Hospital Outpatient Services Billing Codes Effective January 1, 2018
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1 Hospital Outpatient Services Billing Codes Effective January 1, 2018 Revenue Codes: Codes from the Uniform Billing Editor are used to indicate the various services provided during a hospitalization. For more clarification regarding how and when to use these codes, refer back to the National Uniform Billing Editor. *Asterisked codes are exempt from the outpatient cap. Category 025X Description PHARMACY Charges for medication produced, manufactured, packaged, controlled, assayed, dispensed, and distributed under the direction of a licensed pharmacist General Classification 0255 Drugs Incident to Radiology 0258 IV Solutions 0259 Other Pharmacy 026X 027X Note: Submission of a Healthcare Common Procedural Coding System (HCPCS) code with revenue code 0258 requires the appropriate National Drug Code (NDC). IV THERAPY Equipment charge or administration of intravenous solution by specially trained personnel to individuals requiring such treatment General Classification 0261 Infusion Pump 0262* Pharmacy Services 0264* Supplies 0269* Other IV Therapy MEDICAL/SURGICAL SUPPLIES AND DEVICES Charges for supply items required for patient care General Classification 0271 Non-Sterile Supply 0272 Sterile Supply 0273* Take-home supplies 0275 Pace Maker 0276* Intraocular Lens 0278 Other Implants (a) Note: This code can be used to bill the subdermal contraceptive implant or any other medically necessary, non-experimental implant as described below. Cochlear implant handling can also be billed using code (a) Implantables: That which is implanted, such as a piece of tissue, a tooth, a pellet of medicine, or a tube or needle containing a radioactive substance, a graft, or an insert. Also included are liquid and solid plastic materials used to augment tissues or to fill in areas traumatically or surgically removed. An object Page 1 of 8
2 or material partially or totally inserted or grafted into the body for prosthetic, therapeutic or diagnostic purposes. 030X 031X 032X 033X 034X 0279* Other Supplies/Devices Note: This code can be used to bill the burn pressure garment fitted to burn patients. LABORATORY-CLINICAL DIAGNOSTIC Charges for the performance of diagnostic and routine clinical laboratory tests General Classification 0301 Chemistry 0302 Immunology 0304 Non-Routine Dialysis 0305 Hematology 0306 Bacteriology and Microbiology 0307 Urology Note: The lab revenue codes require an HCPCS code. LABORATORY-PATHOLOGICAL Charges for diagnostic and routine laboratory tests in tissues and culture General Classification 0311 Cytology 0312 Histology 0314 Biopsy Note: The pathology revenue codes require an HCPCS code. RADIOLOGY-DIAGNOSTIC Charges for diagnostic radiology services provided for the examination and care of patients. Includes taking, processing, examining, and interpreting radiographs and fluorography General Classification 0321 Angiocardiography 0322 Arthrography 0323 Arteriography 0324 Chest X-Ray 0329 Other Radiology Diagnostic RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION Charges for therapeutic radiology services and chemotherapy administration required for the care and treatment of patients. Includes therapy by injection or ingestion of radioactive substances. Excludes charges for chemotherapy drugs, which should be reported under the appropriate revenue code (025X/063X). 0330* General Classification 0331* Chemotherapy Administration-Injected 0332* Chemotherapy Administration-Oral 0333* Radiation Therapy 0335* Chemotherapy Administration-IV 0339* Other Radiology Therapeutic NUCLEAR MEDICINE Page 2 of 8
3 Charges for procedures and tests performed by a radioisotope laboratory utilizing radioactive materials as required for diagnosis and treatment of patients. 035X 036X 037X 038X 039X 0340 General Classification 0341 Diagnostic 0342 Therapeutic 0343 Diagnostic Radiopharmaceuticals 0344 Therapeutic Radiopharmaceuticals 0349 Other Nuclear Medicine COMPUTER TOMOGRAPHIC (CT) SCAN Charges for computed tomographic scans of the head and other parts of the body General 0351 Head 0352 Body 0359 Other OPERATING ROOM SERVICES Charges for services provided to patients by specially trained nursing personnel who provide assistance to physicians in the performance of surgical and related procedures during and immediately following surgery as well the operating room (heat, lights) and equipment. 0360* General 0361* Minor surgery 0362* Organ transplant-other than kidney 0367 Kidney transplant 0369* Other operating room services ANESTHESIA Charges for anesthesia services in the hospital General 0371 Anesthesia incident to radiology 0372 Anesthesia incident to other diagnostic services 0374 Acupuncture 0379 Other anesthesia BLOOD 0380 General 0381 Packed red cells 0382 Whole blood 0383 Plasma 0384 Platelets 0385 Leucocytes 0386 Other components 0387 Other derivatives (Cryopricipitates) 0389 Other Blood BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE Page 3 of 8
