CMS Pub. 100-04, ch. 4, § 230.2

A. Overview

Drug administration services furnished under the Hospital Outpatient Prospective

Payment System (OPPS) during CY 2005 were reported using CPT codes 90780, 90781,

and 96400-96459.

Effective January 1, 2006, some of these CPT codes were replaced with more detailed

CPT codes incorporating specific procedural concepts, as defined and described by the

CPT manual, such as initial, concurrent, and sequential.

Hospitals are instructed to use the full set of CPT codes, including those codes

referencing concepts of initial, concurrent, and sequential, to bill for drug administration

services furnished in the hospital outpatient department beginning January 1, 2007. In

addition, hospitals are instructed to continue billing the HCPCS codes that most

accurately describe the service(s) provided.

Hospitals are reminded to bill a separate Evaluation and Management code (with

modifier 25) only if a significant, separately identifiable E/M service is performed in the

same encounter with OPPS drug administration services.

B. Billing for Infusions and Injections

Beginning in CY 2007, hospitals were instructed to use the full set of drug administration

CPT codes (90760-90779; 96401-96549), (96413-96523 beginning in CY 2008) (96360-

96549 beginning in CY 2009) when billing for drug administration services provided in

the hospital outpatient department. In addition, hospitals are to continue to bill HCPCS

code C8957 (Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion

(more than 8 hours), requiring use of portable or implantable pump) when appropriate.

Hospitals are expected to report all drug administration CPT codes in a manner consistent

with their descriptors, CPT instructions, and correct coding principles. Hospitals should

note the conceptual changes between CY 2006 drug administration codes effective under

the OPPS and the CPT codes in effect beginning January 1, 2007, in order to ensure

accurate billing under the OPPS. Hospitals should report all HCPCS codes that describe

the drug administration services provided, regardless of whether or not those services are

separately paid or their payment is packaged.

Medicare’s general policy regarding physician supervision within hospital outpatient

departments meets the physician supervision requirements for use of CPT codes 90760-

90779, 96401-96549, (96413-96523 beginning in CY 2008). (Reference: Pub.100-02,

Medicare Benefit Policy Manual, Chapter 6, §20.4.)

Drug administration services are to be reported with a line item date of service on the day

they are provided. In addition, only one initial drug administration service is to be

reported per vascular access site per encounter, including during an encounter where

observation services span more than 1 calendar day.

C. Payments For Drug Administration Services

For CY 2007, OPPS drug administration APCs were restructured, resulting in a six-level

hierarchy where active HCPCS codes have been assigned according to their clinical

coherence and resource use. Contrary to the CY 2006 payment structure that bundled

payment for several instances of a type of service (non-chemotherapy, chemotherapy by

infusion, non-infusion chemotherapy) into a per-encounter APC payment, structure

introduced in CY 2007 provides a separate APC payment for each reported unit of a

separately payable HCPCS code.

Hospitals should note that the transition to the full set of CPT drug administration codes

provides for conceptual differences when reporting, such as those noted below.

• In CY 2006, hospitals were instructed to bill for the first hour (and any

additional hours) by each type of infusion service (non-chemotherapy,

chemotherapy by infusion, non-infusion chemotherapy). Beginning in CY 2007,

the first hour concept no longer exists. CPT codes in CY 2007 and beyond allow

for only one initial service per encounter, for each vascular access site, no matter

how many types of infusion services are provided; however, hospitals will receive

an APC payment for the initial service and separate APC payment(s) for

additional hours of infusion or other drug administration services provided that

are separately payable.

• In CY 2006, hospitals providing infusion services of different types (non-chemotherapy, chemotherapy by infusion, non-infusion chemotherapy) received

payment for the associated per-encounter infusion APC even if these infusions

occurred during the same time period. Beginning in CY 2007, hospitals should

report only one initial drug administration service, including infusion services, per

encounter for each distinct vascular access site, with other services through the

same vascular access site being reported via the sequential, concurrent or

additional hour codes. Although new CPT guidance has been issued for reporting

initial drug administration services, Medicare contractors shall continue to follow

the guidance given in this manual.

(NOTE: This list above provides a brief overview of a limited number of

the conceptual changes between CY 2006 OPPS drug administration codes

and CY 2007 OPPS drug administration codes - this list is not comprehensive

and does not include all items hospitals will need to consider during this

transition)

For APC payment rates, refer to the most current quarterly version of Addendum B on

the CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/.

D. Infusions Started Outside the Hospital

Hospitals may receive Medicare beneficiaries for outpatient services who are in the

process of receiving an infusion at their time of arrival at the hospital (e.g., a patient who

arrives via ambulance with an ongoing intravenous infusion initiated by paramedics

during transport). Hospitals are reminded to bill for all services provided using the

HCPCS code(s) that most accurately describe the service(s) they provided. This includes

hospitals reporting an initial hour of infusion, even if the hospital did not initiate the

infusion, and additional HCPCS codes for additional or sequential infusion services if

needed.