(Medicare Claims Processing Manual)

 Inpatient CAH laboratory ancillary services are covered under Medicare Part B when coverage is unavailable under Medicare Part A.   Charges for inpatient CAH laboratory services are combined with charges for other inpatient ancillary services and reported under revenue code 024X (all -inclusive ancillary) on TOB 12X. Payment is based on 101 percent of an all -inclusive facility specific per diem rate.    Covered CAH outpatient laboratory service charges are combined with all other outpatient charges  for the date of service and reported under revenue code 0510 (clinic visit) on TOB 85X. Payment is based on 101 percent of the facility specific per visit rate.    Swing -bed laboratory service charges are combined with all other swing bed charges in IHS CAH s and are billed under revenue code 0100 (all -inclusive room and board plus ancillary) on TOB 18X. Payment is made on a cost based per diem amount.  100.15 - A/B MAC (A) - Drugs (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS providers, including CAHs, are paid by the A/B MAC (A) for covered drugs and biologicals provided during a covered inpatient hospital stay. All charges are combined and reported under revenue code 0100 (all -inclusive room and board plus ancillary) on TOB 11X. Payment is made to IHS/tribal hospitals under IPPS. IHS CAHs are paid 101 percent of the all inclusive facility specific per diem rate.   The IHS providers are paid by the A/B MAC (A) for covered drugs and biologicals provided during a clinic vi sit.  All charges are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (IHS/tribal hospitals and hospital -based clinics) or TOB 85X (CAHs). Payment is made to IHS providers under the AIR. Payment is made to IHS CAHs based upon 101 pe rcent of the all inclusive facility specific per visit rate.   The IHS hospital swing- bed providers are paid according to the SNF PPS payment methodology for covered drugs and biologicals provided during the IHS hospital swing -bed stay. Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X.   Payment to IHS CAH swing -bed providers for covered drugs and biologicals provided during an IHS CAH swing -bed stay is included in the all inclusive facility specific per  diem rate.   Supply fees are also due when multi -day supplies of any of the following self -administered drugs are provided to IHS hospital outpatients or patients of a provider -based clinic:  oral anti -cancer drugs, oral anti -emetic drugs, or immunosuppressive drugs. Following the same procedures that apply to non- IHS facilities, these multi- day supplies must be billed to the appropriate DME MAC in order to collect the supplying fee.  The supplying fee must be billed on the same claim as the drug itself. For a 1 day supply of the above mentioned drugs, there is no supplying fee, the facility bills the designated A/B MAC (A) and is paid the AIR for the outpatient visit.  For an IHS CAH, payment for a 1 day supply of the drug is based on 101 percent of the all inclusive fa cility specific per visit rate.  A/B MACs (A) will also make payment for multi- day supplies of these particular drugs when provided to a beneficiary in an inpatient Part B stay in an IHS hospital, CAH, or SNF.   For additional information regarding billing for drugs and associated supplying fees, see Chapter 17, 80.7 of Pub. 100- 04, Medicare Claims Processing Manual.   100.16 - A/B MAC (A) --Payment for Telehealth Services to Indian Health Service/Tribal Facilities and Practitioners  (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  For background on the telehealth benefit, see Chapter 12, 190.1 in this manual.  For more information on the payment of Telehealth services, see Chapter 15 of the Benefit Policy Manual.  Telehealth servi ces fall into two categories: an originating site facility service in which the beneficiary is presented to the distant site practitioner, and a distant site service which is generally some type of professional consultation.  100.16.1 - A/B MAC (A) - Teleh ealth Originating Site Facility Fee - Medicare Part B - Payment Policy  (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  Effective January 1, 2009, IHS providers, including CAHs are paid separately from the AIR for the Telehealth Originating Site Facility Fee.  HCPCS code Q3014 (telehealth originating site facility fee) is a Part B benefit.  The fee is updated each calendar year by the Medicare Economic Index announced in the annual Physician Fee Schedule Final Regulat ion.  IHS providers are paid for HCPCS code Q3014 at the fee schedule payment, not the providers usual all -inclusive payment methodology (e.g., inpatient DRG or AIR or CAH per diem).  For CAHs, the payment amount is 80 percent of the fee, not 101 percent of cost.  The Medicare Part B deductible and coinsurance apply to the Telehealth Originating Site Facility Fee, but are waived by the IHS.   100.16.2 - A/B MAC (A) - Telehealth Originating Site Facility Fee - Medicare Part B - Claims Processing  (Rev. 1776, Issued: 07 -24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  The Telehealth Originating Site Facility Fee is reported on TOB 12X, 13X or 85X along with the revenue code 0780 and HCPCS code Q3014 as described in Chapter 12, Section 190 of Pub. 100- 04, Medicare Claims Processing Manual.   No clinic visit shall be billed if this is the only service received.  There is no requirement that a practitioner present the patient for interactive telehealth services.   