent by the resident providing critical care services in their absence. Only time that the teaching physician spends with the patient, or that he/she and the resident spend together with the patient, can be counted toward critical care time.

Provided that all requirements for critical care services are met, the teaching physician ’ s documentation may tie into the resident's documentation. The teaching physician may refer to the resident ’ s documentation for specific patient history, physical findings and medical assessment. 

NOTE: It is the teaching physician ’ s “ stand alone ” documentation that determines whether a critical care services can be billed. 

The teaching physician medical record documentation must provide information including the time the teaching physician spent providing critical care; that the patient was critically ill during the time the teaching physician saw the patient; what made the patient critically ill; and the nature of the treatment and management provided by the teaching physician. 

The following is an example of acceptable teaching physician documentation: 

Patient seen and examined with Dr. Resident. Reviewed and agree with his note and the plan of care we developed together. One hour of critical care time personally performed due to patient ’ s hemo-dynamic instability. Patient was resuscitated with 2 units of packed red blood cells. Additional studies were obtained to determine possible causes for patient ’ s instabilities.

Critical Care Services

Hospitals should separately report all HCPCS codes in accordance with correct coding principles, Procedure  code descriptions, and any additional CMS guidance, when available. Specifically with respect to Procedure  code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes), hospitals must follow the Procedure  instructions related to reporting that Procedure  code. 

Prior to January 1, 2011, any services that Procedure  indicates are included in the reporting of Procedure  code 99291 (including those services that would otherwise be reported by and paid to hospitals using any of the Procedure  codes specified by Procedure ) should not be billed separately by the hospital. 

Instead, hospitals should report charges for any services provided as part of the critical care services. In establishing payment rates for critical care services, and other services, CMS packages the costs of certain items and services separately reported by HCPCS codes into payment for critical care services and other services, according to the standard OPPS methodology for packaging costs.

Beginning January 1, 2011, in accordance with revised Procedure  guidance, hospitals that report in accordance with the Procedure  guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care. CMS will continue to recognize the existing Procedure  codes for critical care services and will establish payment rates based on historical data, into which the cost of the ancillary services is intrinsically packaged. 

The I/OCE conditionally packages payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment. The payment status of the ancillary services does not change when they are not provided in conjunction with critical care services. Hospitals may use HCPCS modifier -59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter.


Beginning January 1, 2007, critical care services will be paid at two levels, depending on the presence or absence of trauma activation. Providers will receive one payment rate for critical care without trauma activation and will receive additional payment when critical care is associated with trauma activation.

To determine whether trauma activation occurs, follow the National Uniform Billing Committee (NUBC) guidelines in the Claims Processing Manual, Pub 100-04, Chapter 25, §75.4 related to the reporting of the trauma revenue codes in the 68x series. 

The revenue code series 68x can be used only by trauma centers/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons. Different subcategory revenue codes are reported by designated Level 1-4 hospital trauma centers. 

Only patients for whom there has been prehospital notification based on triage information from prehospital caregivers, who meet either local, state or American College of Surgeons field triage criteria, or are delivered by inter-hospital transfers, and are given the appropriate team response can be billed a trauma activation charge.

When critical care services are provided without trauma activation, the hospital may bill Procedure  code 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes (and 99292, if appropriate). 

If trauma activation occurs under the circumstances described by the NUBC guidelines that would permit reporting a charge under 68x, the hospital may also bill one unit of code G0390, which describes trauma activation associated with hospital critical care services. Revenue code 68x must be reported on the same date of service. 

The OCE will edit to ensure that G0390 appears with revenue code 68x on the same date of service and that only one unit of G0390 is billed. CMS believes that trauma activation is a one-time occurrence in association with critical care services, and therefore, CMS will only pay for one unit of G0390 per day.

The Procedure  code 99291 is defined by Procedure  as the first 30-74 minutes of critical care. This 30 minute minimum has always applied under the OPPS. The Procedure  code 99292, Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes, remains a packaged service under the OPPS, so that hospitals do not have the ongoing administrative burden of reporting precisely the time for each critical service provided. As the Procedure  guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines.

Under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face-to-face critical care of a critically ill or critically injured patient. If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face-to-face care, the time involved can only be counted once.