4 Charges for administration, processing, and storage of whole blood, red blood cells, platelets, and other blood components, such as plasma and plasma derivatives. 040X 041X 042X 043X 044X 045X 0390 General Classification 0391 Administration (e.g., Transfusions) 0399 Other Processing and Storage OTHER IMAGING SERVICES 0400 General Classification 0401 Diagnostic Mammography 0402 Ultrasound 0403 Screening Mammography 0404 Positron Emission Tomography 0409 Other Imaging Services RESPIRATORY SERVICES (All Ages) Charges for the administration of oxygen and certain potent drugs through inhalation or positive pressure and other forms of rehabilitative therapy through measurement of inhaled and exhaled gases and analysis of blood and evaluation of the patient s ability to exchange oxygen and other gases General 0412 Inhalation 0413 Hyperbaric Oxygen Therapy 0419 Other Respiratory Services PHYSICAL THERAPY (All Ages) Charges for therapeutic exercises, massage, and utilization of effective properties of light, heat, cold, water, electricity, and assistive devices for diagnosis and rehabilitation of patients who have neuromuscular, orthopedic, and other disabilities Visit Charge 0424 Evaluation or Re-Evaluation OCCUPATIONAL THERAPY (Limited to Age 21 Years and Under) Services provided by a qualified occupational therapy practitioner for therapeutic interventions to improve, sustain, or restore an individual s level of function in performance of activities of daily living and work Visit Charge 0434 Evaluation or Re-Evaluation SPEECH-LANGUAGE PATHOLOGY (Limited to Age 21 Years and Under) Charges for services provided to persons with impaired functional communications skills Visit Charge 0444 Evaluation or Re-Evaluation EMERGENCY ROOM Charges for emergency treatment to those ill and injured recipients who require immediate unscheduled medical or surgical care. 0450* General Classification Page 4 of 8
5 046X 047X 048X 049X 051X 0451 Emergency Medical Treatment and Labor Act Emergency Medical Screening Services PULMONARY FUNCTION Charges for tests that measure inhaled and exhaled gases and analysis of blood and for tests that evaluate the patient s ability to exchange oxygen and other gases General Classification 0469 Other Pulmonary Function AUDIOLOGY Charges for the detection and management of communication handicaps centering in whole or in part on the hearing function Diagnostic 0472 Treatment CARDIOLOGY Charges for cardiac procedures rendered in a separate unit within the hospital. Such procedures include, but are not limited to, heart catheterization, coronary angiography, Swan-Ganz catheterization, and exercise stress test General Classification 0481 Cardiac Cath Laboratory 0482 Stress Test 0483 Echocardiology 0489 Other Cardiology AMBULATORY SURGICAL CARE Charges for ambulatory surgery that are not covered by any other category Ambulatory Surgical Care Note: Observation is not reported under this code. It is reported under revenue code CLINIC Charges for scheduled non-emergency outpatient clinic visits for the purpose of providing diagnostic, preventative, curative, and rehabilitative services General Classification 0513 Psychiatric Clinic 061X Note: Use code 0513 in conjunction with the following revenue codes: 0914 Psychiatric Clinic Visit/Individual Therapy 0918 Psychiatric Testing 0944 Drug Rehabilitation 0945 Alcohol Rehabilitation MAGNETIC RESONANCE TECHNOLOGY (MRT) Charges for Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) of the brain and other parts of the body General Classification 0611 MRI-Brain (including Brain Stem) 0612 Spinal Cord (Including Spine) Page 5 of 8
