(Medicare Claims Processing Manual)

NOTE: Inpatient claims submitted with counseling to prevent tobacco use services are processed under the current payment methodologies. In addition, payment is not allowed for inpatients whose primary diagnosis is counseling to prevent tobacco use.   12.4 - Remittance Advice (RA) Notices  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17) Contractors shall use the appropriate claim RA(s) when denying payment for counseling to prevent tobacco use services.   The following messages are used where applicable:    If the counseling services were furnished before August 25, 2010, use an appropriate RA claim adjustment reason code (CARC), such as, 26, Expenses incurred prior to coverage.    If the claim for counseling services is being denied because the coverage criteria are not met, use an appropriate CARC, such as, 272, Coverage/program guidelines were not met.    If the claim for counseling services is being denied because the maximum benefit has been reached, use an appropriate CARC, such as, 119, Benefit maximum for this time period or occurrence has been reached.   12.5 - Medicare Summary Notices (MSNs)  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  (When denying claims for counseling to prevent tobacco use services that were performed prior to the effective date of coverage, contractors shall use an appropriate MSN, such as, MSN 21.11, This service was not covered by Medicare at the time you received it.   When denying claims for counseling services on the basis that the coverage criteria were not met, use an appropriate MSN, such as MSN 21.21, This service was denied because Medicare only covers this service under certain circumstances.   When denying claims for counseling services that have dates of service exceeding the maximum benefit allowed, use an appropriate MSN, such as MSN 17.8, Payment is denied because the maximum benefit allowance has been reached.   12.6 - Post-Payment Review for Smoking and Tobacco- Use Cessation Counseling Services  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  As with any claim, Medicare may decide to conduct post -payment reviews to determine that the services provided are consistent with coverage instructions.  Providers must keep patient record information on file for each Medicare patient for whom a counseling claim is made.  These medical records can be used in any post -payment reviews and must include standard information along with sufficient patient histories to allow determination that the steps required in the coverage instructions were followed.  12.7 - Common Working File (CWF) Inquiry  (Rev. 4203, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The Common Working File (CWF) maintains the number of counseling sessions rendered to a beneficiary.  By entering the beneficiarys Medicare beneficiary identifier, providers have the capability to view the number of sessions a beneficiary has received for  this service via inquiry through CWF.   12.8 - Provider Access to Smoking and Tobacco-Use Cessation Counseling Services Eligibility Data  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  Providers may access coverage period remaining counseling sessions and a next eligible date, when there are no remaining sessions, through the 270/271 eligibility inquiry and response transaction.   20  Billing Requirements for Coverage of Kidney Disease Patient Education Services  (Rev. 1876; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04- 05-10)  Effective for claims with dates of service on and after January 1, 2010, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) determines that kidney disease patient education services are covered when provided to patients with stage IV chronic kidney disease (CKD).  See Pub. 100- 02, chapter 15, section 310, for complete coverage guidelines.   Contractors shall pay for kidney disease education (KDE) services  that meet the following conditions:    No more than 6 sessions of KDE services are provided in a lifetime,   Is provided in increments of 1 hour.  In order to bill for a session, a session must be at least 31 minutes in duration.  A session that lasts at least 31 minutes, but less than 1 hour still constitutes 1 session.   Is provided either individually or in a group setting of 2 to 20 individuals who need not all be Medicare beneficiaries.    Furnished, upon the referral of the physician managing the beneficiarys kidney condition, by a qualified person meaning a:   o physician, physicians assistant, nurse practitioner, or clinical nurse specialist;   o hospital, critical access hospital (CAH), skilled nursing facility (SNF), comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), or hospice, that is located in a rural area, or   o hospital or CAH that is paid as if it were located in a rural area (hospital or CAH reclassified as rural under section 42 CFR 412.103).  NOTE:   A renal dialysis facility (Type of Bill (TOB) 72x) is precluded from providing KDE services.   20.1  Additional Billing Requirements Applicable to Claims Submitted to Fiscal Intermediaries (FIs)  (Rev. 1876; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04- 05-10)  The FI will reimburse for KDE services when services are rendered in a rural area and submitted on the following TOBs: 12X, 13X, 22X, 23X, 34X, 75X, 81X, 82X, and 85X.   NOTE:   FIs shall use the actual geographic location, core based statistical area (CBSA) to identify facilities located in rural areas.  