(Medicare Claims Processing Manual)

20.6.19 - Use of HCPCS Modifier - CG                                                    (Rev. 4513, Issued: 02-04-2020, Effective: 01-01- 2020, Implementation: 01-06-2020)  Effective January 1, 2019, the modifier CG,  Policy criteria applied, can be reported with certain device-intensive procedures to reflect situations in which a device was not used during the device- intensive procedure.   This modifier would be reported on the UB04 form (CMS Form 1450) for hospital outpatient device-intensive procedures.  Report ing of this modifier is not required for Critical access hospitals (CAHs). While this modifier is required, it does not have an effect on payment.  20.7 - Billing of C HCPCS Codes by Non -OPPS Providers (Rev. 976, Issued: 06-09-06, Effective: 10-01-06, Implementation: 10 -02-06)  Prior to October 1, 2006, the C series of HCPCS codes were used exclusively by hospitals subject to OPPS to identify items that may have qualified for transitional pass through payment under OPPS or items or services for which an appropriate HCPCS code did not exist for the purposes of implementing the OPPS.  The C -codes could not be used to bill services payable under other payment systems.  CMS realized that these C -codes evolved and also target services that are uniquely hospital services that may be provided by an OPPS provider, other providers, or be paid under other payment systems.  Effective October 1, 2006, the following non-OPPS providers may elect to bill using the C-codes or an appropriate CPT code on Types of Bill (TOBs) 12X, 13X, or 85X:   Critical Access Hospitals (CAHs);  Indian Health Service Hospitals (IHS);   Hospitals located in American Samoa, Guam, Saipan or the Virgin Islands; and  Maryland waiver hospitals.  The OPPS providers shall continue to receive pass -through payment on items or services that qualify for pass through payment. Non-OPPS providers are not eligible for pass through payments.  The C -codes shall be replaced with permanent codes.  Whenever a permanent code is established to replace a temp orary code, the temporary code is deleted and cross-referenced to the new permanent code.  Upon deletion of a temporary code, providers shall bill using the new permanent code.  Providers are encouraged to access the CMS Web site to view the quarterly HCPC S Code updates.  The URL to view the quarterly updates is http://www.cms.hhs.gov/HCPCSReleaseCodeSets/.  The billing of C- codes by Method I and Method II Critical Access Hospitals (CAHs) is limited to the billing for facility (technical) services.  The C -codes shall not be billed by Method II CAHs for professional services with revenue codes 96X, 97X, or 98X.   30 - OPPS Coinsurance  (Rev. 2141, Issued: 01- 24-11, Effective: 01- 01-11, Implementation:  01-03-11)  OPPS freezes coinsurance for outpatient hospital at 20 percent of the national median charge for the services within each APC (wage adjusted for the providers geographic area), but coinsurance for an APC cannot be less than 20 percent of the A PC payment rate.  As the total payment to the provider increases each year based on market basket updates, the present or frozen coinsurance amount will become a smaller portion of the total payment until coinsurance represents 20 percent of the total paym ent.  Once coinsurance becomes 20 percent of the payment amount, the annual updates will also increase coinsurance so that it continues to account for 20 percent of the total payment.  As previously stated, the wage -adjusted coinsurance for a service under  OPPS cannot exceed the inpatient deductible amount.  Section 111 of BIPA accelerates the reduction of beneficiary copayment amounts by providing that for services furnished on or after April 1, 2001, and before January 1, 2002, the national unadjusted cop ayment amount for any ambulatory payment classification (APC) group cannot exceed 57 percent of the APC payment rate.  The statute makes further reductions in future years so that national unadjusted copayment amounts cannot exceed 55 percent of the APC rate in 2002 and 2003, 50 percent in 2004, 45 percent in 2005, and 40 percent in 2006 and later years.   The annual update of the OPPS Pricer includes updated copayment amounts.  For screening colonoscopies and screening flexible sigmoidoscopies, the coinsurance amount is 25 percent of the payment rate, prior to January 1, 2011. Coinsurance does not apply to screening colonoscopies, screening sigmoidoscopies, and other specified services furnished on or after January 1, 2011.   Coinsurance does not appl y to influenza virus vaccines, pneumococcal pneumonia vaccines, and clinical diagnostic laboratory services (which includes screening pap smears and screening prostate -specific antigen testing).   See 30.2 below for m ore detail.   Future updates will be issued in a Recurring Update Notification.   30.1 - Coinsurance Election  (Rev. 771, Issued: 12- 02-05, Effective: 01- 03-06, Implementation: 01- 03-06)  The transition to the standard Medicare coinsurance rate (20 percent of  the APC payment rate) will be gradual.  For those APC groups for which coinsurance is currently a relatively high proportion of the total payment, the process will be correspondingly lengthy.  The law offers hospitals the option of electing to reduce coin surance amounts and advertise their reduced rates for all OPPS services.  They may elect to receive a coinsurance payment from Medicare beneficiaries that is less than the wage adjusted coinsurance amount per APC.  That amount will apply to all services wi thin that APC.  This coinsurance reduction must be offered to all Medicare beneficiaries.   Hospitals should review the list of APCs and their respective coinsurance amounts that is published in the Federal Register for the applicable year as a final rule.  After adjusting those coinsurance amounts for the wage index applicable to their MSA, hospitals must notify their A/B MACs (A) if they wish to charge their Medicare beneficiaries a lesser amount.  The election remains in effect until the following calenda r year.  