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Transfusion Confusion:
How to Avoid Being a RAC Target
Presented by:
Robin Miller Zweifel, BS, MT(ASCP)
Vice President of Clinical Consulting Services
Panacea Healthcare Solutions
May 28, 2013
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 1
Disclaimer
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Panacea has prepared this seminar using official Centers for Medicare and Medicaid Services (CMS) documents
and other pertinent regulatory and industry resources. It is designed to provide accurate and authoritative
information on the subject matter. Every reasonable effort has been made to ensure its accuracy. Nevertheless,
the ultimate responsibility for correct use of the coding system and the publication lies with the user.
Panacea, its employees, agents and staff make no representation, warranty or guarantee that this information is
error-free or that the use of this material will prevent differences of opinion or disputes with payers. The company
will bear no responsibility or liability for the results or consequences of the use of this material. The publication is
provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied
warranties or merchantability and fitness for a particular purpose.
The information presented is based on the experience and interpretation of the publisher. Though all of the
information has been carefully researched and checked for accuracy and completeness, the publisher does not
accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation.
Current Procedural Terminology (CPT ®) is copyright 2011 American Medical Association. All Rights Reserved. No
fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for
the data contained herein. Applicable FARS/DFARS restrictions apply to government use.
CPT® is a trademark of the American Medical Association.
Copyright © 2013 by Panacea. All rights reserved.
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No part of this presentation may be reproduced in any form whatsoever without written permission from the
publisher
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Published by Panacea, 287 East Sixth Street, Suite 400, St. Paul, MN 55101
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 2
Cost associated with Purchase
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Costs associated with acquisition, storage and processing of blood and blood products continues
to escalate each year.
In 2011 it was estimated that more than 14 million units of red blood cells were transfused
annually in the United States.
Information from this study was taken from a total of 213 surveys completed by hospital-based
blood bank and transfusion service directors.

