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CMS Responds to Inquiry Regarding Appropriate Billing for Blood and Related Services

The Centers for Medicare and Medicaid Services (CMS) has responded to a request from the blood banking community for clarification of agency guidance regarding billing for blood products and related services. In late 2005, AABB, the American Red Cross (ARC), America’s Blood Centers (ABC) and the Advanced Medical Technology Association (AdvaMed) wrote to CMS commenting on CMS Transmittal 496 (March 4, 2005) and providing recommendations for improved guidance related to both outpatient and inpatient reimbursement for blood products and services. The blood community’s questions/recommendations along with CMS’ responses regarding coding requirements, as included in a September 29, 2006, letter to AABB, are summarized below.

Billing for Blood Processing Costs versus Blood Product Costs

Blood Groups: Many hospitals are unclear as to whether they must follow the new blood coding requirements (involving reporting the BL modifier, as well as both the 380 and 390 revenue codes). Since these hospitals obtain their blood from suppliers like ARC that do not charge for the blood itself, the hospitals pay only for blood processing and handling and, therefore, are not subject to these new requirements.

CMS: “All providers that transfuse blood are subject to the new requirements, but different requirements apply when they pay for the blood product along with processing and handling, compared to when they pay only for processing and handling…. [W]hen providers do not purchase blood (as in the case of blood acquired from the ARC) they must comply with the requirements of section 231.1, which requires that they report the HCPCS codes and charges for blood processing and handling, the number of units transfused, and the line item date of service under revenue code 39X. The instruction also states that when providers purchase blood, they must comply with the requirements of section 231.2, which requires that they report the HCPCS codes and charges for blood processing and handling, the number of units transfused, and the line item date of service under revenue code 39X with the BL modifier. They must report the HCPCS code and charges for the blood product, number of units transfused, and the line item date of service under revenue code 38X with the BL modifier.” CMS stated that it will add clarifying language regarding this policy to the updated manual instructions the agency is preparing and will also provide a MLN Matters article on the updated instructions.

Billing for Autologous Blood and Directed Donor Blood

Blood Groups: In section 231.3, CMS directs facilities to report transfused, autologous blood by using the HCPCS code that describes the blood product. The blood community is concerned that section 231.3 does not adequately address the unique costs associated with autologous and directed donor blood collection, processing and storage. “We urge CMS to reinstate its former coding policy to permit facilities to be reimbursed for the autologous collection, storage and processing by reporting CPT 86890, regardless of whether the autologous unit is transfused or not.”

CMS: “It is unclear the extent to which there are additional costs associated with the processing of autologous or directed donor blood that are not offset by savings in donor recruitment and testing costs. Because OPPS payments are based on a system of averages, we believe it is appropriate to make the same payment for all autologous and allogeneic (including directed donor) blood products, with the expectation that the specific differential costs of autologous or allogeneic units will be reflected in hospital charges that are used to establish the median costs that form the basis for the payment rates of the products.”

Blood Groups: Section 231.3 directs the provider to report CPT 86890 or CPT 86891 “on the date when the OPPS provider is certain the blood will not be transfused.” Similarly, section 231.6 directs providers to report freezing and/or thawing services, if a unit is not transfused, “on the date when the OPPS provider is certain the blood will not be transfused.” We are concerned that these date of service directives conflict with other CMS date of service reporting mandates. An appropriate solution to this problem would be to provide a directive that would reconcile with the date of surgery, the date of blood collection, or the date that the product was entered into the blood bank inventory. We also believe that if a thawed product is not transfused, facilities should be allowed to report the freeze and/or thaw on the date the procedure was performed.

CMS: “With regard to the issue of blood banks billing hospitals for the product before it is furnished to the patient, this is not different from other products, such as medical devices, which are furnished in advance of a procedure for use by a specific beneficiary and which are billed by manufacturers to the hospital a the time they are shipped. . . . We believe that if we were to permit hospitals to bill for CPT code 86890 in advance of a decision to not transfuse the blood that is documented in the medical record, the likelihood of an audit discrepancy would be increased rather than reduced. If the blood was later transfused, the hospital would not be entitled to payment for CPT code 86890, which it had wrongly claimed and for which it had been inappropriately paid.”

Billing for Split Units

Blood Groups: Section 231.4 directs hospitals to report HCPCS code P9011 (Blood (split unit), specify amount) for the blood product transfused as well as CPT 86985 (Splitting of blood or blood products, each unit) for each splitting procedure performed to prepare the blood product for a specific patient. We have received feedback from hospitals expressing concern that reporting in this manner will have a negative impact on reimbursement. We recommend that CMS ensure that the total payment for blood products that have been split (taken in the aggregate) be at least equal to the APC rate applicable before the unit was split. We also urge CMS to clarify whether special Medicare coding or documentation requirements exist for HCPCS code P9011 and, if so, to specify what those requirements are.

CMS: “Where a unit of blood is split, the blood remaining in the unit can be given to another patient and billed to Medicare with P9011 or to another payer, if the second patient is not a Medicare beneficiary. Moreover, the unit may be split into more than 2 portions and, in some cases, the hospital will receive more, not less, total payment for the unit of blood than if they had not split the unit. . . . [I]n a system of averaging, total overall payment should be appropriate, particularly when the frequency of billing for split units is so low.”

“We are not aware of [documentation] requirements [related to the instruction to hospitals to specify the amount of product billed under P9011] other than within the definition of the code. We will pursue with the HCPCS editorial board a revision of the code for the 2007 HCPCS to delete the words ‘specify amount.’”

