It involves treating diseases that affect the production of blood and its components, such as blood cells, hemoglobin, blood proteins, bone marrow, platelets, blood vessels, spleen, and the mechanism of coagulation.
Medicare’s Core Billing Guidelines for Blood Transfusions in the Hospital Outpatient Setting:
- Blood or blood component:
- Bill for blood processing under revenue code 0390 and include the product‐specific P‐code.
- Bill per unit.
- Transfusion procedure
- Bill under revenue code 0391 and include the appropriate CPT code.
- CMS allows the transfusion procedure to be billed only once per day/per visit.
- Blood typing, cross matching, and other laboratory services
- Bill under revenue code series 030X (Laboratory) or 031X (Laboratory, Pathological) and include the specific CPT codes for blood typing, cross matching, and other patient‐specific laboratory services performed on the unit.
- In order for hospitals to receive appropriate reimbursement under OPPS, a claim for a transfusion must include both a transfusion CPT code and a blood product P‐code.
- In the hospital outpatient setting, Medicare’s once‐per‐day rule always applies; therefore, hospitals should always report 1 unit of the transfusion procedure.
- The once‐per‐day rule is enforced through a medically unlikely edit (MUE), and through retrospective reviews by Recovery Audit Contractors (RACs). –
- The once‐per‐day rule does not apply in the inpatient setting, although many hospitals voluntarily choose the follow the rule in both settings.
Billing for Patient‐Specific Laboratory Services
- Hospitals should not bill separately for laboratory services that already are described by a product‐specific P‐code. Irradiation, freezing/thawing, and leuko reduction are examples of services that are often included in the charge for the unit.
- If the laboratory service is not included in the HCPCS code for the unit, check to see if there is a CPT code that accurately describes the service.
Guidelines-Patient specific Lab services
Medicare’s OPPS blood billing guidelines instruct hospital outpatient departments to bill these services under revenue code series 030X (Laboratory) or 031X (Laboratory, Pathological).Patient‐specific laboratory services can be billed even if blood units are not transfused
Antigen Screening Using Reagent Serum.
- Antigen screening is an example of a patient‐specific laboratory service that is not included in the HCPCS code for the unit, and is described by a specific CPT code.
Billing for Irradiated Units and Pooled Blood Products
- It is not appropriate to bill irradiation of blood product, each unit in addition to an irradiated P‐code.
- However, hospitals may report CPT code Irradiation of blood product in conjunction with a non‐ irradiated P‐code if an appropriate irradiated P‐code is not available.
- This guidance does not differentiate between irradiating units in‐house vs. obtaining irradiated units from the blood supplier.
- In the hospital outpatient setting, if an irradiated unit is intended for a specific patient but is not transfused, hospitals may bill for the irradiation using CPT code Irradiation of blood product (but may not bill for the blood product or the transfusion procedure).
Billing for Unused Blood Units -:
- Hospitals may never bill Medicare for unused blood units. Hospitals may not submit charges for units that are ordered but not transfused.
- This is a longstanding policy that applies to both the inpatient and outpatient settings.
- Hospitals also may not bill for a transfusion procedure (if no transfusion was performed).
- However, hospitals may: – bill for medically necessary laboratory services related to a specific patient (such as cross matching), even if the blood is not transfused; and – take the overall cost of unused blood into account when setting charges for units that are transfused.
- When billing only for blood processing, hospitals should report charges for blood units using revenue code 0390.
- It is not appropriate to use P9100 for standard pathogen testing performed on all platelet units.
- According to CMS, the code “should be reported to describe the test used for the detection of bacterial contamination in platelets as well as any other test that may be used to detect pathogen contamination…. [the code] should not be used for reporting donation testing for infectious agents such as viruses.
- When billing only for blood processing, OPPS providers should not use revenue code 0380 or the BL modifier, and should not apply the Medicare blood deductible.