• Beginning in CY 2007 hospitals may continue to report a charge with RC 68x without any HCPCS code when trauma team activation occurs. In order to receive additional payment when critical care services are associated with trauma activation, the hospital must report G0390 on the same date of service as RC 68x, in addition to Procedure  code 99291 (or 99292, if appropriate.)

• Beginning in CY 2007 hospitals should continue to report 99291 (and 99292 as appropriate) for critical care services furnished without trauma team activation. Procedure  99291 maps to APC 0617 (Critical Care). (Procedure  99292 is packaged and not paid separately, but should be reported if provided.)

Critical Care (99291 & 99292)

critical care billing CPT 99291, 99292 AND its restriction

Critical Care (99291 & 99292)

When caring for a critically ill patient, for whom the constant attention of the physician is required, the appropriate critical care procedure code (99291 and 99292) must be billed. Critical care guidelines are defined in the Current Procedural Terminology (CPT) and Provider Manual. Critical care is considered a daily global inclusive of all services directly related to critical care.

Coverage of critical care may total no more than four hours per day. The actual time period spent in attendance at the patient's bedside or performing duties specifically related to that patient, irrespective of breaks in attendance, must be documented in the patient's medical record.

RESTRICTIONS:

No individual procedures related to critical care may be billed in addition to procedure codes 99291 and 99292, except:

• An EPSDT screening may be billed in lieu of the initial hospital care (P/C 99221, 99222, or 99223). If screening is billed, the initial hospital care cannot be billed.

• Procedure code 99082 (transportation or escort of patient) may also be billed with critical care (99291 and/or 99292 for recipients 25 months of age and older or 99466 and/or 99467 for recipients

24 months of age or less). Only the attending physician may bill this service and critical care. Residents or nurses who escort a patient may not bill either service.

Counting of Units of Critical Care Services - CPT 99291 AND 99292

The CPT code 99291 (critical care, first hour) is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date. Only one unit of CPT code 99291 may be billed by a physician for a patient on a given date. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician and would not each report CPT 99291on the same date of service.

The following illustrates the correct reporting of critical care services:

Total Duration of Critical Care          Codes

Less than 30 minutes          99232 or 99233 or other appropriate E/M code

30 - 74 minutes             99291 x 1

75 - 104 minutes            99291 x 1 and 99292 x 1

105 - 134 minutes          99291 x1 and 99292 x 2

135 - 164 minutes            99291 x 1 and 99292 x 3

165 - 194 minutes           99291 x 1 and 99292 x 4

194 minutes or longer        99291 – 99292 as appropriate (per the above illustrations)

Critical Care Services and Other Evaluation and Management Services Provided on Same Day 

When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291 - 99292 may be reported. An emergency department visit code may not also be reported.

When critical care services are provided on a date where an inpatient hospital or office/outpatient evaluation and management service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous evaluation and management service may be paid. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.

Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice.

critical care billing CPT 99291, 99292 AND its restriction

Critical Care (99291 & 99292)

When caring for a critically ill patient, for whom the constant attention of the physician is required, the appropriate critical care procedure code (99291 and 99292) must be billed. Critical care guidelines are defined in the Current Procedural Terminology (CPT) and Provider Manual. Critical care is considered a daily global inclusive of all services directly related to critical care.

Coverage of critical care may total no more than four hours per day. The actual time period spent in attendance at the patient's bedside or performing duties specifically related to that patient, irrespective of breaks in attendance, must be documented in the patient's medical record.

RESTRICTIONS:

No individual procedures related to critical care may be billed in addition to procedure codes 99291 and 99292, except:

• An EPSDT screening may be billed in lieu of the initial hospital care (P/C 99221, 99222, or 99223). If screening is billed, the initial hospital care cannot be billed.

• Procedure code 99082 (transportation or escort of patient) may also be billed with critical care (99291 and/or 99292 for recipients 25 months of age and older or 99466 and/or 99467 for recipients

24 months of age or less). Only the attending physician may bill this service and critical care. Residents or nurses who escort a patient may not bill either service. 

CRITICAL CARE SERVICES (CODES 99291-99292)

A. Use of Critical Care Codes

Pay for services reported with CPT codes 99291 and 99292 when all the criteria for critical care and critical care services are met. Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.

Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

Examples of vital organ system failure include, but are not limited to: central nervous system failure, circulatory failure, shock, renal, hepatic, metabolic, and/or respiratory failure. Although critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology(s), critical care may be provided in life threatening situations when these elements are not present.

