(Medicare Claims Processing Manual)

Section 1833 (a)(1)(F) of the A ct stipulates that payment for services performed by a LCSW shall be 80 percent of the lesser of the actual charges for the services or 75 percent of the amount determined for the payment of a psychologist.  Payment is calculated as follows:   ((Facility sp ecific MPFS amount times the LCSW reduction (75%)) minus (deductible and coinsurance)) times 115%.  250.15 - Coding and Payment of Multiple Surgeries Performed in a Method II CAH  (Rev. 2333, Issued: 10- 28-11, Effective: 04- 01-12, Implementation: 04- 02-12)  Multiple surgeries rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   Multiple surgeri es are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co -surgeons, surgical teams, or assistants- at-surgery may participate in performing multiple surgeries on the same patient on the same day.   Medicare pays for multiple surgeries by ranking from the highest MPFS amount to the lowest MPFS amount. When the same physician performs more than one surgical service at the same session, the allowed amount is 100% for the surgical code with the highest MPFS amount. The allowed amount for the subsequent surgical codes is based on 50% of the MPFS amount.  In addition, special endoscopic pricing rules are applied prior to the multiple surgery rules, if applicable. CAH Method II providers may review the multi ple surgery and special endoscopic pricing rules in Pub. 100- 04, Chapter 12, Section 40.6.  In  addition, section 40.6.D addresses rare situations where the above payment rules may be bypassed using modifier 22. Providers shall be aware that CAH claims bill ed with Modifier 22 may be subject to medical review.   250.16 - Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Imaging Procedures Rendered by Physicians  (Rev. 3578, Issued:  08- 05 Effective:  01- 01-17, Implementation:  01- 03-17)  Diagnostic imaging procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   The MP PR on diagnostic imaging applies when multiple services are furnished by the same physician to the same patient in the same session on the same day. Full payment is made for each service with the highest payment under the MPFS.  Effective for dates of services on or after January 1, 2012, payment is made at 75 percent for each subsequent service; and effective for dates of services on or after January 1, 2017, payment is made at 95 percent for each subsequent service.   250.17  - Payment of Global Surgical Sp lit Care in a Method II CAH Submitted with Modifier 54 and/or 55  (Rev. 2574, Issued: 10- 26-12 , Effective:01- 01-13 , Implementation:01- 07-13)  Global surgical procedures rendered by a physician that has reassigned their billing rights to a CAH Method II pr ovider is payable by Medicare only when billed on an 85x type of bill (TOB) with revenue code (RC) 096x, 97x, and/or 98x and modifier 54 (surgical care only) and/or 55 (postoperative management only).   There are occasions when more than one physician provi des services included in the global surgical period, i.e., when the physician who performs the surgical procedure does not furnish the follow -up care. If this occurs, payment for the postoperative or post -discharge care should be split between the physicians when they agree on the transfer of care.   When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative care, result in payment that is higher than the global allowed amount).   CAH Met hod II providers may review the Global Surgical pricing rules in Pub. 100- 04, Chapter 12, sections 40.1 -40.5.  260 - Outpatient Partial Hospitalization Services  (Rev. 1, 10- 03-03)   A3-3661, A-01-93  Medicare Part B coverage is available for outpatient partial hospitalization services provided by hospitals, CAHs, and CMHCs.  260.1 - Special Partial Hospitalization Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals  (Rev. 4204, Issued: 01- 17-19, Effective: 01-01-19, Implementation: 01-07-19)   Medicare Part B coverage is available for hospital outpatient partial hospitalization services.   A. Billing Requirement   Section 1861 ( http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm ) of the Act defines the services under the partial hospitalization benefit in a hospital.  Section 1866(e)(2) of the Act (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)recognizes CMHCs as providers of services but only for furnishing partial hospitalization services.  See 261.1.1  of this cha pter for CMHC partial hospitalization bill review directions.   Hospitals and CAHs report condition code 41 in FLs 18-28 (or electronic equivalent) to indicate the claim is for partial hospitalization services.  They must also report a revenue code and the charge for each individual covered service furnished.  In addition, hospital outpatient departments are required to report HCPCS codes.  CAHs are not required to report HCPCS code for this benefit.  Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under a partial hospitalization program.  In addition, hospital outpatient departments are required to report HCPCS codes.  Component billing assures that only those partial hospitalization services covered under 1861(ff) of the Act are paid by the Medicare program.  Effective January 1, 2017, non- excepted off -campus provider- based departments of a hospital are required to report a PN modifier on each claim line for non- excepted  items  and services.  The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule.  We expect the PN modifier to be reported with each non -excepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.   