The study cited significant statistical variation in acquisition cost by US census region,
division and type of facility.
The mean (SD) acquisition cost for one unit of red blood cells purchased from a supplier ranged
from $172 to $248 with a national mean of $210.74
The mean charge to the patient by the hospital was reported to be between $208 and $478 with a
national mean of $343.63.
Based on information submitted by facilities participating in the survey the variance in associated
costs to perform mandated screening was significant
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median cost to perform mandated screening procedures (n = 56) was $50.00 ± 120 per unit
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median storage and retrieval cost (n = 46) was $68.00 ± 81 per unit.
http://www.ncbi.nlm.nih.gov/pubmed/21174480
Costs to hospitals of acquiring and processing blood in the US: a survey of hospital-based blood banks and transfusion services.
Toner RW, Pizzi L, Leas B, Ballas SK, Quigley A, Goldfarb NI.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 3
Cost associated with Transfusion
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Considering all complex cost factors leading up to and after a red
blood cell transfusion.
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Transfusion cost is $522 to $1,183 per unit.
 37% higher than estimated by prior studies
Annual transfusion costs total $1.6 to $6 Million per hospital surveyed.
Failure to report transfusion, blood product processing charges and pretransfusion tests impacts reimbursement today and tomorrow.
Facilities should NOT assume that transfusion services are consistently
charged, that charges drop to claims or that claims are paid.
New Published Study Finds the Cost of Blood Transfusions is Significantly Under-Estimated, Establishes True Cost at $522 to $1,183 Per Unit - Annual Costs Total
$1.6 to $6 Million Per Hospital Surveyed—Warranting Improved Conservation & Cost Containment Strategies
http://www.prnewswire.com/news-releases/new-published-study-finds-the-cost-of-blood-transfusions-is-significantly-under-estimated-establishes-true-cost-at-522-to1183-per-unit-89909747.html
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 4
Cost of Incomplete Processes
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Auditors consistently find significant issues on claims for
transfusions and transfusion related services
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The issues associated with blood/blood products can stem from:
 Charge master structure
 Late charge entry for blood product
 Account posting errors for patients with multiple, open accounts
 Misinterpretation of CMS billing directives
 Inappropriate bundling of charges and / or service unit issues
Transfusions are an identified RAC issue
 Blood Transfusions, with CPT codes 36430, 36440, 36450, and
36455 should be billed as one (1) per session, regardless of the
number of units transfused on any given date of service
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 5
Today’s Objectives
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Provide simple guidance and assistance that will prepare you to:
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Evaluate charge capture for transfusion and transfusion related services
 Pre-transfusion testing
 Blood product processing, and
 Blood administration
Identify potential issues which may require investigation / remediation
 HCPCS codes for products
 Revenue code assignment
 Units issues
 Missed / Lost charges
 Bundled charges
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 6
Processes to Review
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Coding and charge submission for:
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Laboratory testing of the patient (CPT 86850-86999)
 In house testing (e.g., ABO / Rh typing, crossmatch)
 Referred testing (e.g., antibody ID’s)
 Autologous donor product
 Directed donor product
Blood bank physician services (CPTs 86077-86079)
Blood product storage / processing
 Routine processing (HCPCS P codes)
 Additional processing
o
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Freezing, thawing, splitting of units (CPT 869XX codes)
Blood administration / transfusion (CPT 36430-36460)
Administrative Overhead Cost Accounting
 Delivery fees, stat or after hour charges
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 7
Other Potential Processes
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Facilities who operate donor centers must assess charge
capture and claim submission for:
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Product Acquisition Costs (HCPCS P codes) in addition to blood
processing costs
 Assignment of modifier BL
 Assignment of revenue code 038X
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 8
Transfusion Services
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Most healthcare facilities will provide one or more of the following
transfusion services:
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Product storage
Serologic testing for Compatibility
Product selection for Transfusion
Issuance of selected blood and components as ordered
Exceptions:
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The facility providing transfusion services does not usually collect
blood or process whole blood into components.
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Some facilities may provide limited services for separation of whole
blood to red blood cells and recovered plasma.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 9
Blood Collection Center
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FDA/CBER is responsible for regulatory oversight of the U.S. blood supply.
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FDA promulgates and enforces standards for blood collection and for the
manufacturing of blood products, including both transfusible components of
whole blood, pharmaceuticals derived from blood cells or plasma, and related
medical devices.
Blood in the U.S. is collected by FDA-licensed collection centers.
Each donated unit intended for transfusion must be labeled by the collection
center as either paid donor or volunteer donor.
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According to FDA regulation “if a donor receives monetary payment for a blood
donation, all products collected from that donor that are intended for transfusion
and that are collected during the donation at which the donor received the
monetary incentive must be labeled with the "paid donor" classification
statement.”
The FDA regulation also specifies benefits that would not require the "paid donor"
classification statement and all products that are collected from that donor that
are intended for transfusion may be labeled with the "volunteer donor"
classification statement.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 10
Q&A – American Red Cross
Q.
A.
Does the American Red Cross pay blood
donors?
No. All Red Cross blood donors are volunteers.
In fact, all blood collected for transfusion in the
United States must be from volunteer donors.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 11
Q&A – American Red Cross
Q.
A.
Why am I charged for blood at the hospital when I have
donated blood to the Red Cross previously?
Since 1960, the Red Cross has been reimbursed by hospitals for
the costs associated with providing blood to hospital patients.
 The Red Cross does not charge for the blood itself that you have so
generously donated.
 The Red Cross only recovers the costs associated with the
recruitment and screening of potential donors, the collection of
blood by trained staff, the processing and testing of each unit of
blood in state-of-the-art laboratories, and the labeling, storage, and
distribution of blood components.
 Hospitals may have their own additional charges related to the
administration of blood and may pass on these costs to their
patients.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 12
Helpful Resource Documents
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The Centers for Medicare and Medicaid Services (CMS) 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.
