(Medicare Claims Processing Manual)

 Emergency room services are reported under the 045x revenue code    The line item date of service  for the ER encounter is the date the patient entered the ER even if the patients encounter spans multiple service dates    For all other services related to the ER encounter (i.e., lab, radiology, etc) the line item date of service reported is the date the service was actually rendered   Note:  For patients in a Skilled Nursing Facility (SNF) see Chapter 6, Section 20.1.2.2 Emergency Services for special billing instructions using the ET modifier.  Chapter 6, Section 20.1.2.2 applies to hospital ER services spanning multiple service dates that are provided to patients in a Part A SNF stay and related CWF SNF consolidated billing edits.   For patients with end stage renal disease (ESRD) see Chapter 8, Section 50.1.6 for billing instructions requiring the use of  the ET modifier.  Chapter 8, Section 50.1.6 applies to hospital ER services spanning multiple service dates including laboratory services.   180.7 - Inpatient -only Services                                                           (Rev. 4513, Issued: 02- 04-2020, Effective: 01- 01- 2020, Implementation: 01- 06-2020)   Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment under the OPPS is appropriate and the Secretary has determined that the services designated to be inpa tient only services are not appropriate to be furnished in a hospital outpatient department. Inpatient only services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underly ing physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. An example of an inpatient only service is CPT code 33513, Coronary artery bypass, vein only; four coronary venous grafts. The designation of services to be inpatient -only is open to public comment each year as part of the annual rulemaking process. Procedures removed from the inpatient only list may be appropriately furnished in either the inpatient or outpatient settings and such procedures continue to be payable when furnished in the inpatient setting.  There is no payment under the OPPS for services that CMS designates to be inpatient -only services. These services have an OPPS status indicator of C in the OPPS  Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. For the most current Addendum B and for Addendum E published with the OPPS notices and regulations, see http://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/HospitalOutpatientPPS/index.html.  Excluding the handful of exceptions discussed below, CMS does not pay for an inpatient -only service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the inpatient only procedure.  There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an inpatient -only service that would be paid under the OPPS if the inpatient service had not been furnished:  Exception 1: If the inpatient -only service is defined in CPT to be a separate procedure and the other services billed with the inpatient -only service contain a procedure that can be paid under the OPPS and that has an OPPS SI=T on the same date as the inpatient -only procedure or OPPS SI = J1 on the same claim as the inpatient -only procedure, then the inpatient -only servi ce is denied but CMS makes payment for the separate procedure and any remaining payable OPPS services. The list of separate procedures is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www.cms.gov/Medicare/Coding/O utpatientCodeEdit/.  Exception 2: If an inpatient -only service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the inpatient only service with modifier CA, then CMS makes a singl e payment for all services reported on the claim, including the inpatient only procedure, through one unit of APC 5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure.  As of January 1, 2020, procedures that have been removed from the inpatient -only (IPO) list are exempt from certain medical review activities related to compliance with the 2 -midnight rule, which states that generally services are considered appropriate for inpatient hospital  admission and payment under Medicare Part A when the physician expects the patient to require a stay that crosses at least 2 midnights and admits the patient to the hospital based upon that expectation (78 FR 50913 through 50954).    Specifically, procedu res that have been removed from the IPO list are not eligible for referral to Recovery Audit Contractors (RACs) for noncompliance with the 2- midnight rule within the 2 -calendar years following their removal from the IPO list. These procedures will not be c onsidered by the Beneficiary and Family -Centered Care Quality Improvement Organizations (BFCC -QIOs) in determining whether a provider exhibits persistent noncompliance with the 2- midnight rule for purposes of referral to the RAC nor will these procedures be reviewed by RACs for patient status within the 2 -calendar years following their removal from the IPO list.  During the 2- year exemption period, BFCC -QIOs will have the opportunity to review claims for procedures that have been recently removed from the  IPO list in order to provide education for practitioners and providers regarding compliance with the 2- midnight rule, but claims identified as noncompliant with the 2 -midnight rule will not be denied with respect to the site -of-service under Medicare Part  A. 190  Payer Only Codes Utilized by Medicare  (Rev. 4391, Issued: 09- 06-19, Effective: 07- 01-19, Implementation: 07- 01-19)  This section contains the listing of payer codes designated by the National Uniform Billing Committee to be assigned by payers only.  