Question SI J1


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I have a claim for the following CPT codes, 23412, 29822, 23440 and 23120. All codes have a status indicator of J1. According to what I am reading from Medicare, the only paid CPT will be the 23412 and the other three remaining codes will be bundled into the primary CPT, 23412. Am I reading this information correct?

This is one guideline I have read:
Paid under OPPS; all covered Part B services on the claim are packaged with the primary "J1" service for the claim, except services with OPPS SI=F,G, H, L and U; ambulance services; diagnostic and screening mammography; all preventive services; and certain Part B inpatient services.

Thanks for your help, Gina


True Blue
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You are partially correct - under OPPS, encounters that include a J1 status code are paid at a single case rate and that is usually reflected in the payment seen at the line level of the highest value procedure code. But it's not correct to say that other codes are 'bundled' - rather the terminology is that they are 'packaged', which is a slightly different concept from bundling. Bundled codes are denied as inappropriately reported since the value of those codes is included in another code reported and paid. Packaged codes, on the other hand, are correctly reported and not incidental to another code, but the payment for those codes is included in the case rate assigned to that encounter.

You have to keep in mind that OPPS is, as the name suggests, a 'prospective' reimbursement system which is much different from a fee-for-service methodology. Unlike fee-for-service where each code is assigned a value, under OPPS, similar classes of procedures are grouped together and assigned a payment level which is supposed to represent the average cost of all encounters in that category. Packaged codes are not denied, they are an important part of the correct reporting of the claim, and are in fact used for calculation of payment, but those codes do not get a separate individual payment at line level. On OPPS claims, you have to consider the entire claim to determine the correct payment, not the individual codes or charges. Hope that helps some.