A summary of the blood community’s questions/recommendations along
with CMS’ responses regarding coding requirements are accessible at the
link below:
http://www.aabb.org/programs/reimbursementinitiatives/Pages/cmsrespsumm.aspx
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 13
Helpful Resource Documents
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Medicare Claims Processing Manual (100-04)
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Chapter 4 - Part B Hospital
Section 231 - Billing and Payment for Blood, Blood Products, and Stem Cells
and Related Services Under the Hospital Outpatient Prospective Payment
System (OPPS)
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf
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CMS CR Transmittal #: R1495CP
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Related MLN Matters Number: MM5867
Related Change Request (CR) #: 5867
Release Date: May 2, 2008
Effective Date: October 1, 2008
Implementation Date: October 6, 2008
CMS Transmittal 1702 CR 6416
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Release Date: March 13, 2009
Effective Date: April 1, 2009
Implementation Date: April 6, 2009
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 14
Apply the Statistics
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Helpful numbers to keep in mind when looking for disconnects.
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Nationally, the percentage of inpatients who receive blood falls between
5% and 7%.
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The average number of units transfused to the inpatient is 3.
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Use this ‘given’ to estimate anticipated inpatient blood use.
Two units of blood are typically infused in an outpatient transfusion
encounter (approximately 80% in most studies).
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Use this ‘given’ to estimate anticipated inpatient blood transfusions.
Use this ‘given’ to estimate anticipated outpatient blood use.
Infusion time is typically 98 minutes for the first unit and 92 minutes for
the second unit.
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Use this ‘given’ to estimate if charges cover cost.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 15
Practice Facts
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The number of each ABO (CPT 86900), Rh (D) (CPT 86901) and
antibody screen (CPT 86850) should exceed the number of actual
transfusions
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Every patient transfused must be typed and screened
Every patient who potentially may need blood is also typed and screened
The number of cross matches should exceed the number of actual
transfusions by a ratio of 4 to 1
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Patient’s blood is cross matched in anticipation of a need for blood during
surgery
The number of cross matches performed is two or more per patient tested.
Many cross matches are performed but blood is not always transfused
Blood banks may report more than one CPT depending on the method used for
the cross match
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 16
Q: What’s Wrong?
On review of a university based facility’s revenue and usage
statistics, it was observed that:
 Annual transfusions for CY 2012 total 4365
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35,183 blood products were charged
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20 of 55 line items show utilization
All transfusions are reported from the ED and Infusion Center and Oncology
Center
No transfusions are reported from surgery, PACU, Recovery, Observation,
Inpatient Units or Dialysis
11 blood product charge codes show activity
Total Cross matches (compatibility tests) number 48,621
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CPT 86920
CPT 86922
CPT 86923
44,609
4,012
0
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 17
A: Charge Capture
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Transfusions may be improperly bundled to procedures, inconsistently or
not reported at this facility.
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This facility may be failing to capture >$2 million reimbursement for the
transfusion procedure based on the volume of products transfused vs
transfusions reported.
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Blood transfusions are not being reported when performed in surgery.
Transfusions are performed but not reported in other cost centers with <5000
transfusions reported and >35,000 blood products charged.
Blood products are not reimbursed if a transfusion CPT is not reported on the
claim with the blood products.
The number of transfusion procedures billed is significantly less than
anticipated indicating a potential issue with charge capture.
Disconnects can be identified utilizing revenue and usage statistics.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 18
Investigating Disconnects
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Review transfusion related revenue and usage statistics with the blood
bank supervisor / manager and / or director.
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Compare BB transfusion records to facility revenue and usage
Review statistics to determine if HCPCS P codes assigned to active charge lines
reflect the variation of products transfused, (e.g. if all products are described in
the charge master and the correct coding distinction is made.)
Compare blood bank test records to confirm that the numbers of pre-transfusion /
blood matching tests performed are reflected in the revenue and usage statistics.
Pull claims, detail bills and remits for five outpatient transfusion encounters
and five inpatient encounters with blood transfusion to validate any
perceived disconnects.
Identify department or units where blood is given in the facility and schedule
meetings with the department managers to discuss transfusion charge
capture processes.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 19
Resources / References
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Current AMA CPT codebook
Current HCPCS Level II Code Book
Facility charge master
Facility Revenue and Usage Statistics
Sample Claims and detail bills with remits
CMS Billing Guidelines
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Medicare Claims Processing Manual, Chapter 4, §231-Billing and
Payment for Blood and Blood Products Under the Hospital Outpatient
Prospective Payment System (OPPS) available at
http://www.cms.gov/manuals/downloads/clm104c04.pdf
OPPS APC Addendum B payment rates
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Check the website of your local CMS Part A MAC
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 20
Inpatient/Outpatient Distinction
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CMS discusses the importance of charging all services consistently
between inpatients and outpatients throughout the 2009 IPPS Final
Rule
OPTIONAL
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Hospitals are free to create a separate charge for inpatient blood
administration provided to patients in routine (room & board) cost
centers
REQUIRED
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Hospitals are expected to create a separate charge for blood
administration in an ancillary department, such as the emergency
department, operating room or infusion center for both inpatients and
outpatients
http://edocket.access.gpo.gov/2008/E8-17914.htm See pages 48465-48466
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 21
Routine or Ancillary?
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CMS discusses routine versus ancillary in the Provider Reimbursement
Manual (PRM-I) under Sections 2202.6 and 2202.8
Blood transfusion and blood products are not specifically mentioned in the
definition of ‘routine services’ in the PRM-1 under Section 2202.6 or in the
definition of ‘ancillary services’ in Section 2202.8.
If an item is not specifically enumerated in the above sections, rules in
