(Medicare Claims Processing Manual)

The following bill types are subject to OPPS:     All outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 or 92;  14X and 13X without condition code 41 or 92) with the exception of  bills from hospitals in Maryland, Indian Health Service, CAHs, hospitals located in Saipan, American Samoa, the Virgin Islands and Guam; and hospitals that provide Part B only services to their inpatients.  Effective 4/1/06 the 14X type of bill is for nonpatient laboratory specimens and is no longer applicable for partial hospitalization billing.     CMHC bills (bill type 76X with condition code 41 or 92);     CORF claims for hepatitis B vaccines (bill type 75X);     HHA claims for antigens, hepatitis B vaccines, splints and casts  (bill type 34X); and     For splints, casts and antigens when provided to hospice patients for treatment of a non -terminal illness by other than a hospital outpatient department.  This requires reporting of condition code 07.    As a result, A/B MACs (A) shall instruct CORFs, HHAs, and other providers to report HCPCS for these services, in order to assure payment under this system.  Payment will continue to be made for vaccines provide to hospice patients by the Medicare A/B MAC ( B).  The appropriate HCPCS codes are as follows:    Categories of Services Requiring HCPCS Codes  Category  HCPCS Codes  Angens  95144 -95149, 95165, 95170, 95180, and 95199  Vaccines  90657 -90659, 90732, 90744, 90746, 90747, 90748, G0008, G0009, and G0010  Splints  29105 -29131, 29505 -29515  Casts  29000 -29085, 29305, 29325 -29445, 29450, 29700 -29750, 29799    NOTE:   A/B MACs (HHH) shall advise their HHAs to report the above HCPCS codes with the exception of vaccines under Revenue Code 0550 (Skilled Nursing).  The only time revenue code 0550 may be reported is when the HHA is billing for antigens, splints, or casts.  See Chapter 18 for the reporting of vaccines by HCPCS codes.   120.2 - Routing of Claims  (Rev. 1, 10- 03-03) A-02-00-026  Effective April 1, 2002, the following types of bills (TOBs) should be rerouted back to the OPPS OCE:   TOB  Description  22X Skilled Nursing Facility (SNF) Inpatient Part B  23X SNF/Outpatient  24X SNF Part B  32X Home Health Agency (HHA) visits under a Part B Plan of Treatment (POT)  33X HHA visits under a Part A (POT)  34X HHA visits under a POT  71X Rural Health Clinic  72X Hospital Based or Independent Renal Dialysis Center  73X Federally Qualified Health Center  74X Other Rehabilitation Facility  75X Comprehensive Outpatient Rehabilitation Facility (CORF)  81X Hospice (non -hospital based)  82X Hospice (hospital based)   Claims containing the above TOBs, other than 32X and 33X, with services that span beyond April 1, 2001, must be split prior to their submittal.  For example, if a claim contains services prior to and after April 1, 2002, the provider must submit two separa te claims.  One for the services prior to April 1, 2002, which will be routed to the non- OPPS OCE and another claim for the services April and later which will be routed to the OPPS OCE.  In the event the A/B MAC (A) receives a claim containing pre-  and post -April 1, 2002, dates of service, it returns it to the provider requesting that the claim be split as indicated above.   Claims containing the above TOBs with dates of service January 1, 2002, through March 31, 2002, should continue to be routed through the non- OPPS OCE.   NOTE:   TOBs (12X, 13X, 14X, and 85X) from Critical Access Hospitals, Maryland Hospitals, Indian Health Service Hospitals, U.S.  Virgin Island Hospitals, and those hospitals located in the Pacific (American Samoa, Guam, and Saipan) do not have to be rerouted since they are sent through the non- OPPS OCE.   140 - All-Inclusive Rate Hospitals  (Rev. 1, 10- 03-03) A-01-93, A -03-066  All-inclusive rate hospitals are required to code with HCPCS the outpatient services they provide and bill charges at the HCPCS level.  In addition, they are required to follow bill reporting instructions contained in 30.  Unlike other hospitals, all -inclusive rate hospitals do not have outpatient departmental cost -to-charge ratios from prior year cost reports that may be used for calculating outlier payments, device pass -through payments, or interim transitional corridor  payments.  As a result, A/B MACs (A) use the statewide average urban or rural outpatient cost -to-charge ratio, as appropriate, for all -inclusive rate hospitals.  In the future, once cost and charge data for an all -inclusive rate hospital is available, the A/B MAC (A) will be able to apply a cost -to-charge ratio that is specific to the hospital.  141 - Maryland Waiver Hospitals (Rev. 771; Issued: 12- 02-05; Effective Date: 01 -03-06; Implementation Date: 01 -03-06)  In accordance with 1814 (b)(3) of the Act, services provided by hospitals in Maryland subject to the Health Services Cost Review Commission are paid according to the terms of the waiver, that is 94% of submitted charges subject to any unmet Part B deducti ble and coinsurance. Payment should not be made under a fee schedule or other payment method for outpatient items and services provided except the following situations:    Non-patient laboratory specimens are paid under the clinical diagnostic laboratory fee schedule (bill type 14X); and   Ambulance services which are subject to the ambulance fee schedule.   