(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 4 - Part B Hospital  (Including Inpatient Hospital Part B and OPPS)  Table of Contents  (Rev. 12552; Issued : 03-21-24)    Transmittals for Chapter 4   10 - Hospital Outpatient Prospective Payment System (OPPS)  10.1 -  Background  10.1.1 -  Payment Status Indicators  10.2 -  APC Payment Groups  10.2.1 -  Composite APCs  10.2.2 -  Cardiac Resynchronization Therapy  10.2.3 -  Comprehensive APCs   10.2.4. -  Reporting for Certain Outpatient Department Services (That Are Similar to Therapy Services) (Non -Therapy Outpatient Department Services) and Are Adjunctive to Comprehensive APC Procedures  10.3 -  Calculation of APC Payment Rates  10.4 -  Packaging  10.4.1 -  Combinations of Packaged Services of Different Types That are Furnished on the Same Claim  10.5 -  Discounting 10.6 -  Payment Adjustments  10.6.1 -  Payment Adjustment for  Rural  Sole Community Hospitals  10.6.2 -  Payment Adjustment for Failure to Meet the Hospital Outpatient Quality Reporting Requirements  10.6.2.1 -  Hospitals to which the Payment Reduction Applies  10.6.2.2 -  Services to which the Payment Reduction Applies  10.6.2.3 -  Contractor Responsibilities  10.6.2.4 -  Application of the Payment Reduction Factor in Calculation of the Reduced Payment and Reduced Copayment  10.6.3 -  Payment Adjustment for Certain Cancer Hospitals  10.6.3.1 -  Payment Adjustment for Certain Cancer Hospitals for CY 2012 and CY 2013 10.6.3.2 -  Payment Adjustment for Certain Cancer Hospitals for CY 2014  10.6.3.3 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2015 10.6.3.4 -  Payment Adjustment for Certain Cancer Hospitals   Beginning CY 2016 10.6.3.5 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2017 10.6.3.6 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2018        10.6.3.7 -  Payment Adjustment for Certain Cancer Hospitals         Beginning CY 2019        10.6.3.8 -  Payment Adjustment for Certain Cancer Hospitals         Beginning CY 2020   10.6.4 -  Payment Adjustment for Rural Emergency Hospitals   10.7 -  Outliers  10.7.1 -  Outlier Adjustments  10.7.2 -  Outlier Reconciliation  10.7.2.1 -  Identifying Hospitals and CMHCs Subject to Outlier Reconciliation  10.7.2.2 -  Reconciling Outlier Payments for Hospitals and CMHCs  10.7.2.3 -  Time Value of Money  10.7.2.4 -  Procedures for Medicare Contractors to Perform and Record Outlier Reconciliation Adjustments  10.8 -  Geographic Adjustments  10.8.1 -  Wage Index Changes  10.9 -  Updates  10.10 -  Biweekly Interim Payments for Certain Hospital Outpatient Items and Services That Are Paid on a Cost Basis, and Direct Medical Education Payments, Not Included in the Hospital Outpatient Prospective Payment System (OPPS)  10.11 -  Calculation of Overall Cost to Charge Ratios (CCRs) for Hospitals Paid Under the Outpatient Prospective Payment System (OPPS) and Community Mental Health Centers (CMHCs) Paid Under the Hospital OPPS  10.11.1 -  Requirement to Calculate CCRs for Hospitals Paid Under OPPS and for CMHCs  10.11.2 -  Circumstances in Which CCRs are Used  10.11.3 -  Selection of the CCR to be Used 10.11.3.1 -  CMS Specification of Alternative CCR  10.11.3.2 -  Hospital or CMHC Request for Use of a Different CCR  10.11.3.3 -  Notification to Hospitals Paid Under the OPPS of a Change in the CCR  10.11.4 -  Use of CCRs in Mergers, Acquisitions, Other Ownership Changes , or Errors Related to CCRs  10.11.5 -  New Providers and Providers with Cost Report Periods Less Than a Full Year  10.11.6 -  Substitution of Statewide CCRs for Extreme OPPS Hospital Specific CCRs  10.11.7 -  Methodology for Calculation of Hospital Overall CCR for Hospitals that Do Not Have Nursing and Paramedical Education Programs  for Cost Reporting Periods Beginning Before  May 1, 2010, Under Cost Report Form 2552- 96 10.11.7.1 -  Methodology for Calculation of Hospital Overall CCR for Hospitals That Do Not Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning On or After May 1, 2010, Under Cost Report 2552- 10 10.11.8 -  Methodology for Calculation of Hospital Overall CCR for Hospitals That Have Nursing and Paramedical Education Programs  for Cost Reporting Periods Beginning Before May  1, 2010, Under Cost Report Form 2552- 96 10.11.8.1 -  Methodology for Calculation of Hospital Overall CCR for Hospitals That Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning On or After May 1, 2010, Under Cost Report 2552- 10 10.11.9 -  Methodology for Calculation of CCR for CMHCs  10.11.10 -  Location of Statewide CCRs, Tolerances for Use of Statewide CCRs in Lieu of Calculated CCRs and Cost Centers to be Used in the Calculation of CCRs  10.11.11 -  Reporting of CCRs for Hospitals Paid Under OPPS and for CMHCs  10.12 -  Payment Window for Outpatient Services Treated as Inpatient Services  20 - Reporting Hospital Outpatient Services Using Healthcare Common Procedure Coding System (HCPCS)  20.1 -  General  20.1.1 -  Elimination of the 90 -day Grace Period for HCPCS (Level I and Level II)  20.2 -  Applicability of OPPS to Specific HCPCS Codes  20.3 -  Line Item Dates of Service  20.4 -  Reporting of Service Units  20.5 -  Clarification of HCPCS Code to Revenue Code Reporting 20.6 -  Use of Modifiers  20.6.1 -  Where to Report Modifiers on the Hospital Part B Claim  20.6.2 -  Modifiers - 50 20.6.3 -  Modifiers - LT and -RT 20.6.4 -  Modifiers 73 and 74 20.6.5 -  Modifiers 76 and 77 20.6.6 -  Modifiers for Radiology Services  20.6.7 -  Modifier  CA 20.6.8 -  HCPCS Level II Modifiers  20.6.9 -  Modifier  FB 20.6.10 - Modifier FC  20.6.11 -  Modifier PO  20.6.12 - Modifier PN   20.6.13 -  Modifier CT  20.6.14 -  Modifier FX  20.6.15 -  Modifier FY  20.6.16-  Modifier JG  20.6.17-  Modifier TB  20.6.18-  Modifier ER  20.6.19 -  Modifier CG  20.7 -  Billing of C HCPCS Codes by Non- OPPS Providers  30 - OPPS Coinsurance  30.1 -  Coinsurance Election 30.2 -  Calculating the Medicare Payment Amount and Coinsurance  40 - Outpatient Code Editors (OCEs)  40.1 -  Integrated OCE (July 2007 and Later)  40.1.1 -  Patient Status Code and Reason for Patient Visit for the Hospital OPPS  40.2 -  Outpatient Prospective Payment System (OPPS) OCE (Prior to July 1, 2007)  40.2.1 -  Patient Status Code and Reason for Patient Visit for the Hospital OPPS  40.3 -  Non -OPPS OCE (Rejected Items and Processing Requirements) Prior to July 1, 2007 40.4 -  Paying Claims Outside of the IOCE  40.4.1 -  Requesting to Pay Claims Without IOCE Approval  40.4.2 -  Procedures for Paying Claims Without Passing through the IOCE  40.5 -  Transitional Pass -  Throughs for Designated Drugs or Biologicals    50 - Outpatient PRICER  50.1 -  Outpatient Provider Specific File  50.2 -  Deductible Application  50.3 -  Transitional Pass -Through Payments for Designated Devices  50.4 -  Changes to Pricer Logic Effective April 1, 2002 50.5 -  Changes to the OPPS Pricer Logic Effective January 1, 2003  50.6 -  Changes to the OPPS Pricer Logic Effective January 1, 2003 Through  January 1, 2006  50.7-  Annual Updates to the OPPS Pricer for Calendar Year (CY) 2007 and Later  50.8 -  Annual Updates to the OPPS Pricer for Calendar Year (CY) 2007 and Later  60 - Billing for Devices Eligible for Transitional Pass -Through Payments and Items Classified in New Technology APCs  60.1 -  Categories for Use in Coding Devices Eligible for Transitional Pass -Through Payments Under the Hospital OPPS  60.2 -  Roles of Hospitals, Manufacturers, and CMS in Billing for Transitional Pass-Through Items  60.3 -  Devices Eligible for Transitional Pass -Through Payments  60.4 -   General Coding and Billing Instructions and Explanations                                     60.4.1 -  Explanations of Terms  60.4.2 -  Complete List of Device Pass -through Category Codes  60.4.3. -  Explanations of Certain Terms/Definitions Related to Device Pass -Through Category Codes  60.5 -  Services Eligible for New Technology APC Assignment and Payments  61 - Billing for Devices under the OPPS  61.1 -  Requirements that Hospitals Report Device Codes on Claims on Which They Report Specified Procedures  61.2 -  Edits for Claims on Which Specified Procedures are to be Reported With Device Codes and For Which Specified Devices are to be Reported With Procedure Codes  61.2.1  Bypass Edit Modifier CG for Claims on Which Specified Procedures are to be Reported With Device Codes                          61.2.2  Edit for Level 6 Intraocular Procedures APC 61.3 -  Billing for Devices Furnished Without Cost to an OPPS Hospital or Beneficiary or for Which the Hospital Receives a Full or Partial Credit and Payment for OPPS Services Required to Furnish the Device  61.3.1 -  Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital  Prior to January 1, 2014  61.3.2 -  Reporting and Charging Requirements When the Hospital Receives Full Credit for the Replaced Device against the Cost of a More Expensive Replacement Device Prior to January 1, 2014 61.3.3 -  Reporting Requirements When the Hospital Receives Partial Credit for the Replaced Device Prior to January 1, 2014 61.3.4 -  Medicare Payment Adjustment  Prior to January 1, 2014  61.3.5 -  Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital or When the Hospital Receives a Full or Partial Credit for the Replacement Device Beginning January 1, 2014 61.3.6 -  Medicare Payment Adjustment Beginning January 1, 2014  61.4 -  Billing and Payment for Brachytherapy Sources  61.4.1 -  Billing for Brachytherapy Sources -  General  61.4.2 -  Definition of Brachytherapy Source for Separate Payment  61.4.3 -  Billing of Brachytherapy Sources Ordered for a Specific Patient  61.4.4 -  Billing for Brachytherapy Source Supervision, Handling and Loading Costs  61.4.5 -  Payment for New Brachytherapy Sources  61.5 -  Billing for Intracoronary Stent Placement  70 - Transitional Corridor Payments  70.1 -  TOPs Calculation for CY 2000 and CY 2001 70.2 -  TOPs Calculation for CY 2002