Saturday, October 30, 2010

Radiology outpatient billing - where to report prinipal DX - Radiol elements covreage

For claims submitted to the fiscal intermediary:

Hospital Inpatient Claims:

1. The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of
the UB-04. The principal diagnosis is the condition established after study to be chiefly
responsible for this admission.

2. The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-
67Q if they co-existed at the time of admission or developed subsequently, and which had
an effect upon the treatment or the length of stay. It may not duplicate the principal
diagnosis listed in FL 67.

3. For inpatient hospital claims, the admitting diagnosis is required and should be recorded
in FL 69. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter
25, Section 75 for additional instructions.)


Hospital Outpatient Claims:

1. The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly
responsible for the outpatient services in FL 67. If no definitive diagnosis is made during
the outpatient evaluation, the patient’s symptom is reported. If the patient arrives without
a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM
code for Persons Without Reported Diagnosis Encountered During Examination and
Investigation of Individuals and Populations (V70-V82).

2. The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other
diagnoses that co-existed in addition to the diagnosis reported in FL 67.


Radioelements inserted in the in-patient or outpatient setting should not be billed to Medicare Part
B but to Part A under OPPS or Inpatient billing rules.

In the hospital setting (21 or 22) the radioelement is covered by source specific C-codes. The
code C1717 code should be billed for each fraction of HDR given (77781-4).

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