The MSN is suppressed.   100.16.3 - A/B MAC (A) -- Payment for Distant Site Practitioner Services  (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  Distant site services are listed in 190.3 in Chapter 12 of this manual.  These services are payable only by the A /B MAC (A) to a Method II CAH.  Payment is based on 80 percent of the MPFS.  Deductible and coinsurance apply, but are waived by IHS.   The MSN is suppressed.   110 - Audit  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  110.1 - Audit of IHS Cost Reports  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  All IHS hospitals that convert to CAH status are subject to audit by the A/B MAC (A). CMS audit policy can be found in Chapter 8, Contractor Procedure s for Provider Audit, of Pub. 100- 06, Medicare Financial Management Manual.   The CAHs are reimbursed under the Medicare Principles of Reasonable Costs. These principles are set forth in the Provider Reimbursement Manual 15- 1.  For IHS hospitals that do not  convert to CAH status, their cost reports are not subject to audit by Medicare.   110.2 - Method E Cost Reports  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS has used the Method E cost report since it began filing cost reports with CMS in 1998. Method E is the method of cost apportionment which is used to calculate the all inclusive outpatient per visit rate and the all inclusive inpatient ancillary per  diem rate. Both of these rates are paid under Part B of the Medicare Program. For a more detailed explanation see the Provider Reimbursement Manual 15- I, Chapter 22, 2208.  The Method E cost report filed by the IHS is a modified cost report that is appli cable to AIR no charge structure hospitals. The modified cost report does not use all the worksheets of the regular hospital cost report form (Form CMS - 2552). The worksheets filed by IHS are worksheet S -Part I &II, S -2, S-3, A, A -6, A-8, A-8-1, B-Part I, B -Part III, and B -1. For more detailed information see Provider Reimbursement Manual 15- II, Chapter 36.  110.3 - Critical Access Hospitals  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  All IHS hospitals that elect CAH status , and are certified as such, are reimbursed under the reasonable cost method of reimbursement. The all inclusive inpatient per diem rate, the all inclusive outpatient per visit rate, and the all inclusive inpatient ancillary per diem rate are calculated based upon the individual CAHs cost report filed with the A/B MAC (A). These rates are facility specific rates and are not to be confused with the AIRs published in the Federal Register by the IHS for each calendar year. A CAH cost report is subject to audi t by its A/B MAC (A). The A/B MAC (A) can disallow costs if those costs did not comply with the Principles of Cost Reimbursement published in the Provider Reimbursement Manual 15- 1. Any costs disallowed are subject to appeal by the CAH. There is also a fin al settlement of an IHS CAH cost report. A final settlement necessitates the issuance of a Notice of Program Reimbursement (NPR) by the A/B MAC (A). The NPR advises the CAH if a balance is due the hospital or the program is due repayment. The NPR also advi ses the CAH of any cost disallowance, its appeal and reopening rights. It should be noted that an IHS hospital that is not a CAH does not receive an NPR and does not have a final settlement.   Effective for cost reporting periods beginning on or after Janua ry 1, 2004, payment for inpatient services, other than a distinct part unit, is 101 percent of the reasonable costs. Effective for cost reporting periods beginning on or after January 1, 2004, payment for outpatient services is 101 percent of the reasonabl e costs. For a detailed explanation concerning payments to CAHs, see 42 CFR, 413.70. For cost reimbursement principles see 42 CFR Part 413 and Provider Reimbursement Manual 15- 1. For Cost Reports see the Provider Reimbursement Manual 15- II, the chapter on hospital cost reports.   120 - Payment to Non -Indian Health Service Physicians by Indian Health Service (IHS) Providers for Teleradiology Interpretations  (Rev. 1643, Issued: 12- 05-08, Effective: 01- 01-07, Implementation: 03- 09-09)  The IHS providers may choose to purchase or otherwise contract for teleradiology interpretation from non- IHS practitioners.  Two options are available for payment for these services.   (1) Contractual Reassignment -  Under this provision, non- IHS physicians can reassign their benefit s to the IHS hospital where the technical component is performed.  Non- IHS practitioners providing these services shall enroll with the designated A/B MAC contractor for IHS and complete a Form CMS -855-R form for each IHS hospital performing the test.  Bec ause of IHS status, state licensure and location of the physicians is not an issue and the designated A/B MAC contractor shall make payment based on the Medicare locality in which services are rendered in accordance with current jurisdictional pricing guid elines (see 80.2, paragraph 6 of this Chapter).   Purchased Test - The purchased test method is available for all purchased diagnostic tests including radiology, and the requirements are found in Chapter 1.  Payment for teleradiology interpretations under the purchased test option does not require non- IHS physicians enrollment with the designated A/B MAC contractor for IHS.  All general jurisdictional and pricing rules apply for payment for these services.  Transmittals Issued for this Chapter