American Red Cross
and Reimbursement
Reimbursement Update - Blood Billing under
Medicare’s Outpatient Prospective Payment System (OPPS)
Background
memorandum or other transmittal to the FIs. The
latter has occurred in so-called “donor states”, for the
most part.1 Exhibit B below provides information on
blood product claims processing issues at the seven
FIs the Red Cross has been in contact with.
On December 11, 2000, the Health Care Financing
Administration (HCFA) provided its first guidance
to hospitals on billing for blood products under the
new Outpatient Prospective Payment System
(OPPS), commonly known as Ambulatory Payment
Classifications or APCs (see Exhibit A). Below, the
American Red Cross discusses the implications of
this guidance and provides direction to its hospital
customers. In addition, we provide our hospital
customers with materials to support their coding and
billing efforts. Finally, the Red Cross recently hired
a full-time reimbursement expert to assist customers
with their reimbursement issues.
Many Hospitals Will Need to Change Their
Coding Practices for Blood and Blood
Products
As a result of HCFA’s guidance, hospitals will now
need to bill for Red Cross blood products using the
38X (Blood) series revenue codes, along with the
corresponding Level II HCPCS code (Exhibits C &
D).. Previously, the 38X revenue codes were
reserved for commercially-purchased blood or for
hospitals with in-house blood procurement programs.
That is to say, the 38X series was used mainly in
situations where hospitals purchased blood from a
commercial vendor. The Red Cross does not charge
for blood, rather blood is provided free of charge and
hospitals are accessed processing charges. As a
result, hospitals billed for Red Cross products with
the 39X (Blood, storage and processing) revenue
coding series.
HCFA Guidance Has Been Slow in Coming;
Some FIs Reluctant to Make Changes
OPPS was officially implemented on August 1,
2000, after numerous delays. Even after the delays,
many at HCFA, as well as fiscal intermediary (FIs)
staff believed that the OPPS claims processing
system (“PRICER”) was still not ready. The
pessimists were proven correct and a number of
implementation problems have occurred, with
reimbursement for blood products being one of
them. While the Red Cross has worked to keep
HCFA staff focused on blood reimbursement issues,
there were substantial delays between when the
problems were brought to HCFA’s attention and
when they were addressed.
Before receiving HCFA’s guidance, our billing
recommendations were based on our past experience.
Unfortunately, they appear to have been in error. We
now encourage our hospital customers to bill for Red
Cross blood products as directed by HCFA, with the
appropriate Level II HCPCS code and a 38X revenue
code. As result of HCFA’s guidance, many hospital
customers will need to update their billing systems,
replacing a 39X code with a 38X code, as
appropriate.
The Medicare program provides considerable
discretion to local FIs. As a result, some have
shown a willingness to update their systems based
on the Red Cross’ requests and the December 11th
HCFA guidance. Other FIs have decided to leave
things where they stand until HCFA provides more
detailed directions in the from of a program
_________________________________________________________
1Donor
states have state laws or regulations that prohibit selling or charging of blood products. Claims with a 38X revenue code are
rejected automatically in those states.
1
Hospitals Will Have to Use “Value Codes” to
Receive the Appropriate Reimbursement
What is the Red Cross’ Position on HCFA’s
Guidance?
The Medicare blood deductible provision is
implemented through the use of value codes and the
38X revenue coding series. When Medicare’s claims
processing systems “see” a 38X revenue code, they
“look” for an appropriate value code. Therefore,
hospitals will need to use these value codes (Exhibit
E). Because Red Cross does not charge for the blood
itself and does not charge a non-replacement fee, all
units provided to Medicare patients are assumed to
have been replaced. In other words, a patient that
receives Red Cross whole blood or packed red cells
should NOT be charged the blood deductible and
Medicare should reimburse the treating hospital
starting with the first unit transfused. Exhibit F is a
sample of how hospitals might bill for outpatient
blood claims. Hospitals should check with their FIs
regarding implementation of the blood deductible, if
problems arise.
Clearly, HCFA’s 12/11 guidance represents a
departure from how hospitals had billed in the past,
as well as how the Red Cross had recommended
hospitals bill when APCs were first implemented.
