2.2 Encarecimiento limita acceso a la CBA
Recuadro 3. Impacto de la fortificación de alimentos en Centroamérica.
BCBST will update the BCBST Facility Fee schedule for quarterly additions and deletions to HCPCS/CPT® codes that are effective January 1, April 1, July 1, and October 1 of each year in accordance with the American Medical Association (AMA). For new HCPCS/CPT® codes, the allowable reimbursed by BCBST beginning with theeffective date of the code from January 1 until March 31 will be considered an interim allowable based on the reimbursement pricing methodology below. Revisions for the existing HCPCS/CPT® codes allowable
reimbursement will be updated effective April 1 of each year in accordance with the Provider’s Contract.
a. Laboratory Services
Laboratory Services will be allowed according to the contract unless performed with an all- inclusive service. When filed with an all-inclusive service, the Laboratory Services will be bundled with the all-inclusive service. The Fee Schedule will be allowed when filed separately. These Fee Schedules are priced at the current Medicare reimbursement rate and updated on April 1 of each year.
Revenue Code
Type of Service HCPCS/CPT® Code
Allowed 0300 Laboratory Requires a valid
HCPCS/CPT®Code. Reimbursement is based upon the contract. Refer to Laboratory Fee Schedule. 0301 Chemistry 0302 Immunology 0304 Non-Routine Dialysis 0305 Hematology
0306 Bacteriology & Microbiology 0307 Urology 0309 Other Laboratory 0310 General 0311 Cytology 0312 Histology 0314 Biopsy 0319 Other b. Radiology Services
When filed with all-inclusive services, the radiology procedure will be bundled with the all- inclusive service. The Fee Schedule will be allowed when filed separately. These Fee Schedules are priced at the current Medicare reimbursement rate and updated on April 1 of each year.
Revenue Code
Type of Service HCPCS/CPT® Code Allowed 0320 Radiology Diagnostic Requires a valid
HCPCS/CPT®Code. Reimbursement is based upon the contract. Refer to Radiology Fee Schedule. 0321 Angiocardiography 0322 Arthrography 0323 Arteriography 0324 Chest X-ray 0329 Other Radiology Services 0330 Radiology Therapeutic 0333 Radiation Therapy 0340 General Radiology 0341 Diagnostic Procedures 0342 Therapeutic Procedures 0349 Other Radiology Services 0400 Other Imaging Services 0401 Diagnostic Mammography 0402 Ultrasound
0403 Screening Mammography 0404 Positron Emission
Tomography (PET) 0409 Other imaging Services c. MRI/MRA/CT Scan
MRI/MRA/CT Scan reimbursement includes pharmacy, anesthesia, and/or supplies used in conjunction with the Radiology Services. MRI/MRA/CT Scan claims are allowed via a Fee Schedule. These Fee Schedules are priced at the current Medicare reimbursement rate and updated on April 1 of each year. These services are allowed in addition to the all-inclusive rate(s).
Revenue Code
Type of Service HCPCS/CPT® Code
Allowed
0350 General Scans Requires a valid
HCPCS/CPT®
Code.
Reimbursement is based upon the contract. Refer to MRI/CT Scan Fee Schedule.
0351 Head Scan
0352 Body Scan
0359 Other CT Scan
0610 Magnetic Resonance Technology
(MRT)
General MRI Technology
0611 MRI – Brain (including brainstem)
0612 MRI – Spinal Cord (including spine)
0614 MRI – Other
0615 Magnetic Resonance Angiography –
(MRA) Head and Neck
0616 MRA – Lower Extremities
0618 MRA - Other
0619 MRT – Other
0621 Supplies incidental to radiology HCPCS/CPT®
Code does not affect
reimbursement
Reimbursement is based upon the contract.
0622 Supplies incidental to other diagnostic
services
d. BCBST Facility Fee Schedule Reimbursement Methodology Policy
This policy applies to claims filed on an Institutional claim form/transaction. It defines the reimbursement methodology used for all new codes and existing HCPCS/CPT® codes for BCBST lines of business on the BCBST Facility Fee Schedule. The purpose is to
establish consistent method to add and update HCPCS/CPT® codes on the BCBST Facility Fee Schedule for all contracts.
