CMS Manual System

1 CMS Manual System Department of Health & Human Services (DHHS) Pub. 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) transmittal 51 Date: DECEMBER 19, 2003 CHANGE REQUEST 3027 I. SUMMARY OF CHANGES: January Medicare Outpatient Code Editor (OCE) Specifications Version For Bills From Hospitals That Are Not Paid Under the Outpatient Prospective Payment System (OPPS) NEW/REVISED MATERIAL - EFFECTIVE DATE: Various dates as described in the instruction *IMPLEMENTATION DATE: January 5, 2004 Disclaimer for Manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. II. CHANGES IN Manual INSTRUCTIONS: (N/A if Manual not updated.) (R = REVISED, N = NEW, D = DELETED (Only One Per Row.) R/N/D CHAPTER/SECTION/SUBSECTION/TITLE N/A *III.)

2 FUNDING: These instructions should be implemented within your current operating budget. IV. ATTACHMENTS: Business Requirements Manual Instruction Confidential Requirements One-Time Notification X Recurring Update Notification *Medicare contractors only Recurring Update Notification Pub. 100-04 transmittal : 51 Date: December 19, 2003 Change Request 3027 SUBJECT: January Medicare Outpatient Code Editor (OCE) Specifications Version For Bills From Hospitals That Are Not Paid Under the Outpatient Prospective Payment System (OPPS) I. GENERAL INFORMATION A. Background: This Change Request (CR) informs you that the OCE has been updated with new additions, changes, and deletions to Healthcare Common Procedure Coding System /Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4) codes.

3 CMS sent detailed information about these changes in separate communications. See Program Memorandum AB-03-140, dated September 12, 2003. This OCE is used to process bills from hospitals not paid under the OPPS. B. Policy: The following are changes made to version of the non-OPPS OCE: The new HCPCS/CPT codes as described in Appendix A have been added to the list of valid codes for the non-OPPS OCE. The HCPCS/CPT codes listed in Appendices B and C have been deleted from the non- OPPS OCE. The following ASC procedure codes have been added to the list of ASC procedures and payment groups, effective January 1, 2004: Code Payment Group 1. 36555 1 2. 36556 1 3. 36557 2 4.

4 36558 2 5. 36560 3 6. 36561 3 7. 36563 3 8. 36565 3 9. 36566 3 10. 36568 1 11. 36569 1 12. 36570 3 13. 36571 3 214. 36575 2 15.

5 36576 2 16. 36578 2 17. 36580 1 18. 36581 2 19. 36582 3 20. 36583 3 21. 36584 1 22. 36585 3 23. 36589 1 24. 36590 1 The following new procedure codes have been added to the list of procedures for Females Only, effective January 1, 2004: 1.

6 57425 Laparoscopy, surg, colpopexy 2. 59070 Transabdom amnioinfus w/ us 3. 59072 Umbilical cord occlud w/ us 4. 59074 Fetal fluid drainage w/ us 5. 59076 Fetal shunt placement, w/ us 6. 59897 Fetal invas px w/ us The following codes have been added to the list of Non-Covered procedures, effective January 1, 2004: 1. A9280 2. J7303 3. V5362 4. V5363 5. V5364 The following codes have been removed from the list of Non-Covered procedures, effective January 1, 2001: 1. E0740 2. E0760 The following code has been removed from the list of Non-Covered procedures, effective January 1, 2004: 1. G0282 The codes as described in Appendix D have been added to the list of Non-Reportable procedures. 3 The codes as described in Appendix E which are billable only to the DMERC have been added to the list of Non-Reportable procedures.

7 The following code has been removed from the list of Non-Reportable procedures, effective January 1, 2003: 1. G0257 C. Provider Education: Intermediaries shall inform affected providers by posting either a summary or relevant portions of this document on their Web site within two weeks of receiving this instruction. Also, intermediaries shall publish this same information in their next regularly scheduled bulletin. If they have a listserv that targets affected providers, they shall use it to notify subscribers that information about Non-OPPS OCE HCPCS Updates is available on their Web site. II. BUSINESS REQUIREMENTS Shall" denotes a mandatory requirement "Should" denotes an optional requirement Requirement # Requirements Responsibility Shared Systems Maintainers (SSMs) shall install OCE version into their systems.

