Wiki Facility outpatient infusion clinic coding

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AlisiaJ

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Hello, Does anyone have any information on their denials for billing two initials (96365 x2) on one day ? The internet only manuals for Medicare state that you can with a modifier. However, coding guidance says you can not unless it is two separate lines. I am wondering if there is anyone who has experience with this and could give some insight. As I know within the hospital outpt setting it falls under OPPS rules and one admin per course of service. However, this is a different setting and would not fall under OPPS rules, correct?
Thank you for your insight.
 
I can try to help but I'm a little confused about what you're asking. Coding guidelines (in CPT) do say that multiple initial service codes can be report when 'protocol requires that two separate IV sites must be used' - if that's the case, then you can bill 96365 twice, with modifier 59 (or XU) or on the second code. It shouldn't create a problem with reimbursement - what does their denial say? Also, I'm not sure what you're meaning by it not falling under OPPS because of this being a different setting? Are you billing a hospital or a physician claim? If it's an outpatient hospital claim, then it will fall under OPPS.
 
thomas7331 said:
I can try to help but I'm a little confused about what you're asking. Coding guidelines (in CPT) do say that multiple initial service codes can be report when 'protocol requires that two separate IV sites must be used' - if that's the case, then you can bill 96365 twice, with modifier 59 (or XU) or on the second code. It shouldn't create a problem with reimbursement - what does their denial say? Also, I'm not sure what you're meaning by it not falling under OPPS because of this being a different setting? Are you billing a hospital or a physician claim? If it's an outpatient hospital claim, then it will fall under OPPS.
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Thank you Thomas, yes this is a hospital outpt infusion facility claim, does this still fall under OPPS? Or does this fall under Medicare part b guidelines since the patient is leaving and not actually in the hospital? I don't know what the denial says specifically, just told they are denied. Thanks again :)
 
AlisiaJ said:
Thank you Thomas, yes this is a hospital outpt infusion facility claim, does this still fall under OPPS? Or does this fall under Medicare part b guidelines since the patient is leaving and not actually in the hospital? I don't know what the denial says specifically, just told they are denied. Thanks again :)
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If the two 96365 codes are billed on separate lines and the appropriate modifier was added to the additional code, then this should not have caused a denial - it's either a payer error or there is some other reason or problem on the claim causing the denial.

Not sure what you mean by 'Part B guidelines'? OPPS is the reimbursement methodology for outpatient facility claims - it doesn't really have anything to do with coding guidelines or with whether the service is covered under Part A or Part B.
 
thomas7331 said:
If the two 96365 codes are billed on separate lines and the appropriate modifier was added to the additional code, then this should not have caused a denial - it's either a payer error or there is some other reason or problem on the claim causing the denial.

Not sure what you mean by 'Part B guidelines'? OPPS is the reimbursement methodology for outpatient facility claims - it doesn't really have anything to do with coding guidelines or with whether the service is covered under Part A or Part B.
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I see what you mean why that would be confusing. The argument I am receiving is only two admins can be charged if there are two different access sites regardless of what the guidelines state about a modifier in the facility billing. So what I was trying to determine was where this information is coming from, if I am missing something and where to find it. Do you have any resources you can share for these facility infusions vs physician infusions, what is payable, and documentation stating it has to be a separate site for facility billing? I have shared all I have found IOM, LCD, NCD and I get the same response of needing to be a separate site to bill two admins. Thanks again
 
AlisiaJ said:
I see what you mean why that would be confusing. The argument I am receiving is only two admins can be charged if there are two different access sites regardless of what the guidelines state about a modifier in the facility billing. So what I was trying to determine was where this information is coming from, if I am missing something and where to find it. Do you have any resources you can share for these facility infusions vs physician infusions, what is payable, and documentation stating it has to be a separate site for facility billing? I have shared all I have found IOM, LCD, NCD and I get the same response of needing to be a separate site to bill two admins. Thanks again
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In addition to the guidance in CPT I quoted above, you can find it in the NCCI Policy Manual, Chapter 11, Section B, Paragraph 2:

CPT codes 96360, 96365, 96374, 96409, and 96413 describe “initial” service codes. For a patient encounter, only one “initial” service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate intravenous access sites. To report two different “initial” service codes, use NCCI PTP-associated modifiers.

As far as I know, this applies to both facility and physician billing - I'm not aware of any guidelines that states it would apply only to one or the other.
 
thomas7331 said:
In addition to the guidance in CPT I quoted above, you can find it in the NCCI Policy Manual, Chapter 11, Section B, Paragraph 2:

CPT codes 96360, 96365, 96374, 96409, and 96413 describe “initial” service codes. For a patient encounter, only one “initial” service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate intravenous access sites. To report two different “initial” service codes, use NCCI PTP-associated modifiers.

As far as I know, this applies to both facility and physician billing - I'm not aware of any guidelines that states it would apply only to one or the other.
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Thanks Thomas appreciate you! So are you also interpreting this to mean there has to be different sites in order to report two? I think the other part of that I failed to mention is that the patient left and returned on the same day for two separate infusions of the same drug. But this appears to say they can only be billed if two separate sites were used, correct?
 
AlisiaJ said:
Thanks Thomas appreciate you! So are you also interpreting this to mean there has to be different sites in order to report two? I think the other part of that I failed to mention is that the patient left and returned on the same day for two separate infusions of the same drug. But this appears to say they can only be billed if two separate sites were used, correct?
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Can you send me your link to the NCCI policy manual?
 
AlisiaJ said:
Thanks Thomas appreciate you! So are you also interpreting this to mean there has to be different sites in order to report two? I think the other part of that I failed to mention is that the patient left and returned on the same day for two separate infusions of the same drug. But this appears to say they can only be billed if two separate sites were used, correct?
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Separate sites at any encounter, it says. So if the patient left and then returned, that would be a separate encounter and would qualify for the XE modifier. (But seem to remember that a facility needs to submit separate encounters on separate claim and add an occurrence or condition code to the UB-04 indicate this, if I remember correctly. I don't work on the billing, so I haven't kept current on these things.)
 
thomas7331 said:
Separate sites at any encounter, it says. So if the patient left and then returned, that would be a separate encounter and would qualify for the XE modifier. (But seem to remember that a facility needs to submit separate encounters on separate claim and add an occurrence or condition code to the UB-04 indicate this, if I remember correctly. I don't work on the billing, so I haven't kept current on these things.)
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That is the same argument I had but they are saying no it is not payable because it says separate site and not separate encounter.
 
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AlisiaJ said:
That is the same argument I had but they are saying no it is not payable because it says separate site and not separate encounter. They being supervisor.
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It's an unusual situation you have here and if your supervisor wants to do it that way, I would just let it go. In my opinion, if there's a medically necessary reason for two separate infusions at two separate encounters on the same day, and the second encounter requires starting a new IV access, then the a modifier would be warranted and a new initial service code would be appropriate. But supervisors and managers have to make judgment calls in unusual situations that aren't clearly spelled out in coding guidelines - that's part of their responsibility - so if it's not a frequent situation where you're billing out a lot of claims that are potentially incorrect, I would just defer to them and not worry about it.
 
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