Billing for Frozen and Thawed Blood Products

Blood Groups: Section 231.6 directs providers to bill the specific HCPCS code that describes the frozen and thawed product, if a specific code exists. It further directs that if a specific HCPCS code for the frozen and thawed blood or blood product does not exist, then the provider should bill the appropriate HCPCS code for the blood product, along with the CPT codes for freezing and/or thawing services that are not reflected in the blood product HCPCS code. We recommend that CMS be more specific as to those products that it considers to include both freezing and thawing.

CMS: See chart below to determine which products CMS considers to include both freezing and thawing and for which hospitals cannot also bill CPT codes for freezing and thawing.

HCPCS/
CPT
Short Descriptor Billing of Freezing/Thawing
P9010
Whole blood for transfusion Freezing and thawing are separately billable
P9011
Blood split unit Freezing and thawing are separately billable
P9012
Cryoprecipitate each unit Freezing and thawing codes not separately billable
P9016
RBC leukocytes reduced Alternative P-code for frozen/thawed product available
P9017
Plasma 1 donor frz w/in 8hr Freezing and thawing codes not separately billable
P9019
Platelets, each unit Freezing and thawing are separately billable
P9020
Platelet rich plasma unit Freezing and thawing are separately billable
P9021
Red blood cells unit Alternative P-code for frozen/thawed product available
P9022
Washed red blood cells unit Freezing and thawing are separately billable
P9023
Frozen plasma, pooled, sd Freezing and thawing codes not separately billable
P9031
Platelets leukocytes reduced Freezing and thawing are separately billable
P9032
Platelets, irradiated Freezing and thawing are separately billable
P9033
Platelets leukoreduced irradiated Freezing and thawing are separately billable
P9034
Platelets pheresis Freezing and thawing are separately billable
P9035
Platelets pheresis leukoreduced Freezing and thawing are separately billable
P9036
Platelets pheresis irradiated Freezing and thawing are separately billable
P9037
Platelets pheresis leukoreduced irradiated Freezing and thawing are separately billable
P9038
RBD irradiated Freezing and thawing are separately billable
P9039
RBD deglycerolized Freezing and thawing codes not separately billable
P9040
RBD leukoreduced irradiated Alternative P-code for frozen/thawed product available
P9041
Albumin (human), 5%, 50ml Concept not applicable
P9043
Plasma protein fract, 5%, 50ml Concept not applicable
P9044
Cryoprecipitate reduced plasma Freezing and thawing codes not separately billable
P9048
Plasma protein fract, 5% 250ml Concept not applicable
P9050
Granulocytes, pheresis unit Concept not applicable
P9051
Blood, l/r, cmv-neg Freezing and thawing are separately billable
P9052
Platelets, hla-m, l/r, unit Freezing and thawing are separately billable
P9053
Plt, pher, l/r, cmv-neg, irr Freezing and thawing are separately billable
P9054
Blood, l/r, frozen/degly/wash Freezing and thawing codes not separately billable
P9055
Plt, aph/pher, l/r, cmv-neg Freezing and thawing are separately billable
P9056
Blood, l/r, irradiated Freezing and thawing are separately billable
P9057
RBC, frz/deg/wash, l/r, irrad Freezing and thawing codes not separately billable
P9058
RBC, l/r, cmv-neg, irrad Freezing and thawing are separately billable
P9059
Plasma, frz between 8-24 hour Freezing and thawing codes not separately billable
P9060
Fr frz plasma donor retested Freezing and thawing codes not separately billable

Albumin HCPCS Codes

Blood Groups: We ask CMS to clarify that HCPCS codes P9041 and P9045-P9047 are still valid codes that may be used to report albumin under OPPS.

CMS: “The July 2005 OCE transmittal erroneously stated that four codes for albumin (P9041, P9045-P9047) were deleted as blood products effective 07-01-05, although the intent was to say that the OCE edits governing reporting of blood and blood products would not apply to those codes. The products represented by these codes are separately payable in 2006 as evidenced by their inclusion in Addendum B of the final rule.”

Unused Split Units and Unused Irradiated Units

Blood Groups: We ask that CMS update Sections 231.4 and 231.5 to address situations in which split units and irradiated units are not transfused.

CMS: “We will update the manual to clarify that where a unit of blood is split or irradiated specifically with the intent of transfusion to a beneficiary but is not then used, the hospital may bill for the services of splitting or irradiating the unit of blood but may not bill for the HCPCS code for the blood product that was not transfused. Moreover, the date of service must be the date on which the decision to not use the blood was made and indicated in the patient’s medical record…. Of course, where the unit of blood is split or irradiated and stored without a specific intention to administer it to a Medicare beneficiary at the time of splitting or irradiation and is not subsequently transfused, there is no service to be reported.”

Inpatient Hospital Guidance

Blood Groups: Guidance on reflecting costs associated with the use of blood and blood products in the inpatient setting would help hospitals as they attempt to report costs appropriately. We propose adding a new section, “Blood/Blood Products for Hospital Inpatients,” to the Medicare Claims Processing Manual.

CMS: “There are ten unique ICD-9-CM procedure codes describing blood transfusions … We believe hospital coders are well trained on use of the ICD-9-CM codes and note that they can consult the ICD-9-CM Guidelines for more information about use of these codes. … We do not believe there is a need to add a section to the manual instructing hospitals on how to bill for blood and blood processing services provided to hospital inpatients.”