Section 231, Billing and Payment for Blood and Blood Products under the Hospital Outpatient Prospective Payment System, has been created and added to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 4, to provide and clarify billing instructions for blood and blood products under the OPPS.
Section 231 includes billing instructions regarding the use of new HCPCS modifier BL, billing policies on billing for autologous blood and directed donor blood, split units of blood, irradiation of blood products, frozen and thawed blood and blood products, unused blood, transfusion services, pheresis and apheresis services, and correct coding initiative edits.
Providers paid under the OPPS should report charges for blood and blood products according to the policies addressed within Section 231, effective for services on or after July 1, 2005.
Following is a summary of the new chapter and its contents.
Modifier BL and revenue codes 038X, 0390 and 0399
HCPCS modifier BL was created to be reported with the appropriate blood product HCPCS code. If an OPPS provider incurs charges for the blood or blood product itself and also incurs costs for the processing and storage of the blood, the provider must separate the charges for the two fees. The charge for the blood or blood product should be reported with revenue code 038X along with the line item date of services (LIDOS), the number of units transfused, and the appropriate HCPCS code with modifier BL.
The charge for the processing and storage should be reported on a separate line using either revenue code 0390 or 0399, with the LIDOS, number of units transfused, and the appropriate HCPCS code with modifier BL. Effective on or after July 1, 2005, the Outpatient Code Editor (OCE) will return claims that report charges with revenue code 038X without reporting a separate line item with revenue code 0390 or 0399 for the processing/storage costs. Payment for blood and blood products will be based on the APC group to which the reported HCPCS code is assigned to, multiplied by the number of units transfused.
If the provider only incurs charges for processing and storage, not for the blood product, the provider should bill for these charges using revenue code 0390 or 0399 along with the HCPCS blood code, the number of units transfused, and the LIDOS.
Autologous blood and directed donor blood
When billing for an autologous or directed-donor blood transfusion performed, the OPPS provider should bill for the transfusion service and the blood product HCPCS code on the date that the transfusion occurred, not when the blood was collected. When autologous blood is collected but not transfused, providers should bill with CPT code 86890 or 86891 along with the number of units collected but not transfused. The procedure should be reported on the date that the provider is certain that the transfusion will not occur (i.e. date of discharge or date of a procedure), not the date that the collection took place.
Billing for split unit of blood
If a patient receives a transfusion using a split unit of blood or blood product, HCPCS code P9011 should be coded for the blood product transfused, along with CPT code 86895 for each splitting procedure performed to prepare the blood or blood product for that patient, and a CPT code for the actual transfusion. If there is any remaining blood or blood product that is used in a patient, providers should only report P9011 and the CPT code for the transfusion service, since splitting is not performed on the remaining product.
Billing for irradiation of blood products
If a patient receives a medically reasonable and necessary transfusion of irradiated blood, the provider should bill the appropriate HCPCS code for that product and the CPT code for the transfusion. If a specific HCPCS code is not available for the irradiated blood product, assign a HCPCS code for the blood product, CPT code 86945 for the irradiation of the blood product, and a code for the transfusion. Do not assign code 86945 separately if there is a specific HCPCS code for the irradiated blood product, since the irradiation is inherent in that code assignment. HCPCS codes for irradiated blood include:
P9032: Platelets, irradiated, each unit
P9033: Platelets, leukocytes reduced, irradiated, each unit
P9036: Platelets, pheresis, irradiated, each unit
P9037: Platelets, pheresis, leukocytes reduced, irradiated, each unit
P9038: Red blood cells, irradiated, each unit
P9040: Red blood cells, leukocytes reduced, irradiated, each unit
P9053: Platelets, pheresis, leukocytes reduced, CMV-negative, irradiated, each unit
P9056: Whole blood, leukocytes reduced, irradiated, each unit
P9057: Red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit
P9058: Red blood cells, leukocytes reduced, CMV-negative, irradiated, each unit
Billing for frozen and thawed blood and blood products
If a patient receives a transfusion of frozen blood or blood product that was frozen and thawed for that specific patient prior to transfusion, report a HCPCS code that describes the frozen/thawed product and the CPT code for the transfusion. If a specific HCPCS code is not available for the frozen/thawed product, report a code for the blood product, a CPT code for the freezing and/or thawing services, and a CPT code for the transfusion. Do not assign a CPT code for freezing and/or thawing if a specific HCPCS code is available that specifies that the blood product is frozen and/or thawed.
Billing for unused blood
If processing and storage costs are incurred for a blood or blood product that is not used, the provider may be able to bill for those charges if patient-specific preparation was made, including blood-typing and cross-matching. These costs should be reported using revenue code series 030X or 031X. These charges should be billed on the date the service was provided.
The OPPS provider should report processing and storage costs for unused blood products under cost centers for blood on their Medicare Cost Report. These costs are not considered patient-specific blood preparation services. The OPPS provider should also report costs for purchased but unused blood products under this same cost report.
Billing for transfusion services
To accurately report transfusion services, providers should report the appropriate CPT code with revenue code 0391 along with a HCPCS code for the blood product transfused. Payment is made on a per service basis, not by the number of units transfused. A transfusion APC payment is paid once per day regardless of the number of units or different types of products transfused.
Billing for pheresis and apheresis services
Pheresis and apheresis services should be billed on a per visit basis, not a per unit basis. An Evaluation and Management (E&M) code should be assigned only if a separately identifiable E&M service is performed which extends beyond the usual services provided for pheresis/apheresis. In claims where a separate E&M code is used, it may be appropriate to use modifier -25.
Correct coding initiative (CCI) edits
Providers should consult the most current list of CCI edits to determine if they apply to the services or codes reported. A current list of CCI edits that are applicable to Medicare Part B services paid under OPPS can be found at http://www.cms.hhs.gov/providers/hopps/cciedits.
Refer to Transmittal 496 for further information regarding Billing for Blood and Blood Products Under the Hospital Outpatient Prospective System (OPPS) at http://www.cms.hhs.gov/manuals/pm_trans/r496cp.pdf.