Vhi Surgical Procedure Codes

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type": "Question","name": "Q3: How should facility medical coders use the NHSN procedure code documents for classifying surgical procedures for patient charges?","acceptedAnswer": "@type": "Answer","text": "The NHSN operative procedure code documents, posted on the NHSN site, are not intended to be instructive to medical coders for assigning procedure codes to surgical procedures. The documents are provided as a tool to assist NHSN users participating in SSI reporting with categorizing operative procedures by NHSN procedure categories and to standardize the reporting of surgical procedures between facilities.","@type": "Question","name": "Q4: When are codes updated and how are users notified of updates?","acceptedAnswer": "@type": "Answer","text": "NHSN operative procedure codes are reviewed and updated annually and as needed.

Communication regarding updates to the operative procedure codes are sent via email to individuals and vendors enrolled in NHSN. The emails contain specific details about the updates; therefore, it is critical that all NHSN users review their NHSN user contact information on a regular basis and update as necessary.","@type": "Question","name": "Q5: Are ICD-10-PCS or CPT procedure codes required to enter SSI events into NHSN?","acceptedAnswer": "@type": "Answer","text": "The use of the NHSN operative procedure codes (ICD-10-PCS and/ CPT) is required to determine the correct NHSN operative procedure category but entering the operative procedure code into the NHSN application remains optional.

If the fifth character of the ICD-10-PCS procedure code is a four (4) or F, then the field for scope should be YES.",{"@type": "Question","name": "Q9: When reporting hysterectomy procedures to NHSN, what determines when a procedure is categorized as a vaginal hysterectomy verses an abdominal hysterectomy? Are there definitions for each of these procedures?","acceptedAnswer": {"@type": "Answer","text": "A trained medical coder, using current medical coding guidelines and conventions, should assign the correct procedure code (CPT and ICD-10-PCS) to the hysterectomy procedure.

The hysterectomy procedure approach (5th character of the ICD-10 operative procedure code assigned by a medical coder) identifies whether an abdominal incision was made and determines if the procedure is categorized as a NHSN HYST or VHYS.

The NHSN operative procedure code documents, posted on the NHSN site, are not intended to be instructive to medical coders for assigning procedure codes to surgical procedures. The documents are provided as a tool to assist NHSN users participating in SSI reporting with categorizing operative procedures by NHSN procedure categories and to standardize the reporting of surgical procedures between facilities.

Communication regarding updates to the operative procedure codes are sent via email to individuals and vendors enrolled in NHSN. The emails contain specific details about the updates; therefore, it is critical that all NHSN users review their NHSN user contact information on a regular basis and update as necessary.

The use of the NHSN operative procedure codes (ICD-10-PCS and/ CPT) is required to determine the correct NHSN operative procedure category but entering the operative procedure code into the NHSN application remains optional.

NHSN operative procedure reporting is based on the operative procedure code(s) assigned by a trained medical coder. There are several instructions, guidelines and conventions that govern how and when medical codes are assigned. For questions related to correct procedure code assignment consult with your facility medical coder.

Scope is reported based on the primary incision site. If an open and scope code is assigned to procedures in the same NHSN procedure category, then the procedure should be reported to NHSN as Scope = NO. The open designation is considered a higher risk procedure.

Section 11403 of the Inflation Reduction Act of 2022 (IRA) temporarily increases payment for certain biosimilar biological products that are calculated using the Medicare Average Sales Price Payment Methodology from average sales price (ASP) plus 6 percent to ASP plus 8 percent of the ASP of the reference biological. The increase applies for a 5-year period defined in the statute. For qualifying biosimilar biological products for which payment was made using ASP as of September 30, 2022, the 5-year period begins on October 1, 2022. For qualifying biosimilar biological products for which payment is first made using ASP between October 1, 2022, through December 31, 2027, the 5-year period begins on the first day of the calendar quarter during which such payment is first made. A qualifying biosimilar biological product is defined as a biosimilar with an ASP that is not more than the ASP of the reference biological.

The Outpatient Prospective and Ambulatory Surgical Center payment systems generally use the Medicare Average Sales Price Payment Methodology for biosimilars. Therefore, in accordance with section 11403 of the IRA, the OPPS and ASC addenda files will reflect the temporary increased amount for qualifying biosimilar biological products beginning with the October 2022 file.

The Affordable Care Act requires the Secretary of Health and Human Services to develop a plan to implement a value-based purchasing (VBP) program for payments under the Medicare program for ambulatory surgical centers (ASCs). The Secretary submits a report to Congress containing this plan.

The Report to Congress (PDF) describes the current efforts to improve quality and payment efficiency in ASCs. In addition, it considers the steps required in designing and implementing an ASC VBP program for payments under the Medicare program. CMS views VBP as an important step forward in revamping how Medicare pays for health care services; moving the program towards rewarding better value, outcomes, and innovations, instead of merely volume.

These files contain the procedure codes which may be performed in an ASC under the Medicare program as well as the ASC payment group assigned to each of the procedure codes. The ASC payment group determines the amount that Medicare pays for facility services furnished in connection with a covered procedure. For 2000 - 2006 files, go to the ASC Payment Rates Archive page (see the Left column).

Note: These files contain material copyrighted by the American Medical Association.

Medicare payment for most surgical procedures covers both the procedure and post-operative visits occurring within a global period of either 010 or 090 days following the procedure. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) mandated that CMS collect data on the number and level of post-operative visits to enable CMS to assess the accuracy of global surgical package valuation. To help inform accurate valuation of procedures with global periods (for cataract surgery, hip arthroplasty, and complex wound repair), Medicare required select practitioners from nine states (Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island) to report on their post-operative visits (using CPT code 99024) following high volume or high cost procedures beginning July 1, 2017. The expected number of post-operative visits after a procedure was determined using the time file, which captures the number of visits used in the initial valuation.

In addition to this claims-based data collection, CMS has contracted with RAND to conduct a survey to collect additional data on pre- and post-operative services. For more information on the survey, we refer readers to pages 80222 - 80224 of the CY 2017 PFS final rule (CMS-1654-F).

The ICD-9-CM code identifying the principal or other surgical procedure performed during the beneficiary's stay. This element is part of the MEDPAR surgical procedure group. It may occur up to 25 times.

Providers can refer to the remittance voucher (RV) for overpayment summary, recoupment summary, and recoupment details. A Remittance Voucher User Guide is available for an explanation on how to read the sections in the RV.

Please note that additional denial EOBs may post during reprocessing. For example, if denials post for authorization of services related to accepted conditions, then providers are encouraged to request authorization for the billed service(s).

Effective August 20, 2022, the DFEC program will be implementing new utilization review (UR) for psychological exam and evaluation procedure codes. This change will impact professional, outpatient, and prompt pay bills.

As of July 9, 2022, OWCP will implement enhancements to Surgical Package Authorization and Bill Processing for DFEC. Updates will be made to better reflect the providers involved in providing the surgical procedure.

In order to process prescriptions for DOL's FECA program, pharmacies MUST be part of the Optum/Tmesys Retail Network, process real time, and adjudicate electronically. The FECA program stopped accepting batch pharmacy bills in December, 2017 as a step toward this point-of-sale requirement, and the new PBM is the final step.

Effective 4/30/2021, you MUST submit all pharmacy bills point of sale, regardless of date of service, through the Optum network. Thus, ALL pharmacy paper bills must be submitted before 4/30/2021. As of 4/30/2021, DOL will no longer accept pharmacy paper bills for workers compensation medications covered under the OWCP FECA program. All medications must be processed at the point of sale with our PBM or home delivery program contractor, Optum Workers Compensation

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