Section 2203 of the PRM-I apply.
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This section requires that the common or established practice of providers of the
same class in the same state should be followed.
If there is no common or established classification among providers of the same
class in the same State, a provider’s customary charging practice is recognized
so long as it is consistently followed for all patients…
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 22
Charge Capture Responsibility
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Transfusion services are typically provided in:
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The charge function for blood administration typically occurs in a clinical
area.
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Inpatient rooms including Newborn Nursery and PICU
Observation unit
Surgery or recovery
Chemotherapy / Infusion Center
Emergency Department
Dialysis
Transfusion charge codes (36430-36460 as applicable) should be in the charge
master in each department where blood is transfused.
The Laboratory is responsible for charging product acquisition, processing
and transfusion related ‘blood matching’ tests.
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Serologic / Crossmatch procedures
Product storage & processing
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 23
Referred Tests
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Blood suppliers provide reference laboratory testing
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Facilities pay for the referred tests but often fail to charge patients
Facilities who do charge may assign incorrect CPT code or billing units
Identify charge disconnects and potential for lost or risk charge
1. Obtain the most recent supplier invoice
2. Identify reference laboratory tests that are separately billable to a patient
3. Cross walk the charges to the applicable patient accounts using information on
the invoice or in the blood bank send out test log
4. Audit patient claims to determine if the tests were charged
5. Validate the CPT codes and billing units assigned
6. Validate that reference lab services are described in the charge master and
included in the department IS or on order / entry screens
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 24
Unused Blood
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Hospitals may not bill Medicare for unused blood.
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Units that are ordered but not transfused
This longstanding policy applies to both the inpatient and outpatient
setting.
Hospitals may
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Bill for medically necessary laboratory services related to a specific
patient (such as cross matching), even if the blood in not transfused
Bill for medically indicated processing charges associated with
preparation of a product that is not transfused and is discarded /
destroyed
Take the overall cost of unused blood into account when setting charges
for units that are transfused
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 25
Unused Blood
HCPCS
Code
Short Descriptor
SI
APC
Relative
Weight
Payment
Rate
Minimum
Unadjusted
Copayment
86927
Fresh frozen plasma; each unit thawing
X
0345
0.2519
$17.96
$3.60
86930
Frozen blood, each unit; freezing
X
0347
0.4810
$34.30
$6.86
86931
Frozen blood, each unit; thaw
X
0347
0.4810
$34.30
$6.86
86932
Frozen blood, each unit; freezing and thawing
X
0347
0.4810
$34.30
$6.86
86945
Irradiation of blood product, each unit
X
0345
0.2519
$17.96
$3.60
86960
Volume reduction of blood or blood product (eg,
red blood cells or platelets), each unit
X
0345
0.2519
$17.96
$3.60
86965
Pooling of platelets or other blood products
X
0346
0.3504
$24.99
$5.00
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 26
Blood Bank Physician Services
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Blood bank physician services have a technical component and are
separately payable
Determination by the blood bank physician will determine final
diagnosis code assignment = written report required
HCPCS Code
Short Descriptor
SI
APC
Payment Rate
86077
Physician blood bank service; difficult cross match and / or
evaluation of irregular antibody(s), interpretation and written
report
X
0433
$17.07
86078
Physician blood bank service; investigation of transfusion
reaction including suspicion of transmissible disease,
interpretation and written report
X
0343
$36.48
86079
Physician blood bank service; authorization for deviation from
standard blood banking procedures (e.g., use of outdated blood,
transfusion of Rh incompatible units), with written report
X
0433
$17.07
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 27
CMS IPPS Payment
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Blood product and transfusion payment is included in
MS-DRG payment amount.
CMS adopted a new inpatient cost-to-charge ratio (CCR)
for blood and blood products in 2008.
Hospital Charge x CCR = Medicare Payment Rates
•
To capture reimbursement:
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Set appropriate charges for blood and blood products
Assign the correct revenue code(s)
Consistently report charges on claims
 Department education required!
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 28
Cost Accounting
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With respect to the cost report:
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Hospitals are required to follow the Medicare cost apportionment
regulations at 42 CFR 413.53(a)(1).
The cost of each ancillary department is to be apportioned separately
rather than combined with another department.
The cost report includes a standard cost center for ‘Blood Storing,
Processing and Transfusion” (Line 47 of Worksheet A, under the
‘’Ancillary Service Cost Centers’’).
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Hospitals must use billing codes as directed by the NUBC, regardless
of the cost center in which the cost is reported on the cost report.
When reporting the appropriate revenue code for services, hospitals
should choose the most precise revenue code, or subcode if
appropriate.
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 29
Revenue Codes
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Three key revenue codes series
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The appropriate revenue code for blood carrying only a
processing fee is 0390
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038X (Blood)
039X (Blood and Blood Component Administration,
Processing, and Storage)
030X (Lab)
The Red Cross and Community Blood Banks in the US do not
charge hospitals for blood itself
The Red Cross and Community Blood Banks in the US charge
only for processing and handling
Revenue code series 038X is not applicable for billing in
most hospitals
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 30
Purchased Blood 0380
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When a hospital purchases blood or blood products from a
community blood bank, or runs its own blood bank and assesses a
charge for the blood or blood product, they report blood and blood
products in Revenue Code Series 038X “Blood” along with the
appropriate Healthcare Common Procedure Coding System
(HCPCS) code
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Amount billed must reflect the hospital’s cost related to the purchase or
collection of the blood or blood product
The facility must also report Revenue Code 0390 with the appropriate
HCPCS to reflect the cost of storage and processing
 Claims must include a line item for both 038X and 0390 in order to
be processed
The modifier “BL” must be appended to each line item as appropriate
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 31
Purchased Blood 0380
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When reporting costs under the revenue code 038X series
Payment for the following codes are applied to the blood deductible as
instructed in the Medicare General Information, Eligibility and Entitlement
Manual, Chapter 3, Sections 20.5 through 20.5.4:

•
•
Medicare charges a blood deductible for the first three pints of blood given
to a patient. Blood deductibles are charged for the cost of the blood product
acquisition.
A patient may elect to replace blood or for another to donate in the patients
name
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P9010, P9016, P9021, P9022, P9038, P9039, P9040, P9051, P9054, P9056, P9057, P9058
If all blood given to the patient is replaced, there is no charge for the blood
Deductible amounts and replacements are reported through use of value codes
on the claim
Noridian Medicare Part A article:
https://www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EkpAEFulFlwLpVYZwG&tmpl=part_a_viewnews&style=part_ab_viewnews
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 32
Blood Product Processing 0390
•
When a hospital does not pay for the blood or blood product, it often
incurs an administrative cost from a community blood bank for the
bank’s processing, storage and related expenses

Report these costs in Revenue Code 0390 “Blood Storage/Processing”


•
•
0392 and 0399 are alternative codes which may be assigned
Report the HCPCS code assigned to the blood or blood product and the
number of units transfused
Do not charge for processing of a unit if the blood product is not
transfused. with one exception…autologous blood processing
The cross matching and pre-transfusion tests performed by the
laboratory are billable even if blood is not transfused
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 33
Biologicals 0636
•
•
•
Biologic products not paid on a cost or prospective payment basis
are paid based on OPPS APC rate.
Reimbursement rates for P9041, P9043, P9045, P9046, P9047, and
P9048, are obtained from the Medicare drug pricing files.
Albumin products are infused not transfused.
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
Bill the administration of albumin products as drug administration
Utilize CPT from 9636X series
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 34
Chargemaster Structure for Transfusion
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•
•
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Transfusions must be billed per encounter, not per hour or
per unit infused.
Only one transfusion may be reported per day.
Transfusion times and facility costs vary.
Consider structuring the charge master as follows
CPT Code
CDM Description
Rev Code
Price
36430
Blood Administration, 0-2 hrs
0391
$ base
36430
Blood Administration 2-4 hrs
0391
$ base plus
36430
Blood Administration > 4 hrs
0391
$ base plus
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 35
OPPS Payment System
•
CMS APC payment rates for blood is charge based

