Coding Drug Administration Services for Payment Under the CY 2006 OPPS
CMS issued Transmittal 785 (Change Request 4258), on December 16, 2005 to revise Chapter 4, Section 230 of the Medicare Claims Processing Manual (Pub. 100-04). The manual revision updated payment policies for drug administration services furnished under the Hospital Outpatient Prospective Payment System (OPPS) effective January 1, 2006. In response to requests for further clarification of correct coding for drug administration services paid under the OPPS, CMS further revised Chapter 4, Section 230 of the Medicare Claims Processing Manual in Transmittal 902 (Change Request 4388), issued on April 7, 2006. The link to these transmittals is: http://www.cms.hhs.gov/Transmittals/2006Trans/list.asp.
Transmittal 896, Change Request 5011, issued on March 24, 2006, instructed fiscal intermediaries to implement Version 12.0 of Correct Coding Initiative (CCI) edits for drug administration services paid under the OPPS that are furnished on or after April 1, 2006. When an OPPS claim triggers a CCI edit, the entire claim is not rejected or returned. Rather, only one line item is rejected. That is, the CCI edits identify pairs of codes that are not appropriately reported together unless an edit permits use of a modifier to signal that the codes represent separate and distinct services/procedures.
Hospitals have raised particular concerns about the impact of CCI edits when the following code pairs are reported on the same claim for the same date of service without modifier -59. Because these codes represent services which may be frequently furnished together during a single outpatient encounter, hospitals report that they would have to review virtually every outpatient claim to manually add modifier -59 so that claims with these code pairs would process to payment without triggering a CCI edit.
| Column 1 | Column 2 |
| C8950 | C8952 |
| C8953 | C8950 |
| C8953 | C8952 |
| C8954 | C8950 |
| C8954 | C8952 |
| C8954 | C8953 |
CMS is currently working to resolve as swiftly as possible concerns that have been raised by numerous hospitals about the impact of CCI edits on reporting these particular code pairs. CMS will announce on the CMS website, through the hospital listserv, through contractors, and through other communication channels the steps it is taking to address the issues raised by hospitals in connection with these particular CCI edits. Hospitals are encouraged to await instructions from their fiscal intermediary before modifying internal billing processes.