For that reason, as well as because of the problems
encountered in the handful of donor states, the Red
Cross is recommending that HCFA allow hospitals
to bill for blood and blood products with either
revenue coding series (38X or 39X) and the
appropriate product-specific HCPCS code. The
individual circumstances of a hospital should dictate
which revenue coding series to use. In addition, we
are recommending that HCFA provide official
guidance to the FIs about this issue. Our coding
recommendations is being included in the Red
Cross’ official comment on the 2001 OPPS Interim
Final Rule.
Who Should I Contact if I Have Additional
Questions or Require Clarification?
Hospitals Will Continue to Use the 39X Revenue
Codes for Billing Some Blood-related Services
Hospitals should use the 39X series revenue codes to
bill for lab tests and procedures related to blood
transfusions (i.e., blood administration - 391,
compatibility testing, typing/crossmatch, splitting
units). For transfusion-related lab tests, hospitals can
bill with the 30X series (Laboratory/pathology),
however, the 39X series is more correct. In addition,
hospitals should use the 39X series for storage and
processing related to autologous units, along with the
appropriate CPT code – 86890 Autologous blood or
component, collection processing and storage;
predeposited. Finally, costs related to the provision of
blood and blood products that are not directly billable
to a patient’s account, such as costs associated with
defective or spoiled blood should be assigned to the
blood storage and processing cost center using 39X.
2
Contact Chris Panarites, Reimbursement Officer for
the American Red Cross at 703.312.5724. You can
also e-mail him at panaritesc@usa.redcross.org.
Attachments:
Exhibit A: HCFA Q&A Text
Exhibit B: FIs’ Current Billing Status
Exhibit C: OPPS Coding Guide
Exhibit D: 38X Revenue Code Description
Exhibit E: Value Codes Description
Exhibit F: Sample Outpatient Claim Form
g:\shared\hospmkt\OppsImp\reimbupdateJan01
Exhibit A
From HCFA website OPPS Frequently Asked Questions – Posted December 11,
2000.
Q. 110. How are we supposed to bill for blood use? Our state doesn’t allow blood to be
sold, so we don’t have a charge for blood, only for processing and storage.
A. 110. We have changed the way blood use is shown. We will pay for the
administration of blood using code 36430 (billed once per day for all transfusions)
in revenue code 391. Bill for blood and blood products using the range of HCPCS
codes provided for them, in RCs 380-389. The charge you show should reflect the
charge made by the blood bank (if your hospital purchases blood rather than using
an in-house blood bank). We realize that in most cases the charge is not for the
blood per se, but rather for the costs associated with recruiting donors, hiring
phlebotomists, testing blood for infective agents, and further processing, storage,
and transportation. You may also bill the laboratory codes for typing and cross
matching and other services related to the patient who receives the blood. You may
not bill for blood processing and storage, since those costs are captured in the
payment rate assigned to the blood or blood product. If your hospital runs its own
blood bank, for some or all of the blood you use, you should follow the same
process, since if you bill for processing and storage, rather than units of blood,
your claims will not be paid. We have inserted an edit so that blood or a blood
product must be billed when blood administration is billed. Except in those
instances in which blood itself is paid for, the blood deductible is not applied.
Fiscal intermediaries will change their revenue code edits to reflect this change.
Exhibit B
Current Billing Status
Fiscal
Intermediary
State(s)
Served
Implementation
Billing Recommendations
AdminaStar
Federal
IL, IN, KY, OH
Provider relations staff is aware of
12/11 HCFA guidance.
Implementation in all states served
by AdminaStar (except IL) can begin
immediately. Claims processing
provisions for IL still being worked
out.
Bill as recommended
in all states except IL
(38X revenue codes
with HCPC codes). In
IL, bill as previous,
39X revenue codes.
BCBS of Alabama
AL
Network Services staff was informed
of 12/11 guidance. Unclear whether
any changes are needed.
BCBS of Nebraska
NE
Senior claims processing staff are
aware of 12/11 but will not
implement until “official” direction
from HCFA is obtained.
Bill as recommended;
inform Red Cross
Reimbursement
Officer and local ARC
representative of any
billing or payment
problems.
Bill as previous, 39X
revenue codes with NO
HCPCS codes.
BCBS of
Oklahoma
OK
Claims processing system did not
require major changes for OPPS.
However, FI does not have newer
“C” codes in system. Red Cross is
working to have codes added.
