(Medicare Claims Processing Manual)

Effective January 1, 2017, when the allogeneic stem cell transplant occurs in the outpatient setting, the hospital identifies stem cell acquisition charges for allogeneic bone marrow/stem cell transplants separately in FL 42 of Form CMS -1450 (or electronic  equivalent) by using revenue code 0815 (Other Organ Acquisition).  Revenue code 0815 charges should include all services required to acquire stem cells from a donor, as defined above, and should be reported on the same claim as the transplant procedure in order to be appropriately packaged for payment  purposes.  Revenue code 0815 charges for allogeneic stem cell acquisition costs are reported on Worksheet D Part V, column 2, line 77, cost center 0077 of the hospital Medicare cost report (Form CMS -2552- 10).  The transplant hospital keeps an itemized statement that identifies the services furnished, the charges, the person receiving the service (donor/recipient), and whether this is a potential transplant donor or recipient.  These charges will be reflected in the transplant hospital's stem cell/bone marrow acquisition cost center.  For allogeneic stem cell acquisition services in cases that do not result in transplant, due to death of the intended recipient or other causes, hospitals include the costs associated with the acqu isition services on the Medicare cost  report.   In the case of an allogeneic transplant in the hospital outpatient setting, the hospital reports the transplant itself with the appropriate CPT code, and a charge under revenue center code 0362 or another appropriate cost center. Selection of the cost center is up to the hospital.  231.12 - Correct Coding Initiative (CCI) Edits  (Rev. 1882, Issued:  12- 21-09; Effective Date:  01 -01-10; Implementation Date:  01-04-10)  The OPPS providers should be aware that certain CCI edits may apply when billing for blood and blood product services.  The OPPS providers should consult the most current list of CCI edits to determine whether they apply to the services or HCPCS blood product codes being reported.  A file with the most current list of CCI edits applicable to Medicare Part B services paid by A/B MACs (A) under the OPPS is available at:  http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEHOPPS/list.asp   240 - Inpatient Part B Hospital Services  (Rev. 3106, Issued: 11- 06-14, Effective: 10 -01-13, Implementation: 02- 10-15)   Medicare pays for hospital (including CAH) inpatient Part B services in the circumstances provided in Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6,  10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals).  Hospitals must bill Part B inpatient services on a 12x Type of Bill.  This Part B inpatient claim is subject to the statutory time limit for filing Part B claims described in chapter 1, 70 of this manual.    Inpatient Part B services include inpatient ancillary services that do not require an outpatient status and are not strictly provided in an outpatient setting.  Services that require an outpatient status and are provided only in an outpatient setting are not payable inpatient Part B services, including Clinic Visits, Emergency Department Visits, and Observation Services (this is not a complete listing).   Inpatient routine services in a hospital generally are those services included by the provider in a daily service charge --sometimes referred to as the "Room and Board" charge. They include the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made to Medicare Part A.  Many nursing services provided by the floor nurse (such as IV infusions and injections, blood administration, and nebulizer treatments, etc.) may or may not have a separate charge established depending upon the classification of an item or service as routine or ancillary among providers of the same class in the same S tate.  Some providers customary charging practice has established separate charges for these services following the PRM -1 instructions, however, in order for a providers customary charging practice to be recognized it must be consistently followed for all patients a nd this must not result in an inequitable apportionment of cost to the program.  If the PRM -1 instructions have not been followed, a provider cannot bill these services as separate charges.  Additionally, it is important that the charges for service render ed and documentation meet the definition of the HCPCS in order to separately bill.  240.1 - Editing Of Hospital Part B Inpatient Services: Reasonable and Necessary Part A Hospital Inpatient Denials  (Rev.:11685, Issued:11- 09-22, Effective: 07 -01-22, Implementation: 12- 12-22)  When inpatient services are denied as not medically necessary or a provider submitted medical necessity denial utilizing occurrence span code M1, and the services are furnished by a participating hospital, Medicare pays under Part B for physician service s and the non-physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, 10.1, Reasonable and Necessary Part A Hospital Inpatient Claim Denials.  