6 062X 063X 070X 071X 072X 073X 074X 0614 MRI-Other 0615 MRA-Head and Neck 0616 MRA-Lower Extremities 0618 MRA-Other 0619 Other MRT MEDICAL/SURGICAL SUPPLIES- EXTENSION OF 027X Charges for supply items required for patient care. This category is an extension of 028X for reporting additional breakdown where needed Supplies Incident to Radiology 0622 Supplies Incident to Other Diagnostic Services 0623 Surgical Dressings PHARMACY- DRUGS REQUIRING SPECIFIC IDENTIFICATION This category is an extension of 025X for reporting detailed coding where needed. 0634* Erythropoietin (EPO) less than 10,000 units 0635* Erythropoietin (EPO) 10,000 or more units 0636 Pharmacy/Coded Drugs CAST ROOM Charges for services related to the application, maintenance, and removal of casts General Classification RECOVERY ROOM 0710 General Classification Note: Use code 0710 to bill routine post-operative monitoring during a normal recovery. Recovery room services must not be billed as observation services. LABOR ROOM/DELIVERY Charges for labor and delivery room services provided by specially trained nursing personnel to patients. Includes: prenatal care during labor, delivery, postnatal care in recovery room, and minor gynecologic procedures performed in a delivery suite Labor 0722* Delivery EKG ECG (Electrocardiogram) Charges for operation of specialized equipment to record electromotive variations in actions of the heart muscle on an electrocardiograph for diagnosis of heart ailments General Classification 0731 Holter Monitor 0732 Telemetry 0739 Other EKG - ECG EEG (Electroencephalogram) Charges for operation of specialized equipment to measure impulse frequencies and differences in electrical potential in various areas of the brain to obtain data for use in diagnosing brain disorders. Page 6 of 8
7 075X 076X 079X 082X 083X 084X 085X 088X 090X 0740 EEG/General 0749 Other EEG (Effective 01/01/05) GASTRO-INTESTINAL SERVICES Any service or procedure room charges for endoscopic procedures not performed in the operating room General Classification 0759 Other Gastro-Intestinal (Effective 01/01/05) TREATMENT/OBSERVATION ROOM Charges for the use of a treatment room or for the room charge associated with outpatient observation services Treatment Room 0762 Observation Room LITHOTRIPSY Charges for the use of lithotripsy in the treatment of kidney stones. 0790* General Classification HEMODIALYSIS OUTPATIENT 0820* Hemodialysis Outpatient/General 0821* Hemodialysis Outpatient/Composite 0824* Hemodialysis Outpatient/Maintenance/100 percent 0829* Other Outpatient Hemodialysis PERITONEAL DIALYSIS - Outpatient 0830* Peritoneal Dialysis/General 0831* Peritoneal Dialysis Outpatient/Composite Rate 0834* Peritoneal Dialysis/Maintenance/100 percent 0839* Other outpatient peritoneal dialysis Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home 0840* CAPD/General 0841* CAPD/Composite Rate 0844* CAPD/Maintenance/100 percent 0849* Other outpatient CAPD Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home 0850* CCPD/General 0851* CCPD/Composite Rate 0854* CCPD/Maintenance/100 percent 0859* Other outpatient CCPD MISCELLANEOUS DIALYSIS Charges for dialysis not identified elsewhere. 0880* General Classification 0881* Ultrafiltration (Effective 01/01/05) PSYCHIATRIC TREATMENT Page 7 of 8
8 091X 0901* Electroshock Treatment PSYCHIATRIC SERVICES Charges for providing nursing care and employee, professional services for emotionally disturbed patients, including patients admitted for diagnosis and those admitted for treatment Individual Therapy Note: Code 0513 (Psychiatric Clinic) may be billed with code X 094X 0918 Testing (Effective 1/1/99) Note: Code 0513 (Psychiatric Clinic) may be billed with code OTHER DIAGNOSTIC SERVICES Charges for other diagnostic service not otherwise categorized General Classification (Effective 10/01/01) 0921 Peripheral Vascular Lab 0922 Electromyogram 0924 Allergy Test OTHER THERAPEUTIC SERVICES Charges for other therapeutic services not otherwise categorized General 0943 Cardiac Rehabilitation 0944 Drug Rehabilitation Note: Code 0513 (Psychiatric Clinic) may be billed with Alcohol Rehabilitation Note: Code 0513 (Psychiatric Clinic) may be billed with code Beginning December 30, 2016, outpatient hospital providers will be required to submit procedure codes with the following revenue codes: 0261, 0274, 030X, 031X, 032X, 033X, 034X, 035X, 036X, 0371, 0372, 0374, 0379, 038X, 0391, 040X, 041X, 042X, 043X, 044X, 045X, 046X, 047X, 048X, 049X, 051X, 052X, 053X, 054X, 0561, 0562, 057X, 059X, 060X, 061X, 0623, 0634, 0635, 0636, 064X, 065X, 067X, 0722, 0723, 0724, 073X, 074X, 075X, 0760, 0761, 0769, 077X, 078X, 079X, 0811, 0812, 0813, 0814, 083X, 084X, 085X, 088X, 090X, 091X, 092X, 0940, 0941, 0943, 0944, 0945, 0946, 0947, 0949, 095X Note: Not all codes requiring a procedure code are appropriate for outpatient billing, please refer to the codes mentioned in this document for billing guidance. Page 8 of 8
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See Covered Benefits below. None. $2,000 per Member per calendar year $4,000 per family per calendar year
Schedule of s Harvard Pilgrim Health Care, Inc. THE HARVARD PILGRIM HMO MAINE ID: MD0000002653_F2 X This Schedule of s summarizes your s under The Harvard Pilgrim HMO (the Plan) and states the Member Cost
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