Providing medical care to a critically ill, injured, or post-operative patient qualifies as a critical care service only if both the illness or injury and the treatment being provided meet the above requirements.

Critical care is usually, but not always, given in a critical care area such as a coronary care unit, intensive care unit, respiratory care unit, or the emergency department. However, payment may be made for critical care services provided in any location as long as the care provided meets the definition of critical care.

Consult the American Medical Association (AMA) CPT Manual for the applicable codes and guidance for critical care services provided to neonates, infants and children.

B. Critical Care Services and Medical Necessity

Critical care services must be medically necessary and reasonable. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in a critical care, intensive care, or other specialized care unit should be reported using another appropriate E/M code (e.g., subsequent hospital care, CPT codes 99231 - 99233).

As described in Section A, critical care services encompass both treatment of “vital organ

failure” and “prevention of further life threatening deterioration of the patient’s condition.” Therefore, although critical care may be delivered in a moment of crisis or upon being called to the patient’s bedside emergently, this is not a requirement for providing critical care service. 

The treatment and management of the patient’s condition, while not necessarily emergent, shall be required, based on the threat of imminent deterioration (i.e., the patient shall be critically ill or injured at the time of the physician’s visit).

Chronic Illness

G. Counting of Units of Critical Care Services

The CPT code 99291 (critical care, first hour) is used to report the services of a physician

providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date. Only one unit of CPT code 99291 may be billed by a physician for a patient on a given date. 

Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician and would not each report CPT

99291on the same date of service.

The following illustrates the correct reporting of critical care services:

Less than 30 minutes -99232 or 99233 or other appropriate E/M code

30 - 74 minutes - 99291 x 1

75 - 104 minutes - 99291 x 1 and 99292 x 1

105 - 134 minutes - 99291 x1 and 99292 x 2

135 - 164 minutes - 99291 x 1 and 99292 x 3

165 - 194 minutes - 99291 x 1 and 99292 x 4

194 minutes or longer - 99291 – 99292 as appropriate (per the above illustrations)

H. Critical Care Services and Other Evaluation and Management Services Provided on Same Day

When critical care services are required upon the patient's presentation to the hospital emergency department, only critical care codes 99291 - 99292 may be reported. An emergency department visit code may not also be reported.

When critical care services are provided on a date where an inpatient hospital or office/outpatient evaluation and management service was furnished earlier on the same date at which time the patient did not require critical care, both the critical care and the previous evaluation and management service may be paid. Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician to the same patient.

Physicians are advised to submit documentation to support a claim when critical care is additionally reported on the same calendar date as when other evaluation and management services are provided to a patient by the same physician or physicians of the same specialty in a group practice

Pediatric and Neonatal Critical Care CPT codes - covered by Medicaid

Pediatric and Neonatal Critical Care

99468 Initial Inpatient Neonatal Critical Care, per day for the evaluation and management of a critically ill neonate, 28 days of age or less

Criteria - Not valid for 29 days or older, can be billed by any physician provider type

99469 Subsequent Inpatient Neonatal  Critical Care, per day for the evaluation and management of a  critically ill neonate, 28 days of age or less

Criteria - Not valid for ages 29 days or older, can be billed by any physician provider type

99471 Initial Inpatient Pediatric Critical Care, per day for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

Criteria  - Not valid for 28 days or less, can be billed by any physician provider type

RESTRICTIONS:

No individual procedures related to critical care may be billed in addition to procedure codes 99468-99476 except:

• Chest tube placement

• Pericardiocentesis or thoacentesis

• Intracranial taps

• Initial hospital care history and physical or EPSDT screen may be billed in conjunction with 99468. Both may not be billed.

NOTE: One EPSDT screen for the hospitalization will encompass all diagnoses identified during the hospital stay for referral purposes.

• Standby (99360), resuscitation (99465), or attendance at delivery (99464) may be billed in addition to critical care. Only one of these codes may be billed in addition to neonatal intensive care critical care codes.

CPT 99472, 99472, 99476 BILLING restriction and limitations

Pediatric and Neonatal Critical Care 

99472 Subsequent Inpatient Pediatric Critical Care per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

Note :Not valid for ages 28 days or less, can be billed by any physician provider type

99475 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age

May be billed by any physician provider type

99476 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age

May be billed by any physician provider type

LIMITATIONS:

• Pediatric, neonatal critical care codes and intensive (non-critical) low birth weight service codes are reported once per day per recipient.