BCBS of Texas
(Trailblazers)
TX
Claims processing system did not
require major changes for OPPS.
Empire BCBS
CT, DE, MA, NY
Noridian
AK, AZ, CO, HI,
IA, MN, ND, NV,
OR, SD, WA, WI
Senior claims processing staff are
aware of 12/11 guidance. “P” and
“C” HCPCS codes have been loaded
into system. Empire has sent out
provider bulletin. Red Cross
Reimbursement Officer has copy of
bulletin.
Senior claims processing staff are
aware of 12/11. Implementation in all
states served by Noridian (except
ND) can begin immediately.
Payment provisions for ND still
being determined.
United
Government
Services
MI, VA, WI, WV
Seniour claims processing staff in
United’s VA office pushed change
through system early. United’s WI
office has not made necessary
changes for WI providers.
Bill as recommended
(38X plus HCPCS
codes.) Use only “P”
codes until FI has
added “C” codes to
system.
Bill as recommended
(38X plus HCPCS
codes).
Submit claims as direct
in provider bulletin
(38X plus HCPCS
codes in DE, MA; 39X
plus HCPCS codes in
CT, NY).
Bill as recommended in
all states except ND;
inform Red Cross
representative of any
billing or payment
problems. In ND, bill
as previously, 39X
revenue codes with NO
HCPCS codes.
Submit claims as
recommended in MI,
VA, WV, (38X plus
HCPCS code). In WI,
bill as previous, 39X
and no HCPCS codes.
Coding Guide for ARC Products and Services
Under Medicare’s Outpatient Prospective Payment System (APCs)
Exhibit C
(Revised December 19, 2000)
APC
Level II
HCPCS Code
(Transitional)1
Level II
HCPCS Code
(Permanent)2
0949
N/A
P9023
0950
N/A
P9010
0952
0953
N/A
N/A
P9012
P9013
0954
N/A
P9016
0955
N/A
P9017
0956
0957
N/A
N/A
P9018
P9019
0958
0959
0960
N/A
N/A
N/A
P9020
P9021
P9022
0961
Q0156
N/A
0962
Q0157
N/A
0961
N/A
P9041
0962
N/A
P9042
1009
C1009
P9044
1010
C1010
N/A
1011
C1011
N/A
C1012
P9033
C1013
P9031
1012 (C)4
0954 (P)
1013 (C)4
0954 (P)
1
Revenue
Code
Value
Codes3
383
N/A
382
37 & 39
387
387
N/A
N/A
381
37 & 39
383
N/A
383
384
N/A
N/A
384
381
381
N/A
37 & 39
37 & 39
387
N/A
387
N/A
387
N/A
387
N/A
387
N/A
382
37 & 39
384
N/A
Platelets, leukocytes reduced,
irradiated, each unit
384
N/A
Platelets, leukocytes reduced, each
unit
384
N/A
Description
Plasma, pooled multiple donor,
solvent/detergent treated, frozen, each
unit
Blood (whole), for transfusion, per
unit
Cryoprecipitate, each unit
Fibrinogen unit
Red blood cells, leukocytes reduced,
each unit
Fresh frozen plasma (single donor),
each unit
Plasma protein fraction, each unit
Platelets, each unit
Platelet rich plasma, each unit
Red blood cells, each unit
Red blood cells, washed, each unit
Infusion, albumin (human), 5%, 500
ml
Infusion, albumin (human), 25%, 50
ml
Infusion, albumin (human), 5%, 50 ml
Infusion, albumin (human), 25%, 10
ml
Plasma, cryoprecipitate reduced, each
unit
Blood, leukocytes reduced, CMVnegative
Platelets, pheresis, leukocytes
reduced, HLA-matched
Transitional C-codes will ultimately be discontinued; however, HCFA has not yet established termination
dates for these codes.
2
Codes in italics became effective January 1, 2001.
3
Value codes used to calculate Medicare blood deductible, which applies to the first three units of whole
blood and packed red cells only. The Value code “37” is used to indicate the number of pints (or units) of
blood supplied to the patient and the Value code “39” indicates units of blood replaced. Since ARC does
not charge for blood per se and only charges hospital processing fees, the blood is assumed to have been
replaced.
