Vol. 13 •Issue 4 • Page 14
Coding and Reimbursement in Transfusion Medicine
Transfusion medicine services provided by blood centers and blood banks consist of physician procedures and services; laboratory and outpatient services; and blood component manufacturing/storage/dispensing. Clinical laboratories have long had experience with the Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS Level I) for billing tests performed by the routine sections of chemistry, hematology, microbiology and others. Hospital transfusion services were comfortable with billing inpatients for blood typing, antibody screen/identification, crossmatching, etc. under the CPT system. The blood supplier submitted blood component processing fee charges to the hospital and the supplier was paid for these components. The patient was charged for usual testing performed by transfusion services for the blood component, but the blood was not charged. It was the practice in some blood centers to give “credits” on blood charges if the patient, family or friends provided a “replacement” donation for the number of units received by the patient.
In the last 10 years, however, several changes occurred that required a review and revision of transfusion service billing practices. Specifically, hospital laboratories were no longer a “revenue” center, but a cost center to the hospital budget; blood charges to the hospital from the supplier began to escalate to account for the additional infectious disease testing and stricter regulatory oversight by the FDA and other agencies; the Diagnosis Related Group (DRG)/inpatient prospective payment system (IPPS) for Medicare inpatient beneficiaries was implemented followed recently (August 2000) by an outpatient DRG (outpatient prospective payment system [OPPS]), which resulted in decreased reimbursement for blood-related services; private payers began to emulate Medicare in their reimbursement policies; and fraud and abuse in billing charges were filed against several laboratory providers. These changes required the blood industry to become actively involved in learning about proper coding and billing practices for their unique services.
Coding and Billing
Coding and billing practices in blood/tissue bank services are no different than other laboratory sections—maintain accountability by always doing the right thing (know the rules); perform accurate billing so you are reimbursed for doing the right thing (bill for every blood-related activity performed); and ensure compliance in billing so you know the right thing is done (perform regular audits). Also:
• Use the correct three-digit revenue code (code to designate location where service was performed–38X series for in-house collected blood components; 39X series for blood components received from a supplier; and 30X laboratory series for CPT/HCPCS Level I transfusion medicine services).
• Use the exact CPT/HCPCS Level I transfusion medicine code(s) for all technical procedures performed linked to a blood component regardless of transfusion status. Use the appropriate HCPCS Level II alphanumeric code for blood components and derivatives (J, P, Q). Designate the correct quantity of blood components/derivative “units” actually transfused. Identify the number of tests performed on the blood component ordered for a patient regardless of transfusion .status. Use CPT 36430 once per day per patient receiving blood component transfusions. Use correct International Classification of Disease, Ninth Edition, Clinical Modification (ICD-9-CM) procedure and diagnosis codes for IPPS billing. Review/revise the facility Chargemaster (CDM) at least semi-annually to reflect changes in the Centers for Medicare and Medicaid Services (CMS) coding requirements.
Changes for 2004
The CMS released several revised OPPS codes on Nov. 1, 2003 for transfusion medicine services: All blood component C-codes were converted to P-codes (P9051-P9060). The P9011 code for splitting (aliquotting) blood components was given a “K” status indicator allowing for reimbursement in 2004 for this activity. National Correct Coding Initiative (NCCI) edits for comprehensive/component and mutually exclusive blood-related codes were revised to allow for the use of CCI modifiers where appropriate (additional revisions are .expected).
Also, reimbursement for OPPS blood-related services in 2004 had been proposed by CMS to reflect an 11 percent reduction for these services, but was reversed and frozen at the 2003 rates. As CMS reimbursement rates are based on historical claim charge databases, it is imperative for the blood community to accurately code for all transfusion medicine services to ensure that realistic reimbursement is received.
The American Association of Blood Banks and industry partners have made progress in advising CMS about deficiencies and inaccuracies in transfusion medicine coding and reimbursement, and important changes have been made, particularly in the OPPS rules. Work continues to make the HCPC coding system more user friendly, both in the IPPS and OPPS, by proposals to streamline coding activities; allow for current/future technologies such as electronic crossmatching and pathogen inactivated blood components; and acquire accurate and current cost data associated with blood manufacturing, testing, storing, preparing, issuing and transfusing safe blood components to our patients.
Dr. Lockwood is chair, American Association of Blood Banks Coding & Reimbursement Committee, and director, Transfusion Services, University of Louisville (KY) Hospital & Norton-Kosair Children’s Hospitals.