Or. Admin. R. 410-130-0160 - Codes
(1) ICD-10-CM
Diagnosis Codes:
(a) Always use the principal
diagnosis code in the first position to the highest degree of specificity. List
additional diagnosis codes if the claim includes charges for services that
relate to the additional diagnoses. However, it is not necessary to include
more than one diagnosis code per procedure code;
(b) Diagnosis codes are required on all
billings including those from independent laboratories and portable radiology
including nuclear medicine and diagnostic ultrasound providers;
(c) Always supply the ICD-10-CM diagnosis
code to ancillary service providers when prescribing services, equipment, and
supplies.
(2) CPT and
HCPCS Codes:
(a) Use only codes from the
current year for Current Procedural Terminology (CPT) and Healthcare Common
Procedure Coding System (HCPCS) codes;
(b) Effective January 1, 2005, HIPAA
regulations prohibit the use of a grace period for codes deleted from CPT or
HCPCS. In the past the grace period was from January 1 through March
31;
(c) The division may consider
reimbursement for CPT category III codes included under the following headings:
Adaptive Behavior Assessments, Adaptive Behavior Treatment, and Exposure
Adaptive Behavior Treatment With Protocol Modification. All CPT category II
(codes with fifth character of "F") and all other category III codes (codes
with fifth character "T") are not Division of Medical Assistance Programs'
(Division) covered services;
(d)
Use the most applicable CPT or HCPCS code. Do not fragment coding when services
can be included in a single code (see the "Bundled Services" section of this
rule). Do not use both CPT and HCPCS codes for the same procedure. This is
considered duplicate billing.
(3) The Medical-Surgical Service rules list
the HCPCS/CPT codes that require authorization or have limitations. The Health
Evidence Review Commission's Prioritized List of Health Services (OAR
410-141-3830) determines covered services.
(4) For determining the appropriate level of
service code for Evaluation and Management services, read the definitions in
the CPT and HCPCS codebook. Use the definitions to verify level of service,
especially for office visits. Unless otherwise specified in the
Medical-Surgical provider rule, use the guidelines from CPT and
HCPCS.
(5) Bundled Services:
Reimbursements for some services are "bundled" into the payment for another
service. The Division does not make separate payment for bundled services and
clients may not be billed for bundled services. The Division's Not
Covered/Bundled Services rule, OAR 410-130-0220, provides more information
regarding bundled services.
Notes
Publications: Publications referenced are available from the agency.
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.025 & 414.065
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