2016 Coding Guide. Hospital Outpatient Physician Freestanding Facility. Reimbursement Hotline
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1 2016 Coding Guide Hospital Outpatient Physician Freestanding Facility Reimbursement Hotline solutions.com Ph:
2 2016 Coding & Payment Options Hospital Outpatient, Physician And Freestanding Center The codes listed in this guide are options only and not intended to drive coding or reimbursement. Some codes may be considered a component of another code and not separately payable (e.g., CCI edits). Codes/procedures shown may not always be performed, multiple payment reduction, physician specific coding options, etc. Coding of diagnoses and procedure codes is dependent on the documentation in the patient s medical record. Current Procedural Terminology () is copyright 2015 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Medicare 2016 National Average Hospital Outpatient Payment Rates Possible Coding Options In the Hospital Outpatient Setting APC Group/ Indicator Medicare 2016 National Average CT for treatment planning (optional) N $ Simulation, complex 5613 / S $ Simulation, 3-D 5614 / S $1, Special medical physics consult 5612 / S $ Special treatment procedure 5623 / S $ Unlisted breast procedure (application of catheter) 5091 / T $2, Simulation, simple 5612/ S $ / S $ Treatment device 5611 / S $ * Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels 5624 / S $696 C1717 Radiation source (Ir-192) 2646 / U $294 APC Indicators: N = Packaged; S = Procedure not discounted when multiple; T = Procedure, Multiple Reduction Applies when performed in conjunction with another T status indicator; U = Brachytherapy Source Page 2 January 2016
3 Medicare 2016 National Average Physician Facility Payment Rates Possible Coding Options - Physician Services Provided In the Hospital Outpatient Setting (Facility) The following 2016 Medicare national average payment rates are specific to physician services provided in the facility (e.g., hospital outpatient) setting. Off-site hospital-owned sites are also considered as facilities in the context of payment. Non-facility services are generally provided in a freestanding physician s office and are discussed on the next page. code Medicare 2016 National Average Physician Payment (Facility setting) CT for treatment planning (optional) $ Therapeutic radiology treatment planning, complex $ Simulation, complex $ Simulation, 3-D $ Special medical physics consult $ Special treatment procedure $ Unlisted breast procedure (application of catheter) Paid by Report Simulation, simple $ Treatment device $ * Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels National average physician payment rates are based on the Medicare Physician Fee Schedule (MPFS) rates and conversion factor $ as outlined in the CY2016 MPFS Final Rule. Note: CCI edits should be checked quarterly when using any of the coding options presented. $96 $199 Page 3 January 2016
4 Medicare 2016 National Average Physician Non-Facility Payment Rates Possible Coding Options - Physician Services Provided in the Physician Freestanding Office (Non-Facility) The following 2016 Medicare national average payment rates are specific to physician services provided in the non-facility setting. The term non-facility setting refers to physician-owned freestanding offices or centers. National average physician payment rates are based on the Medicare Physician Fee Schedule (MPFS) rates and conversion factor $ as outlined in the CY2016 MPFS Final Rule. Note: CCI edits should be checked quarterly when using any of the coding options presented. code Medicare 2016 National Average Physician Payment (Non-Facility setting / Freestanding Office) CT for treatment planning (optional) $ Therapeutic radiology treatment planning, complex $ Simulation, complex $ Simulation, 3-D $ Special treatment procedure $ Special medical physics consult $ Unlisted breast procedure (application of catheter) Paid by Report Simulation, simple $ Treatment device $ * Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels Q3001** HDR source ** **Medicare does not pay separately for HDR sources in the Freestanding office. Private payors should be contacted for their billing and payment guidelines in this site of service. $248 $604 Page 4 January 2016
5 FREQUENTLY ASKED QUESTIONS ALL PROVIDERS 1. Why is AccuBoost described as interstitial brachytherapy rather than surface brachytherapy? Brachytherapy can be delivered with needles or catheters within the tumor (interstitial), an applicator within a cavity (intracavitary), or an applicator adjacent to the tumor (surface). New codes were developed effective January 1, 2016 to better describe the work performed for each method of delivery. The new codes and various brachytherapy delivery methods are described as follows: HDR radionuclide surface brachytherapy treatments for skin cancer needed to be accurately described, as the work of treating skin cancers with HDR radionuclide surface brachytherapy is different than the work of treating other tumors with HDR radionuclide brachytherapy. Therefore, two new codes (77767, 77768) specifically for HDR radionuclide skin surface brachytherapy treatment, including basic dosimetry, have been established. In addition, existing codes were revised and renumbered to 77770, 77771, and to describe HDR radionuclide brachytherapy for treating tumors other than skin, and include the work of basic dosimetry calculation (77300). (AMA 2016 Change) 2. Why isn t code (basic dosimetry calculation) included as a coding option? The new 2016 codes used to describe remote afterloading ( 77770, 77771, 77772) include the work of basic dosimetry calculation. An exclusionary parenthetical note indicating that all of the HDR radionuclide brachytherapy codes should not be reported in conjunction with code has been added to the new codes. PHYSICIANS 3. In regards to physician payment, what is meant by freestanding office or non-facility and why is there a difference payment amount? Under the Medicare Physician Fee Schedule (MPFS), some procedures have different payment amounts for physician s professional services when provided in a facility (hospital setting) or a nonfacility (e.g., office). Facility services are generally provided within a hospital, hospital-owned surgery center, ambulatory surgery center, or skilled nursing facility. In the Facility setting the costs of supplies and personnel that assist with services - such as interventional procedures - are borne by the hospital whereas those same costs are borne by the provider of services in a Non-Facility setting. Non-Facility services include, but are not limited to, physician clinics, urgent care centers, home services, etc. In some instances, additional payment is made to physicians for procedures performed in their office (non-facility) to compensate for providing clinical staff, supplies, and equipment. Medicare does not make separate or additional payment for the HDR source in the Freestanding office. Private payors should be consulted for their coding and payment guidelines. Page 5 January 2016
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