A hospital may also be paid for Part B inpatient services if it determines under Medicare's utilization review requirements that a beneficiary should have received hospital outpatient rather than hospital inpatient services, and the beneficiary has already been discharged from the hospital (commonly referred to as hospital self- audit). If the hospital already submitted a claim to Medicare for payment under Part A, the hospital would be required to adjust its Part A claim (to make the provider liable) prior to submitting a claim for payment of Part B inpatient services. Whether or not the hospital had submitted a claim to Part A for payment, we require the hospital to submit a Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services. The hospital could then submit an inpatient claim for payment under Part B for all services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as a hospital inpatient, except where those services specifically require an outpatient status.  A hospital part B inpatient services claim billed when a reasonable and necessary part A hospital inpatient was denied must be billed with:   A condition code W2 attesting that this is a rebilling and no appeal is in process,   A/B REBILLING in the treatment authorization field, and   The original, denied inpatient claim (CCN/DCN/ICN) number.   NOTE: Providers submitting an 837I are instructed to place the appropriate Prior Authorization code above into Loop 2300 REF02 (REF01 = G1) as follows: REF*G1*A/B REBILLING~ For DDE or paper Claims, "A/B Rebilling" will be added in FL 63. NOTE: Providers submitting an 837I are instructed to place the DCN in the Billing Notes loop 2300/NTE in the format: NTE*ADD*ABREBILL12345678901234~ For DDE or paper Claims, Providers are instructed to use the word "ABREBILL" plus the denied inpatient DCN/CCN/I CN shall be added to the Remarks Field (form locator #80) on the claim using the following format: "ABREBILL12345678901234". (The numeric string (12345678901234) is meant to represent original claim DCN/ICN numbers from the inpatient denial.)  Not Allowed Revenue Codes  The claims processing system shall set edits to prevent payment on Type of Bill 012x for claims containing the revenue codes listed in the table below.  010x  011x  012x  013x  014x  015x  016x  017x  018x  019x  020x  021x  022x  023x  029x  0390  0399  045x  050x  051x  052x  054x  055x  056x  057x  058x  059x  060x  0630  0631  0632  0633  0637  064x  065x  066x  067x  068x  072x  0762  082x  083x  084x  085x  088x  089x  0905  0906  0907  0912  0913  093x  0941  0943  0944  0945  0946  0947  0948  095x  0960  0961  0962  0963  0964*  0969  097x  098x  099x  100x  210x  310x           * In the case of Revenue Code 0964, this is used by hospitals that have a CRNA exception.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR  CARC: 96  RARC: M28  MSN: 21.21  CWF shall edit to ensure that DSMT services are not billed on a 012x claim.   Hospitals are required to report HCPCS codes that identify the services rendered.  ort HCPCS codes that identify the services rendered. 240.2 - Editing Of Hospital Part B Inpatient Services:  Other Circumstances in Which Payment Cannot Be Made under Part A  (Rev.:11685, Issued:11- 09-22, Effective: 07 -01-22, Implementation: 12- 12-22)  When Medicare pays under Part B for the limited set of non-physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, chapter 6, 10.2 (that is, when furnished by a participating hospital to an inpatient of the hos pital who is not entitled to benefits under Part A, has exhausted his or her Part A benefits, or receives services not covered under Part A), the contractor shall set revenue code edits to prevent payment on Type of Bill 012x for claims containing the reve nue codes listed in the table below with exceptions as noted.  For the exceptions noted, contractors shall ensure that only the exceptions identified are allowed to process with the revenue code.  Not Allowed Revenue Codes   010x  011x  012x  013x  014x  015x  016x  017x  018x  019x  020x  021x  022x  023x  0250  0251  0252  0253  0256  0257  0258  0259  026x  0270  0271  0272  0273  0277  0279  028x  029x  036x  0370  0374  0379  038x  039x  041x  045x  0470  0472  0479  0480  0481  0489  049x  050x  051x  052x  053x  0541  0542  0543  0544  0546  0547  0548  0549  055x  056x  057x  058x  059x  060x  0620  0624  063x  064x  065x  066x  067x  068x  069x  070x  071x  072x  075x  076x  079X  081x  082x  083x  084x  085x  087x  088x  089x  090x  091x  093x  0940  0941  0942*  0943  0944  0945  0946  0947  0948  0949  095x  0960  0961  0962  0963  0964*  0969  097x  098x  099x  100x  210x  310x          * In the case of Revenue Code 0964, this is used by hospitals that have a CRNA exception.  * In the case of Revenue Code 0942, this is used by rural hospitals for kidney disease education (KDE) services.  The actual geographic location, core based statisti cal area (CBSA) is used to identify facilities located in rural areas. In addition, KDE services are covered when claims are received from section 401 hospitals.  Additionally, models may allow this Revenue Code.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.