Excepted off -campus provider -based departments of a hospital must continue to report existing modifier PO (Services, procedures and/or surgeries provided at off -campus provider -based outpatient departments)  for all excepted items and services furnished. Use of the off -campus PBD modifier became mandatory beginning January 1, 2016.  All hospitals are required to report condition code 41 in FLs 18- 28 to indicate the claim is  for partial hospitalization services.  Hospitals use bill type 13X and CAHs use bill type 85X.  The following special procedures apply.   Bills must contain an acceptable revenue code.  They are as follows:   Revenue Code  Description  0250 Drugs and Biologi cals 043X  Occupational Therapy  0900 Behavioral Health Treatment/Services  0904 Activity Therapy  0910 Psychiatric/Psychological Services (Dates of Service prior to October 16, 2003)  0914 Individual Therapy  0915 Group Therapy  0916 Family Therapy  0918 Behavioral Health/Testing  0942 Education/Training  Hospitals other than CAHs are also required to report appropriate HCPCS codes as  follows:   Revenue Code  Description  HCPCS Code  043X  Occupational Therapy  *G0129 (Partial Hospitalization)  0900 Behavioral  Health Treatment/Services  ****90791 or ***** 90792 0904 Activity Therapy  **G0176 (Partial Hospitalization)  0914 Individual Psychotherapy 90785, 90832, 90833, 90834, 90836, 90837, 90838, 90845, 90865, or 90880  0915 Group Therapy  G0410 or G0411  0916 Family Psychotherapy  90846 or 90847 0918  Behavioral Health/Testing  96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138. 96139, 96146 0942 Education/Training ***G0177  The A/B MAC (A) will edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  The A/B MAC (A) will not edit for matching the revenue code to HCPCS.   *The definition of code G0129 is as follows:   Occupational therapy services requiring skills of a qualified occupational therapist , furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more).   **The definition of code G0176 is as follows:    Activity therapy, such as music, dance, art or play therapies not for recreation, related to care and treatment of patients disabling mental problems, per session (45 minutes or more).  ***The definition of code G0177 is as follows:  Training and educational services related to the care and treatment of patients disabling mental health problems, per session (45 minutes or more).  ****The definition of code 90791 is as follows:  Psychiatric diagnostic evaluation (no medical services) completed by a non -physician.   *****The definition of code 90792 is as follows:  Psychiatric diagnostic evaluation (with medical services) completed by a physician.   Codes G0129 and G0176 are used only for partial hospitalization programs.  Code G0177 may be used in both partial hospitalization program and outpatient mental health settings.   Revenue code 250 does not require HCPCS coding.  However, Medicare does not cover drugs that can be self -administered.   Edit to assure that HCPCS are present when the above revenue codes are billed and that they are valid HCPCS codes.  Do not edit for the matching of revenue code to HCPCS.  B. Professional Services   The professional services listed below when provided in all hospital outpatient  departments are separately covered and paid as the professional services of physicians and other practitioners.  These professional services are unbundled and these practitioners (other than physician assistants (PA) bill the Medicare A/B MAC (B) directly for the professional services furnished to hospital outpatient partial hospitalization patients.  The hospital can also serve as a billing agent fo r these professionals by billing the A/B MAC (B) on their behalf under their billing number for their professional services.  The professional services of a PA can be billed to the A/B MAC (B) only by the PAs employer.  The employer of a PA may be such entities or individuals as a physician, medical group, professional corporation, hospital, SNF, or nursing facility.  For example, if a physician is the employer of the PA and the PA renders services in the hospital, the physician and not the hospital would be responsible for billing the A/B MAC (B) on Form CMS -1500 for the services of the PA.  The following direct professional services are unbundled and not paid as partial hospitalization services.   Physician services that meet the criteria of 42 CFR 415.102, for payment on a fee schedule basis;    Physician assistant (PA) services as defined in 1861(s)(2)(K)(i) of the Act;    Nurse practitioner and clinical nurse specialist services, as defined in 1861(s)(2)(K)(ii) of the Act; and    Clinical psychologist services as defined in 1861(ii) of the Act.  The services of other practitioners (including clinical social workers and occupational therapists), are bundled when furnished to hospital patients, including partial hospitalization patients.  The hospital mu st bill the contractor for such nonphysician practitioner services as partial hospitalization services.  Make payment for the services to the hospital.  C. Outpatient Mental Health Treatment Limitation   The outpatient mental health treatment limitation may  apply to services to treat mental, psychoneurotic, and personality disorders when furnished by physicians, clinical psychologists, NPs, CNSs, and PAs to partial hospitalization patients.  However, the outpatient mental health treatment limitation does not apply to such mental health treatment services billed to the A/B MAC (A) by a CMHC or hospital outpatient  department as partial hospitalization services.   D. Reporting of Service Units