Coding Updates in Medicare’s 2007 OPPS Final Rule

By Caral Edelberg, CPC, CCS-P, CHC

Note: In the February 2007 Coding Edge, Caral Edelberg, CPC, CCS-P, CHC, described the Outpatient Prospective Payment System (OPPS) in application to emergency department services. In summary Edelberg discussed Medicare’s five levels of service in the emergency department and in clinics, and the two levels of critical care services, based on the presence or absence of a trauma response. This month, she takes a look at OPPS changes to drug administration, observation services and critical care hospitals. The Centers for Medicare and Medicaid Services (CMS) published its 2007 hospital OPPS final rule in the Nov. 24, 2006 Federal Register [71 Fed. Reg. 67960]. The policies went into effect Jan. 1, 2007. Drug Administration Codes Initially, each of these four HCPCS codes mapped to an APC (that is, Q0081 mapped to APC 0120, Q0083 mapped to APC 0116, Q0084 mapped to APC 0117, and Q0085 mapped to APC 0118), and the APC payment rates for these codes were made on a per-visit basis. The per-visit payment included payment for all hospital resources (except drugs that are paid separately) associated with drug administration procedures. For 2004, the Centers for Medicare and Medicaid Services (CMS) discontinued using HCPCS code Q0085 to identify drug administration services and moved to a combination of HCPCS codes Q0083 and Q0084 to allow more accurate calculations when determining Outpatient Prospective Payment System (OPPS) rates. In 2005, CMS transitioned to CPT® codes for reporting drug administration while physicians moved from CPT® codes to G-codes. Substantial revisions to the CPT® code descriptors for drug administration caused significant confusion for coding professionals since it required them to manage two different codes and descriptors — Level II G codes and Level I CPT® codes — for one service if both professional and facility billings were performed.

Certified Emergency Department Coder CEDC

In 2006, 33 new drug administration codes were put into practice but these did not reflect the concepts of initial, sequential and concurrent services while the six new HCPCS C-codes paralleled the 2005 codes for the same services. For 2007, CMS has adopted the full set of 2007 CPT® drug administration codes for use in OPPS billing. Reference to time, “up to 8 hours” and “1 to 8 hours,” has been removed for 2007. In addition, since hospitals cannot report CPT® codes inconsistent with their descriptors, the codes now include the minor surgical services (puncture procedures, etc.) that are required to administer the drugs in the drug administration process. Payment for the first hour of infusion will decrease as a result of unpackaging the payment for additional hours of infusion. Payment for multiple pushes of the same drug in a single hospital encounter will not be paid. Similarly, IV pushes and injection for pain management and other clinical conditions will not be paid separately if packaged into payment for an associated procedure. Hospitals may, however, bill for therapeutic drug administration and hydration services provided in the same encounter as long as CPT® coding instructions are followed. For example, the first hour of a therapeutic infusion and the first hour of a hydration infusion provided in one encounter through a single vascular access site will not be paid.

Observation Services CMS may add syncope and dehydration as qualifying diagnoses for observation services paid separately. The agency also will consider separate observation payment for claims that include specific minor or routine procedures withs “T” status indicators. When direct admission to observation is paid separately, HCPCS code G0379 will be assigned to APC 0604 consistent with low-level clinic visits. Critical Access Hospital (CAH) CAH standards will be revised to allow a CAH the flexibility of including a registered nurse, with training and experience in emergency care and who is on site at the CAH, as one of the qualified medical personnel available for emergency services (emergency medical screenings). The nature of the individual’s request for medical care is within the registered nurses’ scope of practice and is consistent with applicable state laws. If screening determines that the nature of the individual’s condition is outside the scope of practice, the physician, physician assistant, nurse practitioner or clinical nurse specialist must be contacted to see the patient within 30 to 60 minutes to conduct the emergency medical screening and provide stabilizing treatment.

CMS requires hospitals to report all drug administration CPT® codes consistent with their descriptions as listed in CPT®. This includes the code number, description, CPT instructions for use, and related correct coding principles. These correct coding principles include use of the drug administration codes when used in addition to separate instances if drug administration is associated with a separate procedure. The CCI edits will be considered as definitive guidance in correct use of these codes and can be reviewed at


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