Oncology & Hematology Coding Alert

Here is why you should have that ABN handy.

Blood transfusion claims are easy if you can discriminate between the collection and transfusion processes. There is clear guidance for autologous blood transfusion in the Medicare Claims Processing Manual (Chapter 4, Section 231.3). Here is a quick review of the essentials for OPPS autologous blood claims.

Tip 1: Check for Autologous Blood Collection vs. Transfusion of Autologous Blood

Consider the following codes for billing services for self-donor blood collection:

• 86890 (Autologous blood or component, collection processing and storage; predeposited), and
• 86891 (Autologous blood or component, collection processing and storage; intra- or postoperative salvage).

What components of services are covered? The codes 86890 and 86891 are inclusive of: collection, processing, transportation, and storage of blood.

What services are not covered? The codes 86890 and 86891 are not inclusive of transfusion services.

Note: OPPS providers submit codes 86890 and 86891 when the autologous blood is collected but not transfused. These codes are permitted in the hospital outpatient setting only.

What is the code for blood transfusion services? Transfusion of blood is discrete from collection of blood. You submit code 36430 (Transfusion, blood or blood components) and the appropriate blood product HCPCS code when billing for blood transfusion. For example, you may submit the blood product codes P9021 (Red blood cells, each unit) for red blood cells and code P9017 (Fresh frozen plasma [single donor], frozen within eight hours of collection, each unit) for fresh frozen plasma.

Remember: Only report one unit of 36430 regardless of how many blood product units you use.

Payers often won’t pay unless you code for both the transfusion and the blood product. If you’re a freestanding center that performs a transfusion, but the hospital supplies the blood, be sure to get an ABN in which the patient agrees to cover any charges Medicare will not.

“An Advance Beneficiary Notice or ‘ABN’ should be obtained any time there is a known reason Medicare will not cover a service that is typically covered, but lacking medical necessity, exceeds frequency limitations or other circumstances such as experimental procedures,” says Kelly Loya, CPC-I, CHC, CPhT, CRMA, Associate Partner at Pinnacle Enterprise Risk Consulting Services LLC located in Charlotte, North Carolina. “Receiving the ABN prior to receiving the service, serves as notice to the patient that Medicare may or may not pay, which ultimately means the patient will be financially responsible. If not obtained and Medicare does not pay, the financial responsibility falls into your lap and you may not collect from the patient (Medicare beneficiary).”

Tip 2: Document Collection and Transfusion as Discrete

Medicare instructs providers to bill for the transfusion on the date the transfusion took place and not on the date of the autologous blood collection.

Do not bill 86890 when autologous blood was transfused: When autologous blood is transfused in the hospital outpatient setting, you may bill for the transfusion service with code 36430 with the appropriate blood product code times the number of units transfused. In this case, you should not submit code 86890.

The collection codes (86890 and 86891) are only submitted when the autologous blood is not transfused on the same day. You should bill a collection code on the date the provider is certain the unit will not be transfused. Again, CMS instructs the use when the autologous unit was collected on the date of the procedure or date of discharge.

Both collection and transfusion in outpatient setting: When the autologous blood is collected and transfused in an outpatient setting, you will bill the transfusion service with code 36430 and also submit the blood product code, e.g. P9021 along with the appropriate revenue code (0390 - 0399).

Note: You will not submit code 86890 for the autologous collection and processing as the payment for these services is included in the billing for P9021.