8 SSMs Fiscal Intermediaries (FIs) shall inform providers of the OCE changes for 2004 detailed in this recurring change notification. FIs III. SUPPORTING INFORMATION AND POSSIBLE DESIGN CONSIDERATIONS A. Other Instructions: X-Ref Requirement # Instructions B. Design Considerations: X-Ref Requirement # Recommendation for Medicare System Requirements C. Interfaces: OCE D. Contractor Financial Reporting /Workload Impact: N/A 4E. Dependencies: N/A F. Testing Considerations: N/A IV. SCHEDULE, CONTACTS, AND FUNDING Effective Date: Various dates as described in the instruction. Implementation Date: January 5, 2004 Pre-Implementation Contact(s): Nicole Atkins (410) 786-8278 Post-Implementation Contact(s): Regional Office These instructions should be implemented within your current operating budget. ATTACHMENTS Appendix ACodeDescriptionEff DateA4570 Splint20011001S9150 Evaluation by ocularist20020401S9484 Crisis intervention per hour20020701S9490 HIT corticosteroid/diem20020701S9900 Christian Sci Pract visit20020701S0104 Zidovudine, oral, 100 mg20021001S0201 Partial hospitalization serv20021001S0207 Paramedicintercep nonhospals20021001S0315 Disease management program20021001S0316 Follow-up/reassessment20021001S0320RN telephone calls to DMP20021001S1040 Cranial remolding orthosis20021001S2262 Abortion maternal indic>=25w20021001S2265 Abortion 25-28wks fetal indi20021001S2266 Abortion 29-31wks fetal indi20021001S2267 Abortion >=32wks fetal indic20021001S3655 Antisperm antibodies test20021001A4580 Cast supplies (plaster)

9 20030101S5100 Adult daycare services 15min20030101S5101 Adult day care per half day20030101S5102 Adult day care per diem20030101S5105 Centerbased day care perdiem20030101S5110 Family homecare training 15m20030101S5111 Family homecare train/sessio20030101S5115 Nonfamily homecare train/15m20030101S5116 Nonfamily HC train/session20030101S5120 Chore services per 15 min20030101S5121 Chore services per diem20030101S5125 Attendant care service /15m20030101S5126 Attendant care service /diem20030101S5130 Homaker service nos per 15m20030101S5131 Homemaker service nos /diem20030101S5135 Adult companioncare per 15m20030101S5136 Adult companioncare per diem20030101S5140 Adult foster care per diem20030101S5141 Adult foster care per month20030101S5145 Child fostercare th per diem20030101S5146 Ther fostercare child /month20030101S5150 Unskilled respite care /15m20030101S5151 Unskilled respitecare /diem20030101S5160 Emer response sys instal&tst20030101S5161 Emer rspns sys serv permonth20030101S5162 Emer rspns System purchase20030101S5165 Home modifications per serv20030101S5170 Homedelivered prepared meal20030101S5175 Laundry serv,ext,prof,/order20030101S5180HH respiratory thrpy in eval20030101112/22/2003 Appendix AS5181HH respiratory thrpy nos/day20030101S5185 Med reminder serv per month20030101S5190 Wellness assessment by nonph20030101S5199 Personal care item nos each20030101S8004 Wholebody radiopharm trgcell20030101H2010 Comprehensive med svc 15 min20030401H2011 Crisis interven svc, 15 min 20030401H2012 Behav hlth day treat, per hr20030401H2013 Psych hlth fac svc, per diem20030401H2014 Skills train and dev, 15 min20030401H2015 Comp comm supp svc, 15 min 20030401H2016 Comp comm supp svc.

10 Per diem20030401H2017 Psysoc rehab svc, per 15 min20030401H2018 Psysoc rehab svc, per diem 20030401H2019 Ther behav svc, per 15 min 20030401H2020 Ther behav svc, per diem 20030401H2021 Com wrap-around sv, 15 min 20030401H2022 Com wrap-around sv, per diem20030401H2023 Supported employ, per 15 min20030401H2024 Supported employ, per diem 20030401H2025 Supp maint employ, 15 min 20030401H2026 Supp maint employ, per diem 20030401H2027 Psychoed svc, per 15 min 20030401H2028 Sex offend tx svc, 15 min 20030401H2029 Sex offend tx svc, per diem 20030401H2030MH clubhouse svc, per 15 min20030401H2031MH clubhouse svc, per diem 20030401H2032 Activity therapy, per 15 min20030401H2033 Multisys ther/juvenile 15min20030401H2034A/D halfway house, per diem 20030401H2035A/D tx program, per hour 20030401H2036A/D tx program, per diem 20030401H2037 Dev delay prev dp ch, 15 min20030401S0136 Clozapine, 25 mg 20030401S0137 Didanosine, 25 mg 20030401S0138 Finasteride, 5 mg 20030401S0139 Minoxidil, 10 mg 20030401S0140 Saquinavir, 200 mg 20030401S0141 Zalcitabine.