4
For these services, the APC codes for the transitional codes are different than those for the permanent
codes; “(C)” indicates a transitional C-code, while “(P)” indicates a permanent P-code.
Coding Guide for ARC Products and Services
Under Medicare’s Outpatient Prospective Payment System (APCs)
(Revised December 19, 2000)
Level II
HCPCS Code
(Transitional)
Level II
HCPCS Code
(Permanent)
1014 (C)
9501 (P)
C1014
P9035
1016
C1016
N/A
C1017
N/A
C1018
P9040
C1019
P9037
C9500
C9501
P9032
P9034
9502
C9502
P9036
9503
C9503
N/A
9504
C9504
P9039
9505
C9505
P9038
APC
4
1017
4
1018 (C)
9504 (P)
4
1019 (C)
9501 (P)
9500
9501
Revenue
Code
Value
Codes
384
N/A
382
37 & 39
384
N/A
Red blood cells, leukocytes reduced,
irradiated, each unit
382
37 & 39
Platelets, pheresis, leukocytes
reduced, irradiated, each unit
384
N/A
384
384
N/A
N/A
384
N/A
383
N/A
381
37 & 39
381
37 & 39
Description
Platelets, pheresis, leukocytes
reduced, each unit
Blood, leukocytes reduced,
frozen/deglycerolized/washed
Platelets, pheresis, leukocytes
reduced, CMV-negative
Platelets, irradiated, each unit
Platelets, pheresis, each unit
Platelets, pheresis, irradiated, each
unit
Fresh frozen plasma, donor retested,
each unit
Red blood cells, deglycerolized, each
unit
Red blood cells, irradiated, each unit
EXHIBIT D
38X REVENUE CODE DESCRIPTION
38X
Blood
Subcategory (3rd Digit)
0
1*
2*
3
4
5
6
7
8
9
Description
Std. Abbreviation
General Classification
Packed Red Cells
Whole Blood
Plasma
Platelets
Leukocytes
Other Components
Other Derivatives (Cryoprecipitates)
Not Used
Other Blood
BLOOD
BLOOD/PKD RED
BLOOD/WHOLE
BLOOD/PLASMA
BLOOD/PLATELETS
BLOOD/LEUKOCYTES
BLOOD/COMPONENTS
BLOOD/DERIVATIVES
N/A
BLOOD/OTHER
*381 and 382 generally carry the Medicare blood deductible; value codes necessary.
Source: NATIONAL UNIFORM BILLING DATA ELEMENT SPECIFICATIONS AS DEVELOPED BY THE
NATIONAL UNIFORM BILLING COMMITTEE, May 12, 1999, Copyright - American Hospital Association.
EXHIBIT E
VALUE CODE INFORMATION
Code Description
Appropriate Use 1
6
Medicare Blood Deductible
Used to indicate the charges associated with unreplaced
deductible pints of blood or units of packed red cells. Not
used if all pints are replaced
37
Pints of Blood Furnished
Used to indicate the number of pints of blood supplied,
regardless of whether they were replaced. Serves as a
basis for counting pints to be applied toward the
deductible.
38
Blood Deductible Pints
Used to indicate the number of unreplaced deductible
pints of blood supplied. Not used is all pints are replaced.
39
Pints of Blood Replaced
Used to indicate the number of pints of blood that were
(or will be) replaced. Blood is considered replaced if the
provider charges only for processing.
Value Code
1Most
responses to question 8 indicated that the FIs use HCFA’s value code definitions when applying the codes. In
this table, we summarize the definitions for the relevant codes. Source: U.S. Department of Health and Human
Services. Health Care Financing Administration. Hospital Manual. (HCFA Pub 10, Sec. 460.) 2000.
Exhibit F: Sample UB-92 Paper Claim
Form for Hospital Outpatient Procedures
Bill Type: Hospitals use to
distinguish between inpatient
and outpatient claims.