150 - Hospitals That Do Not Provide Outpatient Services  (Rev. 1, 10- 03-03) HO- 440.1, A -00-21, A -02-064  Covered Part B -only services furnished to inpatients when they are furnished by a hospital that does no Medicare billing for hospital outpatients services under Part B are excluded from OPPS.  The Part B -only services, which are payable for hospital inpati ents who have either exhausted their Part A benefits or who are not entitled to Part A benefits, are specified in Chapter 3.  These services include, but are not limited to, diagnostic tests; x-ray and radioactive isotope therapy; surgical dressings; limb braces and trusses; and artificial limbs and eyes.  Medicare payment for excluded Part B -only services furnished by these hospitals is determined using the method under which the hospital was paid prior to OPPS.   Hospitals must notify their A/B MAC (A) if they do not submit claims for outpatient Part B services, so that their claims can be excluded from the OPPS.  The hospital must also notify the A/B MAC (A) if it begins to furnish Part B outpatient services.  OPP S will apply at that time unless other exclusions are applicable.   160 - Clinic and Emergency Visits  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  CMS has acknowledged from the beginning of the OPPS that CMS believes that CPT Evaluation and Management (E/M) codes were designed to reflect the activities of physicians and do not describe well the range and mix of services provided by hospitals during visits of clinic and emergency department patients.  While awaiting the development of a national set of facility -specific codes and guidelines, providers should continue to apply their current internal guidelines to the existing CPT codes.  Each hospitals  internal guidelines should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.  Hospitals should ensure that their guidelines accurately reflect resource distinctions between the five levels of codes.   Effective January 1, 2007, CMS is distinguishing between two types of emergency departments: Type A emergency departments and Type B emergency departments.   A Type A emergency department is defined as  an emergency department that is available 24 hours a day, 7 days a week and is either licensed by the State in which it is located under applicable State law as an emergency room or emergency department or it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.  A Type B emergency department is defined as an emergency department that meets the definition of a dedicated emergency department as defined in 42 CFR 489.24 under the EMTALA regulations.  It must meet at least one of the following requirements:    (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;    (2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or    (3) During the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one -third of all o f its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.   Hospitals must bill for visits provided in Type A emergency departments using CPT emergency department E/M codes.  Hospitals must bill for visits provided in Type B emergency departments using the G -codes that describe visits provided in Type B emergency d epartments.   Hospitals that will be billing the new Type B ED visit codes may need to update their internal guidelines to report these codes.   Emergency department and clinic visits are paid in some cases separately and in other cases as part of a composite APC payment.  See section 10.2.1 of this chapter for further details.    160.1 - Critical Care Services  (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)  Hospitals should separately report all HCPCS codes in accordance with correct coding principles, CPT code descriptions, and any additional CMS guidance, when available.  Specifically with respect to CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30 -74 minutes), hospitals must follow the CPT instructions related to reporting that CPT code.  Prior to January 1, 2011, any services that CPT indicates are included in the reporting of CPT code 9 9291 (including those services that would otherwise be reported by and paid to hospitals using any of the CPT codes specified by CPT) should not be billed separately by the hospital.  Instead, hospitals should report charges for any services provided as pa rt of the critical care services. In establishing payment rates for critical care services, and other services, CMS packages the costs of certain items and services separately reported by HCPCS codes into payment for critical care services and other servic es, according to the standard OPPS methodology for packaging costs.  Beginning January 1, 2011, in accordance with revised CPT guidance, hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care.  CMS will continue to recognize the existing CPT codes for critical care services and will establish payment rates based on historical data, into which the cost of the ancillary services is intrinsically packaged.  The I/OCE conditiona lly packages payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment.  The payment status of the ancillary services does not change when they are not provided in conjunction w ith critical care services.  Hospitals may use HCPCS modifier - 59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter.   Beginning January 1, 2007, critical care services will be paid at two levels, depending on the presence or absence of trauma activation.  Providers will receive one payment rate for critical care without trauma activation and will receive additional paymen t when critical care is associated with trauma activation.