Sample Hospital Billing – UB-04 CMS-1450 – MPI PET Multiple...

Sample Hospital Billing – UB-04 CMS-1450 – MPI PET Multiple Study
Hospital Name
One Hospital Place
City, State 00000
Patient Name
Pay – to Name
Pay – to Address
(If different from billing
provider in FL1)
Medical Record #
Patient ID
0404 MPI PET, Multiple Studies
78492
01/01/2013
1
XXXX.XX
0343 Rubidium per dose
A9555
01/01/2013
2
XXX.XX
0482 Cardiac Stress Test
93017
01/01/2013
1
0636 Pharmacologic Stress Agent
JXXXX
01/01/2013
X
Form Locator 42(Rev. CD.)
Enter Revenue Code – For Example
0404 PET or 0341 Nuclear Medicine Diagnostic
(Verify Revenue Coding with Hospital Finance Dept.)
0343 Diagnostic Radiopharmaceutical
0482 Cardiac Stress Test
0636 Drugs requiring detailed coding
Form Locator 44 (HCPCS /Rates/HIPPS Code)
Enter the CPT or HCPCS code for the procedure, radiopharmaceutical and drug.
78492 Myocardial imaging, PET, perfusion; multiple studies at rest and/or stress
A9555 Rubidium Rb-82, diagnostic, per study dose, up to 60 mCi
93017 Cardiovascular stress test, tracing only, without interpretation and report
Use the appropriate HCPCS code for the pharmacological stress used to perform the
study.
Form Locator 67 (Principle Diagnosis Code)
Enter the ICD-9 code for the principle
diagnoses. – For Example
410.00 Myocardial Infarction
Up to eight other diagnoses that co-exist in
addition to the principle diagnosis can be
reported in FL 67 A-H
410.00
Form Locator 46 (Units of Service)
XXX.XX
Enter the number of units based on he
HCPCS code descriptor
XXX.XX
Bracco Diagnostics Inc.
cannot guarantee coverage
or payment for products or
procedures at any particular
level. For more specific
information please contact
your Medicare contractor or
the patient’s insurer.
Current Procedural Terminology (CPT) is copyright 2012 by the American Medical Association.
All rights reserved. CPT is a registered trademark of the American Medical Association.
HOPPS Payment Calculation:
The Medicare Hospital Outpatient Prospective Payment System (HOPPS) went
into effect in August of 2000 and applies to almost all hospital outpatient
departments. HOPPS replaced the former cost-based reimbursement methodology
and is currently based on hospital claims data.
CMS groups procedures into Ambulatory Payment Classifications or APCs. The
procedures within an APC are intended to be clinically comparable and similar in
terms of resource utilization.
The following Cardiac PET Imaging procedures are reassigned to APC 0308 (Positron
Emission Tomography (PET) Imaging) in calendar year 2012.
APC
0308
0308
0308
CPT Code
78459
78491
78492
Procedure
Myocardial Imaging, PET, metabolic evaluation
Myocardial Imaging, PET perfusion, single study at rest or stress
Myocardial Imaging, PET perfusion, multiple studies at rest and/or stress
The national unadjusted payment rate for an APC is determined by multiplying the
prospectively established scaled relative weight by a conversion factor (CF). The
scaled relative weight measures the resource requirements of the service and is
based on the median cost of the services within the APC. The median cost is based
on previous years’ hospital charge data reduced by the hospital department specific
cost to charge ratio. For example the payments for 2012 are based on 2010 hospital
charge data. The charge data is multiplied by the cost to charge ratio on the cost
center under which the service is billed to determine cost information.
Hospital Charge X Cost to Charge Ratio = Cost
The HOPPS payment allowances posted by CMS are national averages and the
actual rates for specific hospitals are determined by applying a geographic
adjustment. Sixty percent of the payment is attributed to labor costs, and forty
percent to non labor costs. The labor-related portion of the payment is adjusted
using the final wage index (FWI) assigned by CMS to area where the hospital being
paid is located. For example:
APC
Relative
Weight
(RW)
X
Conversion
Factor
(CF)
=
Unadjusted
APC
Payment
Geographic Adjustment
(0.6 X APC Payment X Final Wage Index)
Based on
hospital
charge data
reduced by
the CCR
+
(0.4 X APC Payment)
=
Hospital Local
Payment
The HOPPS payments cover only facility or technical fees; professional fees are paid separately
in the Medicare Physician Fee Schedule (MPFS). CMS annually revises and updates APC
groupings, payments and code descriptors to clarify and refine the HOPPS system.
Each year’s proposed and final rules and all supporting files and documentation can be acceded
at www.cms.gov/HospitalOutpatientPPS/HORD/list.asp on the CMS website. To find additional
information about the OPPS, visit www.cms.gov./HospitalOutpatientPPS/01_overview.asp
www.cms.gov/MLNProducts/downloads/HospitalOutpaysysfctsht.pdf
Created: FEB. 2013