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CRIP Set 5
| Question | Answer |
|---|---|
| What modifier is used for live kidney donor and related services? | Q3 |
| How can a designated transplant hospital acquire cadaver kidneys? | Exciting kidneys from cadavers in its own hospital Make an arrangements with a freestanding organ procurement organization that provides cadaver kidneys to any transplant hospital or OPO or by hospital-based OPPO |
| How can a transplant hospital that is also a certified opo acquire cadaver kidneys? | Having the Oregon procurement team excise kidneys from cadavers in other hospitals Making arrangements with participating community hospitals Making arrangements with an OPO that services the transplant hospital as a member of a network |
| If he patient receives a transplant from a hospital that is not an approved facility and later require services as a result of the non-covered transplant, will services be covered? | They will be covered when they are reasonable and necessary |
| What is autologous stem cell transplant? | Uses the patient's own cells which were previously stored to affect hematopoietic reconstitution following severely myelotoxic doses of chemotherapy, and/ or radiotherapy |
| What is allogeneic stem cell transplant? | Uses stem cells from a healthy donor. CMS states it is a procedure in which a portion of a healthy donor's stem cells are obtained and prepared for intravenous infusion to restore normal hematopoietic functions and recipients, having an inherited or acquired hematopoietic deficiency or defect |
| What is bone marrow in peripheral blood stem cell transplantation | A process which includes the mobilization, harvesting, in the transplant of bone marrow or peripheral blood stem cells along with the administration of high dose chemotherapy or radiotherapy prior to the actual transplant |
| What does the acquisition charges for Allogeneic stem cell transplant include? | Donor eval, physician pre-emission/pre-procedure donor eval, prep and processing of stem cells, tissue typing of donor and recipient, national marrow donor program fees, any costs associated with harvesting the cells, post-op/post procedure eval of donor |
| What documentation, at minimum, should be in a patient's chart regarding the need for bariatric surgery? | Pt's medical history Physical exam Results of pertinent diagnostic tests or procedures Evidence of any unsuccessful medical treatment for obesity |
| What are the medical criteria to qualify for bariatric surgery? | Procedure must be one of those listed: Open and lap Roux-en-Y Gastric Bypass Open/Lap Biliopancreatic Diversion with Duodenal Switch Lap Adjustable Gastric Banding BMI greater than or equal to 35 At least 1 co-morbidity related to obesity Unsuccessful with previous treatment |
| What certification does a hospital need to perform covered bariatric surgery? | Certified by the American college of surgeons as a level 1 bariatric surgery Center or certified by the American society for bariatric surgery Center of excellence |
| What level of service do all bariatric procedures covered by Medicare must be considered as? | Inpatient only |
| What bariatric surgery procedure are considered non-covered for all Medicare beneficiaries | Open adjustable gastric banding, open and laparoscopic sleeve gastrectomy, open and lap vertical banded gastroplasty, gastric balloon, intestinal bypass |
| What is the hcpcs code for adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline? | S2083 |
| If a payer does not cover s2083 such as Medicare, what can be reported for the procedure of adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline? | An E&m service CPT code |
| What does IPO stand for? | Inpatient only procedures |
| What is CMS and Tricare list of inpatient only procedures based on | These procedures are identified based on the nature of the procedure, the underlying physical condition of the patient, or the need for at least 24 hours of post-operative recovery time or monitoring before the patient can be be discharged safely |
| If an inpatient procedure was performed on an outpatient claim, does it still get billed? | Yes, the inpatient procedure must still be billed on the outpatient claim for the denial. The inpatient only procedure should not be removed from the claim |
| What is the exception to the inpatient only rule? | If the patient expires before being admitted or if the surgery had to be performed under emergency circumstances. |
| What modifier is appended to the claim for an inpatient only procedure billed as an outpatient using the exception. | CA |
| What conditions must be meant for the facility to receive payment for services billed with a CA modifier? | Patient is an outpatient Patient had an emergent, life-threatening condition The procedure on the inpatient only list is performed on an emergency basis to resuscitate or stabilize the patient. The patient expires without being admitted as an inpatient. |
| If the ca modifier is reported on the ub04 with a discharge status other than 20 (meaning that the patient expired) or if the ca modifier is reported more than once, what will happen to the claim? | It will trigger an OCE edit for the claim to be reviewed. |
| Certain procedures with a status indicator c. That have designated as inpatient supper procedures. What will happen if these procedures are on a claim that is outpatient. | These procedures will be bypassed when performed incidental to a surgical procedure that is not an inpatient only procedure. The inpatient supper procedure will be denied but the rest of the claim will be processed and paid. |
| What should occur if a denial is received for an inpatient supper procedure claim build with outpatient status? | Validate with case management that the patient's outpatient status is correct and that no inpatient order has been written Validate with HIM or the coding department that the CPT code is correct |
| What is a treatment room? | A separate room and is only acceptable substitute for an operating room charge for lesser procedures |
| If an extensive procedure is performed at the patient's bedside, is it appropriate to Bill them? | No, there is not an appropriate site of service revenue code to report them. Therefore, it is not appropriate to separately report these services on the inpatient claim. If hospital routinely uses patient rooms to provide extensive bedside procedures, the facility may want to charge a higher room and board rate for those rooms. |
Created by:
PRO Teacher
larae711
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