(Medicare Claims Processing Manual)

 For inpatient claims correct procedure codes are:   o If ICD -9-CM is applicable, ICD-9-CM procedure code 60.62 (perineal prostatectomy- the definition includes cryoablation of prostate, cryostatectomy of prostate, and radical cryosurgical ablation of prostate)   o If ICD -10 is applicable,ICD-10-PCS procedure code 0V500ZZ (Destruction of Prostate, Open Approach), or 0V503ZZ (Destruction of Prostate, Percutaneous Approach), or 0V504ZZ (Destruction of Prostate, Percutaneous Endoscopic Approach).  180.3  Payment Requirements  (Rev. 1111, Issued: 11- 09-06, Effective: 04-01-07, Implementation: 04-02-07)  This service may be paid as a primary treatment for patients with clinically localized prostate cancer, Stages T1  T3.  The ultrasonic guidance associated with this procedure will not be paid for separately, but is bundled into the payment for the surgical procedure.  When one provider has furnished the cryosurgical ablation and another the ultrasonic guidance, the provider of the ultrasonic guidance must seek compensation from the provider of the cryosurgical ablation.  Effective July 1, 2001, cryosurgery performed as salvage therapy, will be paid only according to the coverage requirements described above.  Type of facility and setting determines the basis of payment:   For services performed on an inpatient or outpatient basis in a CAH, TOBs 11x and 85x: the FI will pay 101 percent of reasonable cost minus any applicable deductible and coinsurance.    For services performed on an inpatient basis in short term acute care hospitals, (including those in Guam, America Samoa, Virgin Islands, Saipan, and Indian Health Services Hospitals) TOB 11x:  the FI will pay the DRG payment minus any applicable deductibl e and coinsurance.    For services performed on an outpatient basis in hospitals subject to the Outpatient PPS, TOB 13x: the FI will pay the assigned APC minus any applicable deductible and coinsurance.    For outpatient services in hospitals that are exempt from OPPS (such as in American Samoa, Virgin Islands, Guam, and Saipan) TOBs 13x: the FI will pay reasonable cost, minus any applicable deductible and coinsurance.    For outpatient services in Indian Health Service hospitals TOBs 13x and 83x: the FI will pay the ASC payment amount for TOB 83x. minus any applicable deductible and coinsurance.    For inpatient or outpatient services in hospitals in Maryland, make payment according to the State Cost Containment system.   For services performed on an inpatient basis: the hospitals exempt from inpatient acute care PPS shall be paid on reasonable cost basis, minus any applicable deductible and coinsurance.   180.4 - Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages (Rev 2544, Issued: 09 -13-2012, Effective: 10 -01-2012, Implementation: 10- 01-2012)   Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for alcohol misuse screening and alcohol misuse behavioral counseling sessions:    For RHC and FQHC claims that contain screening for alcohol misuse HCPCS code G0442 and alcohol misuse counseling HCPCS code G0443 with another encounter/visit  with the same line item date of service, use group code CO and reason code:   o Claim Adjustment Reason Code (CARC) 97  The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.   Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Servic e Payment Information REF) if present     Denying claims containing HCPCS code G0442 and HCPCS code G0443 submitted on a TOB other than 13X, 71X, 77X, and 85X:   o Claim Adjustment Reason Code (CARC) 5 -  The procedure code/bill type is inconsistent with the place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present   o Remittance Advice Remark Code (RARC) M77   Missing/incomplete/invalid place of service   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying  claims that contains more than one alcohol misuse behavioral counseling session G0443 on the same date of service:   o Medicare Summary Notice (MSN) 15.6  The information provided does not support the need for this many services or items within this period of time.   o Claim Adjustment Reason Code (CARC) 151  Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.   o Remittance Advice Remark Code (RARC) M86   Service denied because payment already made for same/similar procedure within set time frame.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying claims that are not submitted from the appropriate provider specialties:   o Medicare Summary Notice (MSN) 21.18  This item or service is not covered when performed or ordered by this provider.   o Claim Adjustment Reason Code (CARC) 185 -  The rendering provider is not eligible to perform the service billed. NOTE:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   o Remittance Advice Remark Code (RARC) N95 -  This provider type/provider specialty may not bill this service.