(Medicare Claims Processing Manual)

Spanish Version: Estos servicios no pueden ser pagados porque sus beneficios se han agotado.  Group Code  CO (Contractual Obligation)  Contractors shall deny/reject claims for PRP services for the treatment of chronic non-healing diabetic wounds, G0465, that dont contain the appropriate diagnosis codes as noted above and use the following messages:  Claim Adjustment Reason Code (CARC) 50 - These are non -covered services because this is not deemed a 'medical necessity' by the payer. Remittance Advice Remark Code (RARC) N386 - This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at: www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD. Medicare Summary Notice (MSN) 15.19 - We used a Local Coverage Determination (LCD) to decide coverage for your claim. To appeal, get a copy of the LCD at www.cms.gov/medicare- coverage- database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor." Spanish Version - Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage- database ( use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.  MSN  15.20 - The following polices were used when we made this decision: NCD 270.3. Spanish Version  Las siguientes polticas fueron utilizadas cuando se tom esta decisin: NCD 270.3. NOTE: Due to system requirement, the Fiscal Intermediary Shared System (FISS) has combined messages 15.19 and 15.20 so that, when used for the same line item, both messages will appear on the same MSN.  Group Code  Contractual Obligation (CO).   12 - Counseling to Prevent Tobacco Use  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  Background: Effective for services furnished on or after March 22, 2005, a National Coverage Determination (NCD) provided for coverage of smoking and tobacco- use cessation counseling services located at Medicare National Coverage Determinations Manual, Publication 100- 03 section 210.4.  CMS established a related policy entitled Counseling to Prevent Tobaccos Use at NCD Manual 210.4.1 effective August 25, 2010.  However, effective September 30, 2016, the conditions of Medicare Part A and Medicare Part B cove rage for smoking and tobacco- use cessation counseling services (210.4) were deleted.  The remaining NCD entitled Counseling to Prevent Tobacco Use (210.4.1), remains in effect, along with HCPCS codes 99406 and 99407, specifically payable for counseling to prevent tobacco use effective October 1, 2016.   12.1 - Counseling to Prevent Tobacco Use HCPCS and Diagnosis Coding  (Rev. 4237, Issued: 02- 08- 19, Effective: 03 -12- 19, Implementation: 03- 12-19)  The following HCPCS codes should be reported when billing for counseling to prevent tobacco use services:   99406 -  Smoking and tobacco- use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes   99407 -  Smoking and tobacco- use cessation counseling visit; intensive, greater than 10 minutes   Note the above codes were effective for dates of service on or after January 1, 2008, and specifically effective for counseling to prevent tobacco use claims on or after October 1, 2016.    Contractors shall allow payment for a medically necessary E/M service on the same day as the counseling to prevent tobacco use service when it is clinically appropriate.  Physicians and qualified non- physician practitioners shall use an appropriate HCPCS c ode, such as HCPCS 99201 99215, to report an E/M service with modifier 25 to indicate that the E/M service is a separately identifiable service from 99406 or 99407.  Contractors shall only pay for 8 counseling to prevent tobacco use sessions in a 12- month period.  The beneficiary may receive another 8 sessions during a second or subsequent year after 11 full months have passed since the first Medicare covered counselin g session was performed.  To start the count for the second or subsequent 12- month period, begin with the month after the month in which the first Medicare covered counseling session was performed and count until 11 full months have elapsed.   Claims for counseling to prevent tobacco use services shall be submitted with an appropriate diagnosis code.   NOTE:   This decision does not modify existing coverage for minimal cessation counseling (defined as 3 minutes or less in duration) which is already considered to be covered as part of each Evaluation and Management (E/M) visit and is not separately billable.   Claims for counseling to prevent tobacco use services shall be submitted with an applicable diagnosis code:   ICD- 9-CM (prior to October 1, 2015)  V15.82, personal history of tobacco use, or  305.1, non- dependent tobacco use disorder  989.84, toxic effect of tobacco   ICD- 10-CM (effective October 1, 2015)  F17.210, nicotine dependence, cigarettes, uncomplicated,  F17.211, nicotine dependence, cigarettes, in remission, F17.213 Nicotine dependence, cigarettes, with withdrawal  F17.218 Nicotine dependence, cigarettes, with other nicotine -induced disorders   F17.219 Nicotine dependence, cigarettes, with unspecified nicotine -induced disorders   F17.220, nicotine dependence, chewing tobacco, uncomplicated,  F17.221, nicotine dependence, chewing tobacco, in remission, F17.223 Nicotine dependence, chewing tobacco, with withdrawal  F17.228 Nicotine dependence, chewing tobacco, with other nicotine -induced disorders   F17.229 Nicotine dependence, chewing tobacco, with unspecified nicotine -induced disorders   F17.290, nicotine dependence, other tobacco product, uncomplicated,  F17.291, nicotine dependence, other tobacco product, in remission, or  F17.293 Nicotine dependence, other tobacco product, with withdrawal  F17.298 Nicotine dependence, other tobacco product, with other nicotine -induced disorders   F17.299 Nicotine dependence, other tobacco product, with unspecified nicotine -induced disorders   Z87.891, personal history of nicotine dependence, unspecified, uncomplicated.  