The first election must be filed by July 1, 2000, for the period August 1, 2000, through December 31, 2000.  Future calendar year elections must be made by December 1st of the year preceding the calendar year for which the election is being made.   Because the final rule on OPPS payment rates for 2002 was not published until March 1, 2002, providers were unable to make election decisions for 2002 by December 1 preceding the year the payment rates  became effective, the typical deadline for making such elections.  The deadline for providers to make elections to reduce beneficiary copayments for 2002 was extended until April 1, 2002.  The elections are effective for services furnished on or after April 1, 2002.  The lesser amount elected:    May not be less than 20 percent of the wage adjusted APC payment amount;   May not be greater than the inpatient hospital deductible for that calendar year ($812 for 2002); and   Will not be wage adjusted by the A/B MAC (A) or CMS.  Once an election to reduce coinsurance is made, it cannot be rescinded or changed until the next calendar year.  National unadjusted and minimum unadjusted coinsurance amounts will be posted each year in the addenda of the OPPS final rule (enter CMS -1005FC) on CMS Web site ( http://cms.hhs.gov/).  This coinsurance election does not apply to partial hospitalization services furnished by CHMCs, vaccines provided by a CORF, vaccines, splints, casts, and antigens provided by HHAs, or splints, casts, and antigens provided to a hospice patient for the treatment of a non-terminal illness.  It also does not apply to screening colonoscopies, screening sigmoidoscopies, or screening barium enemas, or to services not paid under OPPS.  Hospitals must utilize the following format for notification to the A/B MAC (A):  Provider number 1122334455   Provider name XYZ Hospital  Effective from  8/1/2000 - 12/31/2000 Provider contact Joe Smith  Phone # 123-456-7890 Contact e- mail Jsmith@XYZ.ORG  Fax #  123-456-7891  XYZ Hospital elects to reduce coinsurance to the amount shown for the following APCs:  APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__ APC____ Coinsurance___.__  Return to:  Provider Audit & Reimbursement Dept. Attn: John Doe A/B MAC (A) Address    The A/B MAC (A) must validate that the reduced coinsurance amount elected by the hospita l is not less than 20 percent of the wage adjusted APC amount nor more than the inpatient deductible for the year of the election, and must send an acknowledgment to the hospital that the election has been received, within 15 calendar days of receipt.   30.2 - Calculating the Medicare Payment Amount and Coinsurance  (Rev. 1, 10- 03-03) A-02-026  A program payment percentage is calculated for each APC by subtracting the unadjusted national coinsurance amount for the APC from the unadjusted payment rate and dividing the result by the unadjusted payment rate.  The payment rate for each APC group is the basis for determining the total payment (subject to wage -index adjustment) that a hospital will receive from the beneficiary and the Medicare program.  (A hospit al that elects to reduce coinsurance, as described in 30.1, above, may receive a total payment that is less than the APC payment rate.)  The Medicare payment amount takes into account the wage index adjustment and the beneficiary deductible and coinsurance amounts.  In addition, the amount calculated for an APC group applies to all the services that are classified within that APC group.  The Medicare payment amount for a specific service classified within an APC group under OPPS is calculated as follows:   Step 1 -  Apply the appropriate wage index adjustment to the payment rate that is set annually for each APC group;   Step 2 -  Subtract from the adjusted APC payment rate the amount of any applicable deductible;   Step 3 -  Multiply the adjusted APC payment rate, from which the applicable deductible has been subtracted, by the program payment percentage determined for the APC group or 80 percent, whichever is lower.  This amount is the preliminary Medicare payment amount;  Step 4 -  Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less the amount of any applicable deductible.  If the resulting amount does not exceed the annual hospital inpatient deductible amount for the calendar year, the r esulting amount is the beneficiary coinsurance amount.  If the resulting amount exceeds the annual inpatient hospital deductible amount, the beneficiary coinsurance amount is limited to the inpatient hospital deductible and the Medicare program pays the di fference to the provider.   Step 5 -  If the wage -index adjusted coinsurance amount for the APC is reduced because it exceeds the inpatient deductible amount for the calendar year, add the amount of this reduction to the amount determined in Step 3 above to get the final Medicare payment amount.  EXAMPLE 1:   The wage -adjusted payment rate for an APC is $300; the program payment percentage for the APC group is 70 percent; the wage -adjusted coinsurance amount for the APC group is $90; and the beneficiary has not yet satisfied any portion of his or her $100 annual Part B deductible.   A. Adjusted APC payment rate: $300.  B. Subtract the applicable deductible: $300 -  $100 = $200.  C. Multiply the remainder by the program payment percentage to determine the prelimin ary  Medicare payment amount: 0.7 x $200 = $140.    D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less any unmet deductible to determine the coinsurance amount, which cannot exceed the inpatient hospital deductible for the calendar year: $200 -  $140 = $60.   E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible  limitation.  $140 + $0 = $140.  In this case, the beneficiary pays a deductible of $100 and a $60 coinsurance, and the program pays $140, for a total payment to the provider of $300.  Applying the program payment percentage ensures that the program and the beneficiary pay the same proportion of payment that they would have paid if no deductible were taken.