(Medicare Claims Processing Manual)

 HCPCS code C9604 (Percutaneous transluminal revascularization of or through coronary arter y bypass graft (internal mammary, free arterial, venous), any combination of drug -eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);    HCPCS code C9605 (Percutaneous transluminal revasculari zation of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug -eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed;  each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));    HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass gr aft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);    HCPCS code C9607 (Percutaneous transluminal revascularization of chronic total occlusion, coronary art ery, coronary artery branch, or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty; single vessel); and    HCPCS code C9608 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty;  each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).   CPT codes 92928, 92933, 92929, 92934, 92937, 92938, 92941, 92943, and 92944 should be used to describe nondrug -eluting intracoronary stent placement procedures and are assigned to APC 0104.  HCPCS codes C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, and C9608 are assigned to APC 0656.  70 - Transitional Corridor Payments  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)   The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) established transitional payments to limit providers losses under the OPPS; the additional payments are for 3 1/2 years for community mental health centers (CMHCs) and most hospitals, and permanent for cancer hospitals effective August 1, 2000.  Section 405 of BIPA provides that childrens hospitals described in 1886(d)(1)(B)(iii) are held harmless permanently for purposes of calculating TOP amounts, retroactive to August 1, 2000.  Some rural hospitals are also held harmless for several years after the implementation of the OPPS, as discussed in detail below.  Contractors determine TOPs eligibility and calculate interim TOPs.   Beginning September 1, 2000, and every month thereafter until further notice, the shared system maintainers must provide contractors with software that gathers all data required to calculate a TOP amount for each hospital and CMHC.  The software must calculate and pay the TOP amount for OPPS services on claims processed during the preceding month, maintain an audit trail (including the ability to generate a hardcopy report) of these TOP amounts, and transfer to the PS&R system any necessary data.  TOP amounts should be paid before the next month begins and they are not subject to normal payment floor requirements.  Several items contained in the Inpatient or Outpatient Provider Specific File (IPSF or OPSF) are needed to determine TOP eligibility for each hospital or CMHC.  They are:    The provider number;   Fiscal year begin date;    The provider type;   Actual geographic location - CBSA  (from the IPSF);    Wage index location - CBSA  (from the IPSF); and    Bed size (from the IPSF)   Pursuant to 403 of BIPA, a TOP may be made to hospitals and CMHCs that did not file a cost repo rt for the cost reporting period ending in calendar year 1996.  The law was amended to provide that if a hospital did not file a cost report for a cost reporting period ending in calendar year 1996, the payment- to-cost ratio used in calculating a TOP will be based on the hospitals first cost report for a period ending after calendar year 1996 and before calendar year 2001.  This provision is effective retroactively to August 1, 2000.  Future updates will be issued in a Recurring Update Notification.  70.1 - Transitional Outpatient Payments (TOPs) for CY 2000 and CY 2001   (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effective for services provided between August 1, 2000, and December 31, 2001.   Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the total charges to cost by multiplying them by the outpatient cost to charge ratio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all APCs, as well as all outlier payments and transitional pass-through payments for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result  of step 1, go to step 9.  No transitional payment is due this month.   Step 3 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital, go to step 4.  If any other type of hospital, divide the resu lt of step 2 by the result of step 1, skip step 4 and perform step 5, 6, 7, or 8 as appropriate.   Step 4 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital, subtract the result of step 2 from  the result of step 1 and pay .85 times this amount.  Do not perform steps 5- 8.  Step 5 -  If the result of step 3 is equal to or greater than .9 but less than 1.0, subtract the result of step 2 from the result of step 1, and multiply the difference by .8 a nd pay .85 times this amount.   Step 6 -  If the result of step 3 is equal to or greater than .8 but less than .9, subtract .7 times the result of step 2 from .71 times the result of step 1, and pay .85 times this amount.  Step 7 -  If the result of step 3 is  equal to or greater than .7 but less than .8, subtract .6 times the result of step 2 from .63 times the result of step 1, and pay .85 times this amount.  Step 8 -  If the result of step 3 is less than .7, multiply the result of step 1 by .21 and pay .85 ti mes this amount.   Step 9 -  When the result of step 2 is greater than the result of step 1 for the final month of a providers cost report period, do nothing more.  When the result of step 2 is greater than the result of step 1 for any other month, store al l step 1 and step 2 totals and include these totals with the totals for the next months TOP calculation.    70.2 - Transitional Outpatient Payments (TOPs) for CY 2002 (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  For services  provided during calendar years 2002, TOPs were gradually reduced for all providers except those hospitals that receive hold harmless TOPs (cancer hospitals, childrens hospitals, and rural hospitals having 100 or fewer beds).  To avoid TOP overpayments, c ontractors were instructed to revise the monthly interim TOP calculations to reflect the new calculation.   Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effective for services provided between January 1, 2002, and December 31, 2002.   Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the total charges to cost by mu ltiplying them by the outpatient cost- to- charge ratio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all  APCs, as well as all outlier payments and transitional pass-through payments for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result of step 1, go to step 8.  No transitional payment is due this month.   Step 3 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital go to step 4.  If any other type of hospital, divide the result of step 2 by the result of s tep 1, skip step 4 and perform steps 5, 6, or 7 as appropriate.   Step 4 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital, subtract the result of step 2 from the result of step 1 and pay .85 times this amount.  Do not perform steps 5- 7.  Step 5 -  If the result of step 3 is equal to or greater than  .9 but less than 1.0, subtract the result of step 2 from the result of step 1, and multiply the difference by .7 and pay .85 times this amount.   Step 6 -  If the result of step 3 is equal to or greater than  .8 but less than .9, subtract .6 times the result of step 2 from .61 times the result of step 1, and pay .85 times this amount.  Step 7 -  If the result of step 3 is less than .8, multiply the res ult of step 1 by .13 and pay .85 times this amount.   Step 8 -  When the result of step 2 is greater than the result of step 1 for the final month of a providers cost report period, do nothing more.  When the result of step 2 is greater than the result of s tep 1 for any other month, store all step 1 and step 2 totals and include these totals with the totals for the next months TOP calculation.   70.3 - Transitional Outpatient Payments (TOPs) for CY 2003 (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Impl ementation: 01 -05-09)  For services provided during calendar years 2003, TOPs continued to decrease for all providers except those hospitals that receive hold harmless TOPs (cancer hospitals, childrens hospitals, and rural hospitals having 100 or fewer be ds).  To avoid TOP overpayments, contractors were instructed to revise the monthly interim TOP calculations to reflect the new calculation.   Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effe ctive for services provided between January 1, 2003, and December 31, 2003.   Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the  total charges to cost by multiplying them by the outpatient cost to charge ratio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all APCs, as well as all outlier payments and transitional pass-through payments for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result of  step 1, go to step 7.  No transitional payment is due this month.