• Subsequent Hospital Care codes (99231-99233) cannot be billed on the same date of service as neonatal critical care codes (99468-99476)

 • Only one unit of critical care can be billed per child per day in the same facility. Medicaid pays the first claim received and denies subsequent claims (first in, first out policy).

• Critical care is considered to be an evaluation and management service. Although usually furnished in a critical or intensive care unit, critical care may be provided in any inpatient health care

setting. 

Services provided which do not meet critical care criteria, should be billed under the appropriate hospital care codes. If a recipient is readmitted to the NICU/ICU, the provider must be the primary physician in order for NICU critical care codes to be billed again.

• Once the patient is no longer considered by the attending physician to be critical, the Subsequent Hospital Care codes (99231-99233) should be billed. Only one unit can be billed per day per physician regardless of specialty. Medicaid pays the first claim received and denies subsequent claims (first in, first out policy).

• Transfers to the pediatric unit from the NICU cannot be billed using critical care codes. Subsequent hospital care would be billed in these instances.

• Global payments encompass all care and procedures that are included in the rate. Providers may not perform an EPSDT screen and refer to a partner or other physician to do procedures. 

All procedures that are included in the daily critical care rate, regardless of who performed them, are included in the global critical care code.

• Consultant care rendered to children for which the provider is not the primary attending physician must be billed using consultation codes. 

Appropriate procedures may be billed in addition to consultations. If, after the consultation the provider assumes total responsibility for care, critical care may be billed using the appropriate critical care codes as defined above. The medical record must clearly indicate that the provider is assuming total responsibility for care of the patient and is the primary attending physician for the patient. 

Pediatric and Neonatal Critical Care

CPT 99472, 99472, 99476 BILLING restriction and limitations

Pediatric and Neonatal Critical Care

99472 Subsequent Inpatient Pediatric Critical Care per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

Note :Not valid for ages 28 days or less, can be billed by any physician provider type

99475 Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age

May be billed by any physician provider type

99476 Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or you child, 2 through 5 years of age

May be billed by any physician provider type

LIMITATIONS:

• Pediatric, neonatal critical care codes and intensive (non-critical) low birth weight service codes are reported once per day per recipient.

• Subsequent Hospital Care codes (99231-99233) cannot be billed on the same date of service as neonatal critical care codes (99468-99476)

 • Only one unit of critical care can be billed per child per day in the same facility. Medicaid pays the first claim received and denies subsequent claims (first in, first out policy).

• Critical care is considered to be an evaluation and management service. Although usually furnished in a critical or intensive care unit, critical care may be provided in any inpatient health care

setting. 

Services provided which do not meet critical care criteria, should be billed under the appropriate hospital care codes. If a recipient is readmitted to the NICU/ICU, the provider must be the primary physician in order for NICU critical care codes to be billed again.

• Once the patient is no longer considered by the attending physician to be critical, the Subsequent Hospital Care codes (99231-99233) should be billed. Only one unit can be billed per day per physician regardless of specialty. Medicaid pays the first claim received and denies subsequent claims (first in, first out policy).

• Transfers to the pediatric unit from the NICU cannot be billed using critical care codes. Subsequent hospital care would be billed in these instances.

• Global payments encompass all care and procedures that are included in the rate. Providers may not perform an EPSDT screen and refer to a partner or other physician to do procedures. All

procedures that are included in the daily critical care rate, regardless of who performed them, are included in the global critical care code.

• Consultant care rendered to children for which the provider is not the primary attending physician must be billed using consultation codes. Appropriate procedures may be billed in addition to

consultations. If, after the consultation the provider assumes total responsibility for care, critical care may be billed using the appropriate critical care codes as defined above. The medical

record must clearly indicate that the provider is assuming total responsibility for care of the patient and is the primary attending physician for the patient.