APP ROVE D OMB NO. 0938-0279
Anytown Hospital
20 Hospital Drive
Anytown, USA
2
4 TYPE
OF B ILL
3 PATIENT CONTROL NO.
5 FED. TAX NO.
6 STATE MENT COVERS PERIOD
FROM
THROUGH
7 COV D.
8 N-C D.
9 C-I D.
10 L-R D.
11
09012001 09012001
13 PATIENT A DDRESS
12 PATI ENT NAME
123 Main Street, Anytown, Anystate 12345
Smith, Jane
14 BI RTHDATE
15 SE X 16 MS
A DM ISS ION
1 7 DAT E
18 HR
19 T YPE
20 SRC
CONDI TION CODES
21 D HR 22 S TAT 23 M EDI CA L RECORD NO.
24
01201928 F
32
OCCURENCE
CODE
DATE
33
OCCURENCE
CODE
34
DAT E
OCCURENCE
CODE
35
DATE
OCCURENCE
CODE
DATE
36
OCCURENCE S PAN
CODE
FROM
25
27
28
29
30
31
37
A
B
B
A
T HRO UG H
a
Value Codes:
b
26
C
C
38
39
OCCURENCE
CODE
37 - Units transfused
40
AM OUNT
b
41
AM OUNT
37
39
a
39 - Units replaced
VALUE CODE S
CODE
VALUE CODE S
CODE
AM OUNT
3
3
a
b
c
c
d
42 REV. CD.
381
391
1
2
43 DE SCRI PTION
44 HCPCS/ RATE S
BLOOD/PKD RED
BLOOD ADMINISTRATION
d
45 SERV. DATE
P9021
36430
46 SERV. UNITS
09012001
09012001
3
47 TOTA L CHARGES
3
1
450
200
48 NON-COVERED CHA RGE S
49
00
00
1
2
3
4
4
5
5
6
7
8
9
10
11
Revenue Codes:
HCPCS/CPT Codes:
Service Units:
Enter appropriate
revenue codes for all
services provided.
Enter HCPCS code P9021
for Red Blood Cells.
Enter the appropriate number
that represents the multiple of
the administered units. Use
only whole numbers.
13
14
15
16
7
Enter CPT code (36430)
that represents the
transfusion procedure
performed.
Per HCFA’s 12/11/00
guidance, hospitals are
instructed to bill for blood
transfusions using the “391”
revenue code.
12
6
8
9
10
11
12
Blood administration should be
billed per visit/session, not per unit
transfused.
13
14
15
16
17
17
18
18
19
19
20
20
21
21
22
22
23
23
50 PAYE R
52 RE L
INFO
51 PROVI DE R NO.
53 ASG
BEN
54 PRIOR PAYME NTS
55 ES T. AM OUNT DUE
56
xxxxxx
A
B
C
DUE FROM PATIENT
57
58 INSURED'S NAME
A
59 P. RE L
60 CERT. - SS N - HI C - ID NO.
61 GROUP NAME
62 INSURANCE GROUP NO.
Diagnosis
Codes:
012-34-5678
Smith, Jane
B
A
B
Enter appropriate primary and secondary ICD-9-CM diagnosis codes.
Under APCs, they will not impact payment. Relevant diagnosis codes
include: 285.9 Anemia. 66 EM PLOYER LOCATION
C
C
A
A
B
B
C
O THER DIAG. CO DES
67 PR IN. DIA G. CD .
68 CO DE
69 CODE
70 CODE
71 CODE
72 CODE
73 CODE
Procedure Codes:
74 CODE
75 CO DE
C
76 ADM DIA G. CD.
77 E-CODE
78
285.9
79 P. C.
80
P RI NCIP LE PROCE DURE
CODE
DATE
99.04 09012001
OTHER PROCE DURE
CODE
C
a
b
c
d
DATE
81
OTHE R PROCEDURE
CODE
DATE
A
OTHER PROCE DURE
CODE
D
DATE
OTHE R PROCEDURE
CODE
DATE
OTHE R PROCEDURE
CODE
DATE
Enter appropriate ICD-9-CM procedure code(s).
Under APCs, they will not impact payment.
OT HER P HY S. ID
Relevant procedure codes include:
A
99.04 Transfusion of packed
cells.
82 ATTE NDING PHYS . ID
B
83
E
84 REMA RKS
OT HER P HY S. ID
85 PROV IDER REPRES ENTATI VE
x
UB-92 HCFA-1450
a
b
a
b
a
b
B
86 DATE
I CE RTI FY THE CERT IFICATI ONS ON THE REVE RS E APP LY TO THIS BILL AND ARE MADE A PART HE REOF.
HM 01-002