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•
Based on past Medicare claims
Rate setting methodology resulted in decreased payment for the most
commonly used blood products in CY 2010
Facility charge should reflect real costs
Supplier Cost + Facility Cost of Entering Blood into Inventory= Product Cost
Example:
 Hospital blood banks must perform confirmatory typing of units prior
to entering them into the hospital inventory. This is an additional
cost that should be reflected in the facility charge for the blood
product when the product is transfused
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 36
Capturing OPPS Reimbursement
APC
Payment
2 units given
w IS Xmatch
2 units given w
AHG Xmatch
CPT/ HCPCS
Revenue Code
ABO
86900
0300/302
$9.67
$9.67
$9.67
Rh
86901
0300/302
$9.67
$9.67
$9.67
Antibody Screen
86850
0300/302
$17.96
$17.96
$17.96
Crossmatch, IS
86920
0300/302
$17.96
$35.92
Crossmatch, Incubation
86921
0300/302
$17.96
Crossmatch AHG
86922
0300/302
$24.99
RBCs, LR per unit
P9016
0390
$193.24
$386.48
$386.48
Blood Administration
36430
0391
$260.44
260.44
260.44
$720.14
$734.20
TOTAL
©2013 PANACEA Healthcare Solutions, Inc.
49.98
SLIDE 37
Blood Typing / Blood Matching
American Red Cross Blood Typing Table
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 38
HCPCS Code Selection
•
When determining the appropriate HCPCS P-code for the blood
product:



