Wiki Billing 64493 in OR (rev 360)

[dottay997]

Looking for CMS guidelines for 64493 and appropriate revenue code for billing. Specifically, looking for billing guidelines; off-campus (Not ASC) facility OR (revenue code 360)? In reviewing CMS LCD, it does state that neither conscious sedation nor monitored anesthesia care is considered necessary, so I am trying to understand the medical necessity of billing in OR vs treatment/procedure room.
I am currently a student preparing for my COC certification.
Any help would be greatly appreciated.

Thank you!

 

[thomas7331]

Revenue codes mainly exist to designate hospital department revenue centers for internal accounting purposes, and are not for coding information or reporting of services, although some payers may require specific revenue codes be used per their payment policies or contracts. So the assignment of a revenue code should be based on hospital policy, not on any coding guidelines. CMS does not require specific CPT codes to be associated with certain revenue codes but offers a HCPCS/Revenue Code Chart as a guide in Chapter 4 of the Medicare Claims Processing Manual, link below, which is also a good reference for other outpatient hospital billing questions - see section 20.5, which indicates that this "is intended only as a guide to be used by hospitals to assist them in reporting services rendered. Hospitals that are currently utilizing different revenue/HCPCS reporting may continue to do so. They are not required to change the way they currently report their services to agree with this chart":

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04aug_op_hospital.pdf

Because the CMS OPPS system reimburses based on the HCPCS code and not on the revenue code, your CPT 64493 will reimburse the same amount whether it is performed in the operating room or a treatment room. There is no medical necessity requirement, that I've ever encountered, for determining eligibility for the use of the OR, and that is generally a decision that is left up to the physician. Although the use of the OR would incur higher costs to the facility, since the reimbursement is the same, it is not likely to be an area for scrutiny in a coding audit since there would not be an overpayment involved. The OPPS system, unlike a fee-for-service system, is designed not to reimburse based on the specific service rendered at that encounter, but rather to group similar services together and make a payment that is an average amount that would cover the costs for that class of services.

 

[dottay997]

Thank you very much for the information; this is very helpful