BCBST will update the BCBST Facility Fee Schedule for quarterly additions and deletions to HCPCS/CPT® codes that are effective January 1, April 1, July 1, and October1 of each year in accordance with the American Medical Association (AMA). For new HCPCS/CPT® codes, the allowable reimbursed by BCBST beginning with the effective date of the code from January 1 until March 31 will be considered an interim allowable based on the reimbursement pricing methodology below. Revisions for the existing HCPCS/CPT® codes allowable reimbursement will be updated effective April 1 of each year in accordance with the Provider’s contract.
To establish the codes that are added to the BCBST Facility Fee Schedule, BCBST will utilize Appendix 3, "Numeric List of HCPCS Codes with Recommended Revenue Code (RC) Assignments," of the OPTUM Uniform Billing (UB) Editor or its successor. These codes will be updated annually on July 1st from the First Quarter OPTUM Uniform Billing (UB) Editor Updates.
The reimbursement methodology within this policy does not apply to “C” codes such as drugs, biologicals, radiopharmaceuticals, and devices that have alternate reimbursement methodologies.
The established BCBST Facility allowable will be based on the published maximum allowable non-facility rate. BCBST will not establish an allowable for an unlisted code. Some exceptions may apply.
To determine the allowable, BCBST will utilize the following reimbursement pricing methodology hierarchy excluding laboratory (see laboratory pricing grid):
Order Description
1st Current Year Medicare RBRVS fee schedule TC component (Calculated using the CMS formula) x contract multiplier.
2nd Current Year Medicare RBRVS fee schedule *Global (Calculated using the CMS formula) x contract multiplier %.
3rd Current Year Cahaba GBA (or its successor) Complete RBRVS TC component x contract multiplier %.
4th Current Year Cahaba GBA (or its successor) Complete RBRVS *Global x contract multiplier %.
5th Current Year OPTUM (or its successor) Complete RBRVS TC
component (Calculated using the CMS formula) x contract multiplier %. 6th Current Year OPTUM (or its successor) Complete RBRVS
*Global (Calculated using the CMS formula) x contract multiplier %. 7th Current Year National Medicare APC Payment Rate as a flat rate. 8th Allowables that were not priced by any source mentioned above remain
at zero dollars with “BR – By report” to be reviewed and priced by using a similar HCPCS/CPT® code.
To determine the allowable, BCBST will utilize the following reimbursement pricing methodology hierarchy for laboratory:
Order Description
1st Current Year Cahaba GBA (or its successor) Clinical Laboratory fee schedule x contract multiplier.
2nd Current Year Medicare Physician fee schedule TC
component (Calculated using the CMS formula) x contract multiplier %. 3rd Current Year Medicare Physician fee schedule *Global (Calculated using
the CMS formula) x contract multiplier %.
4th Current Year Cahaba GBA (or its successor) Physician fee schedule TC component x contract multiplier %.
5th Current Year Cahaba GBA (or its successor) Physician fee schedule *Global x contract multiplier %.
6th Current Year OPTUM (or its successor) Complete RBRVS TC component (Calculated using the CMS formula) x contract multiplier. 7th Current Year OPTUM (or its successor) Complete RBRVS
*Global (Calculated using the CMS formula) x contract multiplier %. 8th Allowables that were not priced by any source mentioned above remain
at zero dollars with “BR – By report” to be reviewed and priced by using a similar HCPCS/CPT® code.
* Global represents the 5-digit code on fee schedule with no modifiers.
e. Reimbursement Policy and Billing Guidelines for the Commercial Acute Care Drug Schedule
This policy is to establish the codes that are added to the Drug and Radiopharmaceutical Fee Schedule, BCBST will utilize Appendix 3, "Numeric List of HCPCS Codes with Recommended Revenue Code (RC) Assignments," of the OPTUM Uniform Billing (UB) Editor or its successor. CPT®/HCPCS codes that are appropriate to be billed under RC(s) 0250, General Drugs; 0343, Radiopharmaceuticals Diagnostic; 0344,
Radiopharmaceuticals Therapeutic; and 0636, Drugs Requiring Detail Coding will be added to the fee schedule annually on July 1 from the First Quarter OPTUM Uniform Billing (UB) Editor Updates.