Select the code that describes the base product as well as the attributes
that reflect the way in which the product was processed
If none of the available P-code descriptors exactly describes all of a
product’s attributes, select the code that is the closest match
Example:
 If leuko-reduced red blood cells are transfused, report:
o HCPCS P-code whose descriptor includes both “red blood
cells” and “leukocytes reduced,”
o P9016 Red blood cells, leukocytes reduced, each unit
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 39
HCPCS Coding Options
•
•
•
There are thirty-five HCPCS codes that describe blood
products – if you include the albumin codes
OPPS reimbursement varies by product and attributes
Don’t report ‘regular’ if ‘premium’ is provided
For example P9019
P9031
P9032
P9033
P9034
P9035
P9036
P9037
Platelets,
Platelets
Platelets,
Platelets
Platelets,
Platelets,
Platelets,
Platelets,
each unit
leukocytes reduced
irradiated
leukoreduced irradiated
pheresis
pheresis leukoreduced
pheresis irradiated
pheresis leukoreduced irradiated
©2013 PANACEA Healthcare Solutions, Inc.
$91.61
$118.34
$134.23
$156.45
$431.99
$511.27
$675.77
$674.16
SLIDE 40
HCPCS Coding Options
HCPCS
Code
Short Descriptor
SI
APC
Relative
Weight
Minimum
Unadjusted
Payment Rate Copayment
P9016
RBC leukocytes reduced
R
0954
2.7097
$193.24
$38.65
P9017
Plasma 1 donor frz w/in 8 hr
R
9508
1.1037
$78.71
$15.75
P9019
Platelets, each unit
R
0957
1.2846
$91.61
$18.33
P9020
Platelet rich plasma unit
R
0958
2.4626
$175.62
$35.13
P9021
Red blood cells unit
R
0959
2.1285
$151.79
$30.36
P9022
Washed red blood cells unit
R
0960
4.1562
$296.39
$59.28
P9023
Frozen plasma, pooled, sd
R
0949
1.0129
$72.23
$14.45
P9031
Platelets leukocytes reduced
R
1013
1.6595
$118.34
$23.67
P9032
Platelets, irradiated
R
9500
1.8822
$134.23
$26.85
P9033
Platelets leukoreduced irrad
R
0968
2.1939
$156.45
$31.29
P9034
Platelets, pheresis
R
9507
6.0577
$431.99
$86.40
P9035
Platelet pheres leukoreduced
R
9501
7.1694
$511.27
$102.26
P9036
Platelet pheresis irradiated
R
9502
9.4761
$675.77
$135.16
P9037
Plate pheres leukoredu irrad
R
1019
9.4536
$674.16
$134.84
P9038
RBC irradiated
R
9505
2.8319
$201.95
$40.39
P9039
RBC deglycerolized
R
9504
6.7273
$479.74
$95.95
P9040
RBC leukoreduced irradiated
R
0969
3.8309
$273.19
$54.64
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 41
HCPCS Coding Options
HCPCS
Code
Short Descriptor
SI
APC
P9041
Albumin (human),5%, 50ml
K
0961
P9043
Plasma protein fract,5%,50ml
R
0956
P9044
Cryoprecipitate reduced plasma
R
1009
P9045
Albumin (human), 5%, 250 ml
K
P9046
Albumin (human), 25%, 20 ml
P9047
Relative
Weight
Minimum
Unadjusted
Payment Rate Copayment
$22.63
$4.53
0.2848
$20.31
$4.07
0.9531
$67.97
$13.60
0963
$60.67
$12.14
K
0964
$30.24
$6.05
Albumin (human), 25%, 50ml
K
0965
$69.20
$13.84
P9048
Plasmaprotein fract,5%,250ml
R
0966
0.6613
$47.16
$9.44
P9050
Granulocytes, pheresis unit
R
9506
22.6900
$1,618.09
$323.62
P9051
Blood, l/r, cmv-neg
R
1010
2.5982
$185.29
$37.06
P9052
Platelets, hla-m, l/r, unit
R
1011
10.8739
$775.45
$155.09
P9053
Plt, pher, l/r cmv-neg, irr
R
1020
9.2615
$660.47
$132.10
P9054
Blood, l/r, froz/degly/wash
R
1016
1.7169
$122.44
$24.49
P9055
Plt, aph/pher, l/r, cmv-neg
R
1017
4.7192
$336.54
$67.31
P9056
Blood, l/r, irradiated
R
1018
2.4667
$175.91
$35.19
P9057
RBC, frz/deg/wsh, l/r, irrad
R
1021
5.1700
$368.69
$73.74
P9058
RBC, l/r, cmv-neg, irrad
R
1022
4.0183
$286.56
$57.32
P9059
Plasma, frz between 8-24hour
R
0955
1.0591
$75.53
$15.11
P9060
Fr frz plasma donor retested
R
9503
0.7967
$56.82
$11.37
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 42
CPTs for Transfusion Medicine
•
See CPT series 86850-86999



•
Assign revenue code 0300 or 0302
Follow coding directives seen in parentheticals throughout the section
Report each code with the CPT defined unit of testing
 Each technique
 Each antiserum
 Per unit screened
 Each antigen
 Each screen
 Each unit
Other Services – non-transfusion


Therapeutic apheresis, see CPT 36511-36512
Therapeutic phlebotomy, see CPT 99195
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 43
Autologous Blood
•
•
When an autologous unit is unused and is destroyed, the
hospital may bill for the special processing and handling
cost with CPT code 86890
CMS states that the date of service must be the date on
which it is known that the blood will not be transfused—
typically, the date of discharge


This determination must be indicated in the patient’s medical
record
This instruction does not apply to the directed donor unit
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 44
Splitting of Products
•
•
CPT 86985 for splitting of a product is billable in addition to P9010
with the exception of the last aliquot
Where a unit of blood is split specifically with the intent of
transfusion but is not then transfused


