(Medicare Claims Processing Manual)

100 - Medicare Summary Notice (MSN)  (Rev. 1, 10- 03-03)  Effective for claims with dates of service on or after August 1, 2000, A/B MACs (A) must modify the MSN for services provided by providers under OPPS to reflect the addition of an APC number.  This APC number should be placed next to the HCPCS code included under the Services Provided column, and must be wit hin a parenthesis.  The coinsurance column should reflect the coinsurance amount for which the beneficiary is responsible.  In addition, the back of the notice must be modified.  In place of the current language, the notice should reflect the following lan guage:   THE AMOUNT YOU MAY BE BILLED for Part B services includes:   Annual deductible, the first $100 of Medicare Part B charges each year;   After the deductible has been met for the year, depending on services received, a coinsurance amount  (20 percent of  the amount charged), or a fixed copayment  for each service; and   Charges for services or supplies that are not covered by Medicare.  You may not have to pay for certain denied services.  If so, a note on the front will tell you.  The Spanish version shoul d read as follows:   La cantidad por la cual usted podra ser facturado incluye:   Un deducible anual, los primeros $100 de Medicare Parte B de cargos aprobados cada ao, Despus de que haya cumplido con el deducible, dependiendo de los servicios recibidos, un coaseguro (20% de la cantidad cobrada), o un copago fijo por cada servicio ; y   Cargos por servicios/suministros que no estn cubiertos por Medicare.  Es posible que usted no tenga que pagar por ciertos cargos se servicios denegados.  De ser el caso, una NOTA en la parte del frente le indicar.   Also, A/B MACs (A) print the following message in the General Information Section:    If the coinsurance amount you paid is more than the amount shown on your notice, you are entitled to a refund.  Please contact y our provider.   Spanish Version:   Si la cantidad de coaseguro que usted pag es mayor que la cantidad que muestra su notificacin, tiene derecho a un reembolso.  Por favor comunquese con su proveedor.   110 - Procedures for Submitting Late Charges Under OPPS  (Rev. 1, 10- 03-03) A-01-93  Hospitals and CMHCs may not submit a late charge bill (code 5 in the third position of the bill type) for bill types 12X, 13X, 14X, and 76X effective for claims with dates of service on or after August 1, 2000.  They must submit an adjustment bill for any services required to be billed with HCPCS codes, units and line item dates of service.  A 7 in the third position of the bill type indicates an adjustment.  See Chapter 25 f or additional instructions for reporting adjustments.  Separate bills containing only late charges will not be permitted for these bill types.   The submission of an adjustment bill, instead of a late charge bill, will ensure proper duplicate detection, bundling, correct application of coverage policies and proper editing by OCE and payment under OPPS.  120 - General Rules for Reporting Outpatient Hospital Services  (Rev. 3019, Issued: 08- 07-14, Effective: 01- 01-12, ICD -10: Upon Implementation of ICD-  10, Imp lementation: 09 -08-14, ICD -10: Upon Implementation of ICD - 10)   Hospitals use the electronic ASC X12 837 institutional claim transaction format or the hardcopy Form CMS -1450 to bill for covered outpatient services (type of bill 13X or 83X, and 85X).  The ASC X12 837 institutional claim transaction is required unless the hospital meets certain exception criteria.  These criteria are described in Chapter 24, 90- 90.5.4 of this manual.  See:   Medicare Benefit Policy Manual, Chapter 6, for definition of an outpatient;  Medicare Claims Processing Manual, Chapter 3, Inpatient Part A Hospital Billing, for outpatient services treated as inpatient services;   Medicare Claims Processing Manual Chapter 24, 90- 90.5.4 for when paper billing is permissible; and   Medicar e Claims Processing Manual, Chapter 25, for general instructions for completing the hospital claim data set.    The HCPCS code is used to describe services where payment is under the Hospital OPPS or where payment is under a fee schedule or other outpatient payment methodology.  Line item dates of service are reported for every line where a HCPCS code is required under OPPS.  For providers paid via OPPS, A/B MACs (A) return to provider (RTP) bills where a line item date of service is not entered for each HCPC S code reported, or if the line item dates of service reported are outside of the statement -covers period.  This includes those claims where the from and through dates are equal.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims on TOB 83X for ASCs.  All IHS ASC providers must submit their claims to the designated A/B MAC (B).   120.1 - Bill Types Subject to OPPS  (Rev. 795, Issu ed:  12 -30-05; Effective:  10- 01-04; Implementation: 04 -03-06)  The following bill types are subject to OPPS:    All outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 14X and 13X without condition code 41) with the exception of bil ls 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 non-patient laboratory specimens and is no longer applicable for partial hospitalization billing.    CMHC bills (bill type 76X);   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 CO RFs, 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 fol lows:   Categories of Services Requiring HCPCS Codes  Category  HCPCS Codes  Antigens  95144 -95149, 95165, 95170, 95180, and 95199  Vaccines  90657 -90659, 90732, 90744, 90746, 90747, 90748, G0008, G0009, and G0010   Category  HCPCS Codes  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 b e 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 (n on-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 separate 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 Mar ch 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 deductible and coinsurance. Payment should not be made under a fee schedule or other payment method for outpatient i tems 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.  OPPS will apply at that time unless other excl usions are applicable.