In addition, KDE services are covered when claims containing the above mentioned TOBs are received from section 401 hospitals .  Revenue code 0942 should be reported when billing for KDE services in the following: SNFs, HHAs, CORFs, hospices, and CAHs.  Hospital outpatient departments bill for this service under any valid/appropriate revenue code. They are not required to report revenue code 0942.  Hospices report this service on a separate claim from any hospice services. Hospice claims billed for revenue code 0942 that contain any other services will be returned to the provider. In addition, hospices report value code 61 or G8 when billing for KDE services.   NOTE:   KDE services are not covered when services are submitted on TOB 72X.  20.2 - Healthcare Common Procedure Coding System (HCPCS) Procedure Codes and Applicable Diagnosis Codes  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  Effective for services performed on and after January 1, 2010, the following new HCPCS codes have been created for KDE services when provided to patients with stage IV CKD.    G0420:  Face -to-face educational services related to the care of chronic kidney disease; individual, per session, per one hour    G0421:   Face -to-face educational services related to the care of chronic kidney disease; group, per session, per one hour   When billing for KDE services the applicable ICD diagnosis code shall be used:    If ICD -9-CM is applicable, ICD -9-CM -  585.4 (chronic kidney disease, Stage IV (severe)), or    If ICD -9-CM is applicable, ICD -10-CM  N18.4 (Chronic Kidney Disease, stage 4.  NOTE :  Claims with HCPCS codes G0420 or G0421 and ICD -9 code 585.4, if applicable, or, if ICD -10 is applicable, ICD -10 code N18.4 that are billed for KDE services are not allowed on a professional and institutional claim on the same service date.   20.3 - Medicare Summary Notices (MSNs) and Claim Adjustment Reason Codes (CARCs)  (Rev.  2998, Issued: 07- 25-14, Effective: Upon implementation of ICD -10; 01- 01-12 - ASC X12, Implementation: 08- 25-2014 -  ASC X12; Upon Implementation of ICD -10)  The following messages are used by Medicare contractors when denying non- covered services associated with KDE services  when provided to patients with stage IV CKD:   When denying claims for KDE services billed without diagnosis code 585.4 contractors shall use:   MSN 16.10 -  Medicare does not pay for this item or service.    CARC 167 -  This (these) diagnosis(es) is (are) not covered.  NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   When denying claims for KDE services when submitted for more than 6 sessions contractors shall use:    MSN 15.22 -  The information provided does not support the need for this many services or items in this period of time so Medicare will not pay for this item or service.    CARC 119 -  Benefit maximum for this time period or occurrence has been reached.   When denying claims for KDE services when two claims are billed (professional and institutional) on the same service date, contractors shall use:   MSN 15.5  The information provided does not support the need for similar services by more than one doctor during the same time period.   CARC 18  Exact duplicate claim/service (Use only with Group Code OA except where state workers' compensation regulations requires CO).   A/B MACs (A) shall deny KDE services when rendered in an urban area unless:    The provider is a hospital on the section 401 list or    The claim is submitted on TOB 85X.  A/B MACs (A) shall deny payment for KDE services when submitted on TOB 72X. Use the following messages:    MSN 21.6  This item or service is not covered when performed, referred or ordered by this provider.   CARC 170  Payment is denied when performed/billed by this type of provider in this type of facility. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.   20.4 - Advance Beneficiary Notice (ABN) Information  (Rev. 1876; Issued:  12- 18-09; Effective Date:  01 -01-10; Implementation Date:  04- 05-10)  If a signed ABN was provided, contractors shall use Group Code PR (Patient Responsibility) and the liability falls to the beneficiary.   If an ABN was not provided, contractors shall use Group Code CO (Contractual Obligation) and the liability falls to the provider.   30 - Hyperbaric Oxygen (HBO) Therapy  (Rev. 187, 05- 28-04)  30.1 - Billing Requirements for HBO Therapy for the Treatment of Diabetic Wounds of the Lower Extremities  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Hyperbaric Oxygen Therapy is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. Effective April 1, 2003, a National Coverage Decision expanded the use of HBO therapy to include coverage for the treatment of diabetic wounds of the lower extremities. For specific coverage criteria for HBO The rapy, refer to the National Coverage Determinations Manual, Chapter 1, section 20.29.  NOTE: Topical application of oxygen does not meet the definition of HBO therapy as stated above. Also, its clinical efficacy has not been established. Therefore, no Medicare reimbursement may be made for the topical application of oxygen.    Billing Requirements for A/B MACs  (A)  Claims for HBO therapy should be submitted using the ASC X12 837 institutional claim format or, in rare cases, on Form CMS -1450.  a. Applicable Bill Types   The applicable hospital bill types are 11X, 13X and 85X.  b. Procedural Coding