Wiki Can this revenue code be billed without a CPT/HCPCS?

CarlyN

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I've just received my CPC-A and have no billing experience. I'm trying to educate myself with these billing scenarios and would appreciate guidance on what steps I would take to find the conclusion.

"A home health and hospice care facility is billing revenue code 272 with no HCPCS or CPT code.
This revenue code is not included in the provider’s contract but can be added if it is determined that the
code is payable with no HCPCS code. Can you confirm if the revenue code can be billed without a
CPT/HCPCS?"

Doesn't it depend on the insurance provider? And does each payer have their own list of revenue codes that are billable without HCPCS/CPT codes? Also, wouldn't I need to know under what setting it's being billed such as care received at home, a nursing home, or the hospital? Again, any guidance would be greatly appreciated!
 
This is a complex area but the short answer is yes, it does depend on the insurance provider. Hospital reimbursement is based on the contract with the payer and their reimbursement policies, or in the case government payers, on the regulations. Some payment methods are based on HCPCS codes and their assigned fee schedules, and other pay a percentage of billed charges without consideration for the HCPCS codes billed. Medicare's OPPS is especially complex, because it considers some HCPCS codes, but others are 'packaged' under certain conditions, which means that the specific HCPCS code is not separately paid on that claim when another procedure includes a case rate that covers the entire encounter. So how and when a HCPCS code is required, and whether or not that code may affect the final payment, will vary greatly between payers and even between different kinds of claims.

All that said, revenue code 272 typically does not require a HCPCS code, because this revenue is used by most facilities to capture a wide variety of supply charges, many of which do not have assigned codes, and which are also usually considered incidental to some other service performed at the encounter. Revenue code 272 is usually not a primary service since a hospital normally does not just dispense supplies to patients, and the charges allocated to that revenue code are most often just a sum of the various supplies used, for example, during an infusion or a surgical procedure. Revenue code 360, by contrast, usually does require a HCPCS code (on an outpatient claim) since that identifies the primary surgery that often defines the payment for the entire claim. But again, this can vary between payers, and by contract.

Regarding your last question, the bill type of the facility claim will tell you the setting, whether it's hospital inpatient, outpatient, nursing facility, home health, hospice, etc. Revenue codes are shared among all of these settings, but the bill type tells the payer what type of claim it is.

For Medicare, a good place to start reading in this area is Chapter 4 of the Claims Processing Manual, which you can find under the link below. You'll find some of the specific guidance on reporting of HCPCS codes for supplies starting in section 20.1 on page 52.

 
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This is a complex area but the short answer is yes, it does depend on the insurance provider. Hospital reimbursement is based on the contract with the payer and their reimbursement policies, or in the case government payers, on the regulations. Some payment methods are based on HCPCS codes and their assigned fee schedules, and other pay a percentage of billed charges without consideration for the HCPCS codes billed. Medicare's OPPS is especially complex, because it considers some HCPCS codes, but others are 'packaged' under certain conditions, which means that the specific HCPCS code is not separately paid on that claim when another procedure includes a case rate that covers the entire encounter. So how and when a HCPCS code is required, and whether or not that code may affect the final payment, will vary greatly between payers and even between different kinds of claims.

All that said, revenue code 272 typically does not require a HCPCS code, because this revenue is used by most facilities to capture a wide variety of supply charges, many of which do not have assigned codes, and which are also usually considered incidental to some other service performed at the encounter. Revenue code 272 is usually not a primary service since a hospital normally does not just dispense supplies to patients, and the charges allocated to that revenue code are most often just a sum of the various supplies used, for example, during an infusion or a surgical procedure. Revenue code 360, by contrast, usually does require a HCPCS code (on an outpatient claim) since that identifies the primary surgery that often defines the payment for the entire claim. But again, this can vary between payers, and by contract.

Regarding your last question, the bill type of the facility claim will tell you the setting, whether it's hospital inpatient, outpatient, nursing facility, home health, hospice, etc. Revenue codes are shared among all of these settings, but the bill type tells the payer what type of claim it is.

For Medicare, a good place to start reading in this area is Chapter 4 of the Claims Processing Manual, which you can find under the link below. You'll find some of the specific guidance on reporting of HCPCS codes for supplies starting in section 20.1 on page 52.


Thank you so much, Thomas, for your quick and thorough reply. This information is very helpful to me and I have a better understanding of it.

Cheers!
 
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