A drug or radiopharmaceutical that is not addressed by OPTUM may be added to the fee schedule at BCBST discretion in accordance with BCBST Policy, "Quarterly
Reimbursement Changes," if it is appropriate to be reimbursed to an Acute Care Hospital under the CMS Hospital Outpatient Prospective Payment System (OPPS) methodology. OPTUM updates the UB-Editor periodically. In this instance, the Schedule may be adjusted if OPTUM addresses the code in a subsequent publication of the UB-Editor. These periodic updates to the Drug and Radiopharmaceutical Fee Schedule will be made in accordance with BCBST Policy, "Quarterly Reimbursement Changes."
The base allowed is the equivalent of the CMS National APC Payment Rate under the Medicare OPPS methodology. Drugs and radiopharmaceuticals not priced by CMS that are on the Fee Schedule are to be presented with a zero allowed indicating BCBST will not make payment. The BCBST allowed is a negotiated percentage of the base allowed that is defined in the hospital contract.
Unclassified drugs or radiopharmaceuticals must exceed $1,000 per line to be considered for manual pricing, otherwise reimbursement will be set at $0.00. Drugs will be priced in accordance with BCBST Policies for Vaccines, and Toxoids, or "Unclassified Infusion Therapy, Immunosuppressive, Immune Globulins, Nebulizer, Chemotherapy and Other Injectable Drugs Billed by Facility. Radiopharmaceuticals will be priced in accordance with BCBST Policy for "Unclassified Radiopharmaceuticals and Contrast Materials Billed by an Acute Care Facility." Drugs and radiopharmaceuticals billed without a valid CPT®/HCPCS code under RC(s) 0250, 0343, 0344, and 0636 will not be considered for payment.
The Drug and Radiopharmaceutical Fee Schedule is to be updated quarterly in conjunction with the CMS quarterly updates.
Only those CPT®/HCPCS codes on the fee schedule will be considered for reimbursement when filed with one of the RC(s) listed in the table below. Services billed outside of the Agreement are subject to recovery.
Note: BCBST will not make a payment to an Acute Care Facility for any CPT®/HCPCS code where the UB-Editor indicates it is not appropriate to reimburse for these codes in an Acute Care Hospital Outpatient setting. In the circumstance that an inappropriate payment has occurred, BCBST reserves the right to re-coup the reimbursement as necessary. The appropriate CPT®/HCPCS code should be billed in conjunction with the
corresponding RC according to the following chart:
Revenue Code Description CPT®/HCPCS Code
0250 General Drugs Required 0251 Generic Drugs Required 0252 Non-generic Drugs Required 0254 Drugs Incident to Other Diagnostic
Services Required
0255 Drugs Incident to Radiology Required 0257 Non-prescription Required 0258 IV Solutions Required 0259 Other Pharmacy Required 0343 Radiopharmaceuticals Diagnostic Required, if applicable 0344 Radiopharmaceuticals Therapeutic Required, if applicable 0636 Drugs Requiring Detail Coding Required, if applicable Providers filing electronic claims should refer to the Electronic Billing Instructions of this Manual.
f. Reimbursement Policy and Billing Guidelines for the Facility Drug Schedule This policy is to establish the codes that are added to the BCBST Facility Drug Fee Schedule. BCBST will utilize Appendix 3, "Numeric List of HCPCS Codes with
Recommended Revenue Code (RC) Assignments," of the OPTUM Uniform Billing (UB) Editor or its successor.
BCBST will identify the HCPCS codes that are appropriate to be billed under RC(s) 0250, General Drugs; 0251, Generic Drugs; 0252, Non-generic Drugs; 0254, Drugs Incident to Other Diagnostic Services; 0255, Drugs Incident to Radiology; 0257, Non-prescription; 0258, IV Solutions; 0259, Other Pharmacy; 0343, Radiopharmaceuticals Diagnostic; 0344, Radiopharmaceuticals Therapeutic; and 0636, Drugs Requiring Detail Coding, as
indicated in the OPTUM Uniform Billing (UB) Editor or its successor and add these codes to the fee schedule.