Providers shall not submit these codes on their claims forms.  The definitions indicating Medicares usage for these syste matically assigned codes are indicated next to each code value.   Condition Codes   12-14 - Not currently used by Medicare.   15  Clean claim is delayed in CMS Processing System.   16  SNF Transition exception.  60  Operating Cost Day Outlier.   61  Operating Cost Outlier.   62  PIP Bill.   63  Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.   64  Other Than Clean Claim.   65  Non -PPS Bill.   98  Data Associated With DRG 468 Has Been Validated.   EY  Lung Reduction Study Demonstration Claims.  M0  All -Inclusive Rate for Outpatient -  Used by a Critical Access Hospital electing to be paid an all -inclusive rate for outpa tient services.   M1  Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV). Code indicates the influenza virus vaccine or pneumonia vaccine (PPV) is being billed via the roster billing method by providers that mass immunize.   M2  Allows Home Health claims to process if provider reimbursement > $150,000.00. HHA Payment Significantly Exceeds Total Charges. Used when payment to an HHA is significantly in excess of covered billed charges.    M3  SNF 3 Day stay bypass for NG/Pioneer ACO waiver.   M4  Presence of infected wound or wound with morbid obesity    M5  Not currently used by Medicare   M6  PA Rural Health Model    M7-M9  Not currently used by Medicare.   MA  GI Bleed. (Bill Type 72x)   MA  Managed Care Enrollee (Bill Type 12x, 13x, and 76x)   MB  Pneumonia. (Bill Type 72x)   MC  Pericarditis. (Bill Type 72x)   MD -  Myelodysplastic Syndrome. (Bill Type 72x)   ME -  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 72x)   MF -  Monoclonal Gammopathy. (Bill Type 72x)   MG  Grandfat hered Tribal Federally Qualified Health Centers.   MH-MO  Not currently used by Medicare.   MP  PHP claim contains initial admit week   MQ  PHP claim contains final discharge week    MR-MW  Not currently used by Medicare.   MX  Wrong Surgery on Patient (Inpatient)   MY  Surgery Wrong Body Part (Inpatient)   MY  Outlier Cap Bypass (CMHC)   MZ  Surgery Wrong Patient (Inpatient)   MZ  IOCE error code bypass   UU  Not currently used by Medicare.    Occurrence Codes   23 - Date o f Cancellation of Hospice Election period.  48 - Date hospice face- to-face encounter was untimely   49  Original Notice of Election (NOE) receipt date   Occurrence Span Codes   79 - Verified non- covered stay dates for which the provider is liable.   Value Codes   17- Operating Outlier Amount  The A/B MAC (A) reports the amount of operating outlier payment amount made (either cost or day (day outliers have been obsolete since 1997)) in CWF with this code.  It does not include any capital outlier payment in this entry.   18  Operating Disproportionate Share Amount  The A/B MAC (A) REPORTS THE OPERATING DISPROPORTIONATE SHARES AMOUNT APPLICIALBE.  It uses the amount provided by the disproportionate share field in PRICER.  It does not include any PPS capital IM E adjustment entry.   19  The Medicare shared system will display this payer only code on the claim for low volume providers to identify the amount of the low volume adjustment being included in the providers reimbursement.  This payer only code 19 is als o used for IME on hospital claims.  This instruction shall only apply to ESRD bill type 72x and must not impact any existing instructions for other bill types.   19 - Operating Indirect Medical Education Amount  The A/B MAC (A) reports operating indirect medical education amount applicable.  It uses the amount provided by the indirect medical education field in PRICER.  It does not include any PPS capital IME adjustment in this entry.   20  Total payment sent provider for capital under PPS, including HSP, F SP, outlier, old capital, DSH adjustment, IME adjustment, and any exception amount.  62   On Type of Bill 032x:  HH Visits -  Part A -  The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.  On Type of Bills 081x 0r 082x: Number of High Routine Home Care Days -  Days that fall within the first 60 days of a routine home care hospice claim.   63  On Type of Bill 032x:  HH visits  Part B -  The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.  On Typ e of Bills 081x 0r 082x: Number of Low Routine Home Care Days -  Days that come after the first 60 days of a routine home care hospice claim.  63  On Type of Bills 081x 0r 082x: Number of Low Routine Home Care Days - Days that come after the first 60 days of a routine home care hospice claim.   64 - HH Reimbursement  Part A -  The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount.  This Part A payment reflects the shift of payments from the Part A to the Part B  Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   65 - HH Reimbursement  Part B -  The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount.  This Part B payment reflects the shift of payments  from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   70 - Interest Amount -  The contractor reports the amount of interest applied to this Medicare claim.