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CRIP, section 4-1

Certified Revenue Integrity Professional, Surgical Services and Procedures

QuestionAnswer
Kidney Transplant: How is it billed? The excising hospital charges to the transplant hospital. Transp hospital keeps an ibill for all charges incurred. Transplant should be billed as average all-inclusive cost associated with each type of transplant (live donor vs. cadaver) Rev Code: 081X
Live Donors: how are they billed? excision svcs are hospital part A. svcs rendered to a living donor and all physician svcs provided to recipient are billed to MC in the same manner as all MC part B svcs. donor's physician's svcs are billed on recipients acct w/ Mod Q3
What does Modifier Q3 mean? Live kidney donor and related services.
Rev codes for Living vs Cadaver Donors 0811: Living Donor Kidney Acquisition 0812: Cadaver Donor Kidney Acquisition
What does MCE stand for? Medicare Code Editor
What is Occurence Code 36 and when is it used? The date of the IP hospital discharge for covered transplant patients. this would be used on a donors bill to the recipient's insurance for bill incurred for complications from donor procedure. Mod Q3 should also be used on all related HCPCS codes
Relationship code for organ donor use patient relationship code 39 - Indicating an organ donor
What is a stem cell transplant? A process where stem cells are harvested from either the patient's (autologous) or donor's (allogeneic) bone marrow or by peripheral blood for intravenous infusion.
Autologous stem cell transplant: Uses pt's own cells that were previously stored to effect hematopoietic reconstitution following severely myelotoxic doses of chemo and/or radiation.
Allogenic stem cell transplant: A portion of a healthy donor's stem cells are obtained and prepared for intravenous infusion to restore normal hematopoietic function in recipients having an inherited or acquired hematopoietic deficiency or defect.
How does MC reimburse for stem cell acquisition when there is a donor involved (allogeneic)? pmt is included in the MS-DRG pmt for the transplant when it is done as IP. When done as OP, it is made based on OPPS APC pmt. MAC doesn't make a separate pmt b/c hospitals can only bill for svcs provided to the recipient of a stem cell transplant.
What is Revenue Code 0819 reserved for? Other Organ Acquisition (eg: use for acquisition of stem cells when billing as OP)
What is Revenue Code 0362 reserved for? Organ Transplant, other than kidney (eg: use for the charges for stem cell transplant)
Per the CMS NCD for it, what needs to be noted for Bariatric Surgery? Medical hX physical exam results of pertinent dx tests or procedures Evidence of any unsuccessful medical treatment for obesity
What are the procedures that are reimbursable for Bariatric Surgery? - An open laparoscopic Roux-en-Y Gastric bypass - open laparoscopic biliopancreatic diversion w/ duodenal switch - laparoscopic adjustable gastric banding
What are the patient requirements for Bariatric surgery per MC NCD? - must have BMI of 35 or greater - must have at least 1 co-morbidity related to obesity - must have been previously unsuccessful w/ medical trmt for obesity
Where can bariatric surgery be done per CMS guidelines? only at facilities that are: Certified by the American College of Surgeons as a level 1 bariatric surgery center OR - Certified by the American Society for Bariatric Surgery Center of Excellence All procedures are IP only
What procedures are NOT covered for MC beneficiaries? - Open adjustable gastric banding - Open and laparoscopic sleeve gastrectomy - Open and laparoscopic vertical banded gastroplasty - Gastric balloon -Intestinal bypass If billing for one of these, HINN must be obtained prior to surgery.
What does a Status Indicator C mean per CMS and Tricare? The procedure is IP only (IPO), based on the nature of the procedure, physical condition of the pt or the need for at least 24 hrs of post-op recovery or monitoring time prior to safe discharge.
What does OCE stand for and what does it do? Outpatient Code Editor edits any OP claim containing a CPT code that has a status indicator C. Under APCs, IPO claims billed as OP is not assigned to an APC and therefore not payable. Must be billed for denial, should not be removed from the claim.
What is the exception to the IPO rule for CMS and Tricare? - If the procedure was performed under emergency circumstances or - If the pt expires prior to admission after procedure is performed. In this case, use a CA modifier
What are the rules for billing with a CA modifier? - The patient is an outpatient - pt had an emergent, life threatening condition -The procedure on the IPO list is performed on an emergency basis to resuscitate or stabilize the patient -Pt expired without being admitted to the hospital
When will a CA modifier trigger an OCE edit review? If there is a CA modifier on the UB with a discharge status other than 20 (meaning pt expired) or the CA modifier is reported more than once.
Inpatient Separate Procedures Certain Status Indicator C procedures CMS and Tricare will bypass when performed incidental to a surgical procedure that is not IPO. Charge line w/ status indicator C will be denied but the rest of the claim will be processed and paid.
What steps should be taken if a denial is received due to an IPO procedure being billed as OP? Validate w/ Case Management that the OP status is correct and that no IP order has been written. Validate w/ HIM or the Coding Dept that the CPT code is correct.
Bedside Procedure rules - A treatment room is considered a separate room and is the only acceptable sub for an operating room charge for lesser procedures. No appropriate rev code for extensive procedures performed at pt's bedside, so cannot be reported on IP claim.
Created by: Amy17349
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