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying claims without the appropriate POS code:   o Medicare Summary Notice (MSN) 21.25  This service was denied because Medicare only covers this service in certain settings.   o Claim Adjustment Reason Code (CARC) 58  Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.  Note:  Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) if present.   o Remittance Advice Remark Code (RARC) N428  Not covered when performed in this place of service.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying claims for alcohol misuse screening HCPCS code G0442 more than once in a 12- month period, and denying alcohol misuse counseling sessions HCPCS code G0443 more than four times in the same 12 -month period:   o Medicare Summary Notice (MSN) 20.5  These services cannot be paid because your benefits are exhausted at this time.   o Claim Adjustment Reason Code (CARC) 119  Benefit maximum for this time period or occurrence has been reached.   o Remittance Advice Remark Code (RARC) N362  The number of Days or Units of service exceeds our acceptable maximum.   o Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.  o Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.  NOTE: For modifier GZ, use CARC 50 and MSN 8.81 per instructions in CR 7228/TR 2148.    Denying claims for alcohol misuse counseling session HCPCS code G0443 when there is no claim in history for the screening service HCPCS code G0442 in the prior 12 months:    Medicare Summary Notice (MSN) 16.26  Medicare does not pay for services or items related to a procedure that has not been approved or billed.   Claim Adjustment Reason Code (CARC) B15  This service/procedure requires that a qualifying service/procedure be received and covered.  The qualifying other service/procedure has not been received/adjudicated.  Note: Refer to the 835 Healthcare Policy Iden tification Segment (loop 2110 Service Payment Information REF), if present.    Remittance Advice Remark Code (RARC) M16   Alert:  Please see our web site, mailings, or bulletins for more details concerning this policy/procedure/decision.     Group Code PR (Patient Responsibility) assigning financial liability to the beneficiary, if a claim is received with a modifier indicating a signed ABN is on file.    Group Code CO (Contractual Obligation) assigning financial liability to the provider, if a claim is received without a modifier indicating no signed ABN is on file.  180.5  Additional CWF and Contractor Requirements  (Rev 2544, Issued: 09- 13-2012, Effective: 10 -01-2012, Implementation: 10- 01-2012)    When applying frequency, CWF shall count 11 full months following the month of the last alcohol misuse screening visit, G0442, before allowing subsequent payment of another G0442 screening.     CWF shall reject incoming claims when G0443 PROF is billed if four G0443 services have been billed and posted to the BEHV auxiliary file within the 12 month period.     CWF shall continue to reject incoming claims with consistency error code 32#3 when HCPCS code G0442 PROF and HCPCS code G0443 PROF are billed on same day for TOB 71X, 77X, 85X with 096X, 097X and 098X.   Contractors and CWF shall use the last date of G0442 PROF for counting the 12- month period for G0443 PROF services.     Contractors and CWF shall apply all the same TOBs (13x,71x, 77x and  85x with Rev. Code 96, 97 and 98) POS (11, 22, 49 and 71), no deductible/co- insurance and institutional/professional processing for G0443 that was implemented for G0442 in CR 7633.    If a claim with G0442 is cancelled, CWF shall do a look back for claims with G0443 and create an IUR (Information Unsolicited Response) along with a Trailer 24 back to the contractor to reject the G0443 claim(s) paid within the 12 month period of the G0442 claims.     CWF shall display the number of counseling sessions remaining for G0443 PROF on all CWF provider query screens (HUQA, HIQA, HIQH, ELGA, ELGB, ELGH).    CWF shall display the remaining PROF services counting DOWN from four (4) for the HCPCS code G0443 on the MBD/NGD extract file.    CWF shall calculate a next eligible date for G0442 PROF and G0443 PROF for a given beneficiary.     The calculation shall include all applicable factors including beneficiary Part B entitlement status, beneficiary claims history and utilization rules.    When there is no next eligible date, the CWF provider query screens shall display an 8- position alpha code in the date field to indicate why there is not a next eligible date.    Any change to beneficiary master data or claims data that would result in a change to any next eligible date shall result in an update to the beneficiarys next eligible date.   NOTE:  If G0442 is not paid, the beneficiary is not eligible for G0443.    CWF shall create a utility to remove previously posted G0442 TECH for the AUX file.