Government Relations
GR News
January 15, 2008
Hospital Billing Alert: Claims without a Radiopharmaceutical Will Be Returned For Correction & Status "N" Reminder To Hospitals
Effective January 1, 2008, CMS implemented an Outpatient Code Edit (OCE) that will result in the return of (for correction) any claim for a nuclear medicine procedure that does not contain a HCPCS Level II radiopharmaceutical code. CMS does not state that any specific radiopharmaceutical be used with a particular nuclear medicine CPT procedure code, but one must be included on the claim form.
In setting an appropriate charge for radiopharmaceuticals, hospitals should be following the still current CMS guidelines. Federal Register Vol. 70, No 217, p. 68654, CMS states that they (CMS) “believe that hospitals can appropriately adjust their charges for radiopharmaceuticals so that the calculated costs properly reflect their actual costs. Specifically, it is appropriate for hospitals to set charges for these agents based on all costs associated with the acquisition, preparation, and handling of these products so that their payments under the OPPS can accurately reflect all of the actual costs associated with providing these products to hospital outpatients.”
The SNM cautions hospitals against applying token one cent ($0.01) or one dollar ($1.00) charges simply to get claims paid. CMS will use these claims and charges to set future payments for nuclear medicine procedures, thus causing risk to future payments should hospitals only apply token charges.
Additionally the 2008 HOPPS rule contained significant bundling, including several nuclear medicine add-on procedure codes such as CPT 78478 and CPT 78480. We have heard from SNM members that they are getting pressure from Hospital charge-master managers, billing mangers or administrators to remove any status "N" add-on codes from the final bill sent to Medicare. The SNM does not recommend deleting any status "N" CPT codes. It is important to remember that items and services labeled with status indicator "N" are still considered paid by CMS. The costs of these status "N" services were and will be used by CMS to set the final payment rates and are included in the 2008 and future APC major procedure payments. All coders and billers (charge master managers) should remember to follow HIPAA standards and report all services performed, even those with status indicator "N."
If you or your charge master managers have any questions regarding these CMS policies, please contact the SNM coding advisor, Denise A. Merlino, CNMT at dmerlino@snm.org.