•
The hospital may bill for the splitting the unit of blood
(CPT 86985)
The hospital may not bill the HCPCS code for the blood product
The date of service must be the date on which the decision not to
use the blood was made

This determination must be indicated in the patient’s medical record
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 45
Irradiated Products
•
•
•
Do not bill separately for the irradiation of a product if a valid
HCPCS code exists that defines the irradiated unit
When a P-code is not defined by CMS for a specific irradiated
product, it is appropriate to bill the HCPCS that most accurately
represents the transfused product plus CPT 86945 for irradiation
Where an irradiated unit is requested with the intent of transfusion
but is not transfused, a charge for irradiation (86945) may be billed.
However, the P-code for the unused product is not billable
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 46
Freeze and Thaw
•
•
If a product-specific frozen or thawed P-code does not
exist, OPPS providers may bill the appropriate freezing
and / or thawing CPT code(s) in addition to the P-code
that most accurately represents the blood product
When a frozen / thawed product is not infused and is
destroyed, the hospital may bill the appropriate freezing
and / or thawing CPT code(s) but not the P-code for the
unused blood product
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 47
Units of Service
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 48
ICD-9 CM Codes
•
•
HIM typically assigns ICD-9 CM procedure codes for inpatient
transfusions
In 2011, there are five new ICD-9 CM codes that must be assigned
to report ABO incompatibility reactions





•
999.60
999.61
999.62
999.63
999.69
ABO incompatibility reaction, unspecified
ABO incompatibility reaction not specified as acute or delayed
ABO incompatibility with acute hemolytic transfusion reaction
ABO incompatibility with delayed hemolytic transfusion reaction
Other ABO incompatibility reaction
Be aware that CMS considers these to be hospital acquired
conditions (HAC) for which Medicare will not pay the additional costs
associated with the complication
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 49
Auditing Tips
•
•
Analyze documentation for the service
Review claims for outpatient blood transfusion services

•
Blood bank can give you patient names, DOS, MR #
Look at the claims


You should see revenue code 0391 with CPT 364XX x 1
You should see revenue code 0390, 0392 or 0399 with a HCPCS P
code

•
Billing units may be 1 or more
You should see revenue codes 0380 with HCPCS P codes only if
your facility operates a donor center or ‘buys’ blood

Modifier BL must also appear on these claims
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 50
Review Audit Findings
•
Internal Audits



•
Do you know what the nurse auditors said about transfusion and
transfusion related services?
Have auditors cited issues relative to transfusions and / or transfusion
related issues?
Have the issues been investigated and remediated?
External Audits

HIGHLY RECOMMENDED



Nurse auditors may not be familiar with blood bank
procedures
Blood bank managers are not always familiar with billing
guidelines issued by CMS
TAKE ACTION
 If you suspect something is wrong, it usually is
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 51
Assess Charge Code Usage
•
Look at volumes associated with charge codes for transfusions / blood
administration,


Charge codes assigned revenue code 0391 and
CPT 36430, 36440, 36450, or 36455

•
Look at charge lines used to report blood product processing


Charge codes assigned revenue code 0390, 0392 or 0399
HCPCS ‘P’ code

•
Note the number; Note the departments that have volume
Add up the units
Make an assessment


Assume that an outpatient will receive on average 2 units of blood.
Assume that 5-7% of inpatient admissions will receive blood, and each of these
patients will receive an average of 3 units of blood.
Do the ratios indicate there is not a reason for concern, there is a potential
problem, or the potential of a significant issue?
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 52
Summing It Up
•
•
•
Provide detailed CPT and Level II HCPCS codes in order to receive
complete outpatient Medicare reimbursement
Audit and Monitor to Identify charge capture disconnects
Ensure that you have implemented coding structures for the
following:




Pre-transfusion workups such as blood typing, antibody screens and
blood processing work (pooling of platelets, bone marrow / stem cell
preparation)
Cross-matches, transfusion reactions and antigen typing
Blood and blood products
Transfusions
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 53
THANK YOU FOR
ATTENDING
©2013 PANACEA Healthcare Solutions, Inc.
SLIDE 54