Pediatric and Neonatal Critical Care CPT codes - covered by Medicaid

Pediatric and Neonatal Critical Care

99468 Initial Inpatient Neonatal Critical Care, per day for the evaluation and management of a critically ill neonate, 28 days of age or less

Criteria - Not valid for 29 days or older, can be billed by any physician provider type

99469 Subsequent Inpatient Neonatal  Critical Care, per day for the evaluation and management of a critically ill neonate, 28 days of age or less

Criteria - Not valid for ages 29 days or older, can be billed by any physician provider type

99471 Initial Inpatient Pediatric Critical Care, per day for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

Criteria  - Not valid for 28 days or less, can be billed by any physician provider type

RESTRICTIONS:

No individual procedures related to critical care may be billed in addition to procedure codes 99468-99476 except:

• Chest tube placement

• Pericardiocentesis or thoacentesis

• Intracranial taps

• Initial hospital care history and physical or EPSDT screen may be billed in conjunction with 99468. Both may not be billed.

NOTE: One EPSDT screen for the hospitalization will encompass all diagnoses identified during the hospital stay for referral purposes.

• Standby (99360), resuscitation (99465), or attendance at delivery (99464) may be billed in addition to critical care. Only one of these codes may be billed in addition to neonatal intensive care critical care codes. 

Lab test performed in office and outside lab

Lab Tests Performed in Physician’s Offices When performing laboratory tests in the physician’s office:

1. The Physician must be CLIA certified to perform the test,

2. The Physician must have the appropriate equipment to perform the test, and

3. The Physician’s office bills for the tests performed but not the collection fee.

When specimens are sent to an outside lab:

1. The Physician’s office should not bill the laboratory code, and

2. The Physician’s office may bill a collection fee with a “90” modifier for blood specimens

Repeat lab procedure guideline for modifier

Repeat Lab Procedures - Medicaid

Modifier 91 may be utilized to denote a repeat clinical laboratory test performed on the dame date of service for the same recipient. Providers should use modifier 91 instead of modifier 76 for repeat lab procedures

A physician CANNOT bill the following pathology/laboratory procedure codes, however the above collection fee can be billed, if applicable:

82775 Galactose – 1 – phosphate uridyl transferase; quantitative

83498 Hydroxyprogesterone, 17 – d

84030 Phenylalanine (PKU) blood

84437 Thyroxine; total requiring elution (e.g., neonatal)

Renal Dialysis Facility

End Stage Renal Disease (ESRD) services are outpatient maintenance services provided by a freestanding ESRD facility or hospital-based renal dialysis center

National Provider Identifier, Type, and Specialty A provider who contracts with Alabama Medicaid as a renal dialysis provider is added to the Medicaid system with the National Provider Identifiers provided at the time application is made. Appropriate provider specialty codes are assigned to enable the provider to submit requests and receive reimbursements for dialysis-related claims.

NOTE:

The 10-digit NPI is required when filing a claim.

Renal Dialysis Facility providers are assigned a provider type of 30 (Renal Dialysis Facility). The valid specialty for Renal Dialysis Facility providers is Hemodialysis (300).

Global Surgical Packages

Effective for dates of adjudication 10/1/06 and thereafter, Medicaid will adopt Medicare’s RVU file designation for global surgical days. In the past and through date of adjudication September 30, 2006, Medicaid has used a 62 day post op period after major surgeries.

Effective for dates of adjudication 10/1/06 and thereafter, Medicaid will use a zero, 10 day, and 90 day post op period for routine surgical care. The codes in the following list include a 10 day post op period and an office, hospital, or outpatient visit for routine post op care should not be billed within 10 days of surgery. Claims for these services will be subject to post payment review.

The major surgery codes that include a 90 day post op period will not be published. Post operative office visits for routine surgical care should not be billed as they are considered inclusive of the global surgical package. Additionally, surgical procedure codes with zero day post op period are not published and may be located on the Medicare RVU file. Procedure Codes that include 10 day pos t op care:

FROM TO FROM TO FROM TO

10040 10180 31000 31002 54505

11010 31239 54620

11043 11044 31290 31294 54700

11200 36470 36471 55100

11400 11446 36557 36566 55450

11600 11646 36570 36571 55705 55706

11750 11752 36576 36578 56405 56515

11760 11770 36581 36583 56700

12001 13101 36585 36590 56740 56800

37609

13120 13121 38230 56810

13131 13132 38300 57000

13150 13152 38500 57022 57065

15340 38510 57105

15786 38570 38572 57130 57135

17000 39400 57180

17004 40800 40805 57415

17110 17111 40808 40812 57505 57513

17260 17286 40820 40831 57558

17340 17360 41000 41005

19101 41010 58120

20000 20005 41100 41110 58345 58356

20100 20103 41115 58350

20240 20251 41250 41252 58615

20500 41530 58661

20520 20525 41800 41806 59160 59841

20615 20650 41822 59840

20665 20670 41825 41826 60000

21076 41828 41830 61888

21085 42000 42106 62194 62264

21315 21320 42160 42182 62263 62282

21355 21356 42280 42281 62350 62365

Professional and Technical Components

Some procedure codes in the 70000, 80000, 90000, and G series are a combination of a professional component and a technical component. Therefore, these codes may be billed one of three different ways; (1) as a global, (2) as a professional component, or (3) as a technical component.

NOTE: Not all providers are allowed to bill any or all of the three ways to bill. Specific coverage questions should be addressed to the Provider Assistance Center.

• Global, the provider must own the equipment, pay the technician, review the results, and provide a written report of the findings. The procedure code is billed with no modifiers. The Global component

should be billed only for the following place of service locations:

− 11 (Office)

− 81 (Independent Laboratory)

hemodialysis and ESRD benefits and limitation

Benefits and Limitations

This section describes program-specific benefits and limitations. Refer to Chapter 3, Verifying Recipient Eligibility, for general benefit information and limitations.

Medicaid covers maintenance dialysis treatments when they are provided by a Medicaid-enrolled hospital-based renal dialysis center or a freestanding ESRD facility. The maintenance dialysis treatments do not count against the routine outpatient visit limit.

Hemodialysis is limited to 156 sessions per year, which provides three sessions per week.

Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuing Cycling Peritoneal Dialysis (CCPD) are furnished on a continuous basis, not in discrete sessions, and will be paid a daily rate, not on a per treatment basis.

Providers are to report the number of days in the units field on the claim. The daily IPD or CAPD/CCPD payment does not depend upon the number of exchanges of dialysate fluid per day (typically 3-5) or the actual number of days per week that the patient undergoes dialysis. The daily rate is based on the equivalency of one week of IPD or CAPD/CCPD to one week of hemodialysis, regardless of the actual number of dialysis days or exchanges in that week.

Place of Service Codes

Full PLACE OF SERVICE CODES
PLACE OF SERVICE CODES

00    NOT SUPPLIED
01    PHARMACY
03    SCHOOL
04    HOMELESS SHELTER
05    INDIAN HEALTH SERVICE FREE-STANDING FACILITY
06    INDIAN HEALTH SERVICE PROVIDER-BASED FACILITY
07    TRIBAL 638 FREE-STANDING FACILITY
08    TRIBAL 638 PROVIDER-BASED FACILITY
11    OFFICE
12    HOME
13    ASSISTED LIVING FACILITY
14    GROUP HOME
15    MOBILE UNIT
20    URGENT CARE FACILITY
21    INPATIENT HOSPITAL
22    OUTPATIENT HOSPITAL
23    EMERGENCY ROOM - HOSPITAL
24    AMBULATORY SURGICAL CENTER
25    BIRTHING CENTER
26    MILITARY TREATMENT FACILITY
31    SKILLED NURSING FACILITY
32    NURSING FACILITY
33    CUSTODIAL CARE FACILITY
34    HOSPICE
41    AMBULANCE (LAND)
42    AMBULANCE (AIR OR WATER)
49    INDEPENDENT CLINIC
50    FEDERALLY QUALIFIED HEALTH CENTER
51    INPATIENT PSYCHIATRIC FACILITY
52    PSYCHIATRIC FACILITY, PARTIAL HOSPITALIZATION
53    COMMUNITY MENTAL HEALTH CENTER
54    INTERMEDIATE CARE FACILITY/MENTALLY RETARDED
55    RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY
56    PSYCHIATRIC RESIDENTIAL TREATMENT CENTER
57    NON-RESIDENTIAL SUBSTANCE ABUSE TREATMENT FACILITY
60    MASS IMMUNIZATION CENTER
61    COMPREHENSIVE INPATIENT REHABILITATION FACILITY
62    COMPREHENSIVE OUTPATIENT REHABILITATION FACILITY
65    END STAGE RENAL DISEASE TREATMENT FACILITY
71    STATE OR LOCAL PUBLIC HEALTH CLINIC
72    RURAL HEALTH CLINIC
81    INDEPENDENT LABORATORY
99    OTHER UNLISTED FACILITY

