Q&A: Medicare billing for recurring services

Q: Could you discuss or explain evaluating encounter billing vs. monthly billing for recurring outpatient services such as chemotherapy infusions or radiation oncology?

A: If you go to the Medicare Claims Processing Manual, Chapter 1, section 50.2.2, titled “Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services,” there’s a lot of discussion and examples regarding this topic. 

There is no requirement for chemotherapy and radiation therapy as types of services that would need to be billed or defined as repetitive services. Occupational therapy and physical therapy, for instance, are listed as repetitive services. If you continue scanning in that section, there’s very clear language that says revenue codes usually reported for chemotherapy and radiation are not on the list of codes that may be billed monthly. Therefore, hospitals should bill chemotherapy and radiation on separate claims.

With repetitive services, people are getting courses of care over multiple encounters, several weeks, or even over the course of the month. Hospitals have the option of reporting those recurring services on a single bill. They can do that, but they are not required to.

If you put everything on a single claim, then when conditional packaging is applied at the claim level or the comprehensive APC (C-APC), where this is a single payment for everything on the claim, you might find yourself surprised if you were to evaluate a few of those claims to see the financial impact.

One good example of this is stereotactic radio surgery. Those are the radiation therapy services paid as C-APCs. If you had five sessions in a month, and you billed them all on a monthly claim, you get one C-APC payment for all five sessions. That’s it. But if you billed each of those sessions on an individual claim as you are absolutely allowed to do, you would get the C-APC payment five times for the five treatments within the month. That is a dramatic difference in payment.

Given that conditional packaging is applied at the claim level and you have C-APCs, it may be time to rethink how you bill for these services.

Editor’s Note: Jugna Shah, MPH, president and founder of Nimitt Consulting, and Valerie A. Rinkle, MPA, lead regulatory specialist and instructor for HCPro's Revenue Integrity and Chargemaster Boot Camp®, as well as an instructor for HCPro’s Medicare Boot Camp®—Hospital Version and Medicare Boot Camp®—Utilization Review Version, answered this question during the HCPro webinar, “2018 OPPS Final Rule: Implement 340B Changes and Other Major Provisions.” Hear more from them regarding hospital billing for drug administration in the upcoming webinar, "2018 Injections and Infusions Coding: CMS’ New Packaging Policies and Reimbursement Implications."

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