Drug codes submitted for consideration, but not listed in the BCBST Facility Drug Fee Schedule are not eligible for reimbursement and will be denied as non-contracted.
Effective 3/17/14, any of the above indicated RC(s) filed without a HCPCS/CPT® code will also be denied as non-contracted. Drug codes submitted that are on this schedule with a $0.00 fee and no indicator in note to review for manual pricing will be denied – exceeds the scheduled rate. In the circumstance that an inappropriate payment has occurred, BCBST reserves the right to re-coup the reimbursement as necessary.
BCBST shall reimburse acute care hospitals contracted for BCBST Facility Drug Fee Schedule for eligible outpatient drug codes based on a percentage of the Average Sales Price (ASP), or in the absence of a published ASP, Wholesale Acquisition Cost (WAC) or Average Wholesale Price (AWP). The table below indicates the Base Facility Drug Fee Schedule pricing for each of the above methodologies.
BCBST Base Facility Drug Fee Schedule Pricing Methodology Percentage of
Base Allowed Average Sales Price (ASP) X % Wholesale Acquisition Cost (WAC) X % Average Wholesale Price (AWP) X %
Eligible outpatient drugs will be reimbursed in addition to other outpatient services filed on the CMS-1450 (UB-04 or successor) claim form, including but not limited to Outpatient Surgery, Emergency Room, Observation and Cardiac Care.
In the event a valid outpatient drug C code is considered to be a covered procedure and there is not an acceptable CPT® code that could be used, BCBST will reimburse the C code by using ASP multiplied by an indicated contract percentage. The source for this reimbursement is derived from the Medicare Hospital Outpatient Prospective Payment System (OPPS) methodology.
Any new eligible outpatient drug codes that apply to this schedule and do not have a fee will be added to schedule with $0.00 allowable and “BR” indicator. These codes as well as Not Otherwise Classified (NOC) and Unlisted/Miscellaneous/Non-Specific HCPCS Codes will be reviewed for manual pricing according to BCBST’s policy for Unlisted,
Miscellaneous, Non-specific, and Not Otherwise Classified Procedures/Services until a CMS fee has been established. In situations where fees may not be established for an eligible drug then invoice pricing may be utilized. These fees will be updated in
accordance with BCBST’s Policy “Quarterly Reimbursement Changes”. Failure to submit the following information for these codes will result in delay of reimbursement.
Not Otherwise Classified (NOC) and Unlisted/Miscellaneous/Non-Specific HCPCS Codes:
Requires submission of drug name; National Drug Code (NDC) in field 43,
“Revenue Description/ IDE/ Medicaid Drug Rebate”, on the CMS-1450 claim form; and dosage administered
Note: Percentages and base allowables as set forth in the Base Facility Drug Fee Schedule are not eligible for an annual contract increase pursuant to the Outpatient language excluding services reimbursed at a percentage of Medicare or percent of Covered charges. Also, any items identified as over the counter or drugs not requiring a prescription, self-administered and oral medications and medications not reimbursed by Medicare have been excluded from this BCBST Facility Drug Fee Schedule.
g. Ambulance Services
Ambulance services shall be paid in accordance with the Institutional Ambulance Fee Schedule. The ambulance codes are based on those established by CMS codes. These codes are reimbursed based on Provider’s contract and updated April 1 of each year. h. Implants and Pacemaker and Orthotic/Prosthetic Devices
Facilities that bill BCBST in excess of the contracted amount are subject to recovery. Likewise, hospitals that cannot support a charge for an Implant or Pacemaker with a manufacturer’s invoice, or other documentation, meeting BCBST satisfaction verifying the cost, (that excludes shipping & handling and state sales tax) and a medical record indicating that it was provided to a BCBST Member are subject to recovery.
Orthotic and Prosthetic (O & P) devices must be billed with an appropriate HCPCS code under RC 0274. The reimbursement for all these services is based on the Provider’s contract. When not specifically contracted, the allowable will be zero.
BCBST requires Providers to file the most appropriate HCPCS codes in accordance with the National Uniform Billing Guidelines on an Institutional claim form for Implant RCs 0274, 0275, and 0278.