Place of Service Crosswalk

Place of Service Crosswalk
Type of Bill	Type of Bill Position 1 (Type of Facility)	Type of Bill Position 2 (Bill Classification)	Place of Service*	Place of Service Description
11X	Hospital	Inpatient	21	Inpatient Hospital
12X	Hospital	Inpatient	21	Inpatient Hospital
13X	Hospital	Outpatient	22	Outpatient Hospital
14X	Hospital	Other	22	Outpatient Hospital
18X	Hospital	Swing Bed	21	Inpatient Hospital
21X	Skilled Nursing	Inpatient	31	Skilled Nursing Facility
22X	Skilled Nursing	Inpatient	31	Skilled Nursing Facility
23X	Skilled Nursing	Outpatient	32	Nursing Facility
28X	Skilled Nursing	Swing Bed	32	Nursing Facility
32X	Home Health	Inpatient	12	Home
33X	Home Health	Outpatient	12	Home
34X	Home Health	Other	12	Home
41X	Religious Nonmedical	Inpatient	21	Inpatient Hospital
42X	Religious Nonmedical	Inpatient	21	Inpatient Hospital
43X	Religious Nonmedical	Outpatient	22	Outpatient Hospital
65X	Intermediate Care	Intermediate Care—Level I	54	Intermediate Care Facility/Mentally Retarded
66X	Intermediate Care	Intermediate Care—Level II	54	Intermediate Care Facility/Mentally Retarded
71X	Clinic or Hospital Based Renal Dialysis Facility	Rural Health Clinic (RHC)	72	Rural Health Clinic
72X	Clinic or Hospital Based Renal Dialysis Facility	Hospital Based or Independent Renal Dialysis Facility	65	End-Stage Renal Disease Treatment Facility
73X	Clinic or Hospital Based Renal Dialysis Facility	Free Standing Provider-Based Federally Qualified Health Center (FQHC)	49	Independent Clinic
74X	Clinic or Hospital Based Renal Dialysis Facility	Outpatient Rehabilitation Facility (ORF)	49	Independent Clinic
75X	Clinic or Hospital Based Renal Dialysis Facility	Comprehensive Outpatient Rehabilitation Facility (CORF)	62	Comprehensive Outpatient Rehabilitation Facility
76X	Clinic or Hospital Based Renal Dialysis Facility	Community Mental Health Center (CMHC)	53	Community Mental Health Center
79X	Clinic or Hospital Based Renal Dialysis Facility	OTHER	49	Independent Clinic
81X	Special facility or hospital ASC surgery	Hospice (Nonhospital Based)	34	Hospice
82X	Special facility or hospital ASC surgery	Hospice (Hospital Based)	34	Hospice
83X	Special facility or hospital ASC surgery	Ambulatory Surgical Center Services to Hospital Outpatients	24	Ambulatory Surgical Center
84X	Special facility or hospital ASC surgery	Free Standing Birthing Center	25	Birthing Center
85X	Special facility or hospital ASC surgery	Critical Access Hospital	22	Outpatient Hospital

Place of Service Codes (POS) Payable for Evaluation and Management CPT Codes 99315-99350

CMS has defined the payable place of service codes for Evaluation and Management (E/M) for patients residing in facilities or at home (CPT Codes 99315 to 99350), Effective for dates of service on or after August 1, 2004 services billed without a payable POS will be rejected.

A table of these payable Place of Service codes follows.

CPT Payable Place of Service (POS) Codes

99315 32, 31, 54, 56
99316 32, 31, 54, 56
99341 12, 14
99342 12, 14
99343 12, 14
99344 12, 14
99345 12, 14
99347 12, 14
99348 12, 14
99349 12, 14
99350 12, 14

Key to Place of Service (POS) Codes

12 – Patient’s Home
13 – Assisted Living Facility
14 – Group Home
31 – Skilled Nursing Facility
32 – Nursing Home/Nursing Facility
33 – Custodial Care Facility
34 – Hospice Facility
54 – Intermediate Care Facility – Mentally Retarded
55 – Residential Substance Abuse Facility
56 – Psychiatric Residential Treatment Center
57 – Non-Residential Substance Abuse Treatment Facility