T65.211A, Toxic effect of chewing tobacco, accidental (unintentional), initial encounter  T65.212A, Toxic effect of chewing tobacco, intentional self -harm, initial encounter  T65.213A, Toxic effect of chewing tobacco, assault, initial encounter  T65.214A, Toxic effect of chewing tobacco, undetermined, initial encounter  T65.221A, Toxic effect of tobacco cigarettes, accidental (unintentional), initial encounter  T65.222A, Toxic effect of tobacco cigarettes, intentional self -harm, initial encounter  T65.223A, Toxic effect of tobacco cigarettes, assault, initial encounter  T65.224A, Toxic effect of tobacco cigarettes, undetermined, initial encounter  T65.291A, Toxic effect of other tobacco and nicotine, accidental (unintentional), initial encounter  T65.292A, Toxic effect of other tobacco and nicotine, intentional self -harm, initial encounter  T65.293A, Toxic effect of other tobacco and nicotine, assault, initial encounter  T65.294A, Toxic effect of other tobacco and nicotine, undetermined, initial encounter   12.2 - Counseling to Prevent Tobacco Use A/B MAC (B) Billing Requirements  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  A/B MACs (B) shall pay for counseling to prevent tobacco use services billed with codes 99406 and 99407 for dates of service on or after October 1, 2016 A/B MACs (B) shall pay for counseling services billed with codes G0436 and G0437 for dates of service on and after August 25, 2010, through September 30, 2016.  The type of service (TOS) for each of the new codes is 1.   A/B MACs (B) pay for these services billed based on the Medicare Physician Fee Schedule (MPFS).  Deductible and coinsurance are waived.  Claims from physicians or other providers where assignment was not taken are subject to the Medicare limiting charge, w hich means that charges to the beneficiary may be no more than 115% of the allowed amount.  Physicians or qualified non- physician practitioners shall bill the A/B MAC (B) for counseling to prevent tobacco use services using the ASC X12 837 professional claim format or the Form CMS -1500.  12.3 - A/B MAC (A) Billing Requirements  (Rev.3848, Issued: 08-  25-17, Effective: 09 -26-17, Implementation: 09-  26-17)  The A/B MACs (A) shall pay for counseling to prevent tobacco use services with codes 99406 and 99407 for dates of service on or after October 1, 2016.  A/B MACs (A) shall pay for counseling services billed with codes G0436 and G0437 for dates of service on or after August 25, 2010, through September 30, 2016. Deductible and coinsurance are waived.   A. Claims for counseling to prevent tobacco use services should be submitted using the ASC X12 837 institutional claim format or Form CMS -1450.  The applicable bill types are 12X, 13X, 22X, 23X, 34X, 71X, 77X, 83X, and 85X. Effective April 1, 2006, type of bill 14X is for non- patient laboratory specimens and is no longer applicable for counseling to prevent tobacco use services.   Applicable revenue codes are as follows:   Provider Type  Revenue Code  Rural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs)  052X  Indian Health Services (IHS)  0510  Critical Access Hospitals (CAHs) Method II  096X, 097X, 098X  All Other Providers  0942   NOTE:  When these services are provided by a clinical nurse specialist in the RHC/FQHC setting, they are considered incident to and do not constitute a billable visit.   Payment for outpatient services is as follows:   Type of Facility  Method of Payment  Rural Health Centers (RHCs)  All-inclusive rate (AIR) for the encounter  Federally Qualified Health Centers (FQHCs)  FQHC Prospective Payment System (PPS) for the encounter  Indian Health Service (IHS)/Tribally owned or operated hospitals and hospital - based facilities  AIR IHS/Tribally owned or operated non-hospital -based facilities  Medicare Physician Fee Schedule (MPFS)  IHS/Tribally owned or operated Critical Access Hospitals (CAHs)  Facility Specific Visit Rate  Hospitals subject to the Outpatient Prospective Payment System (OPPS)  Ambulatory Payment Classification (APC)  Hospitals not subject to OPPS  Payment is made under current methodologies  Skilled Nursing Facilities (SNFs)   NOTE:   Included in Part A PPS for skilled patients.  MPFS  Home Health Agencies (HHAs)  MPFS  Critical Access Hospitals (CAHs)  Method I: Technical services are paid at 101% of reasonable cost. Method II: technical services are paid at 101% of reasonable cost, and Professional services are paid at 115% of the MPFS Data Base  Maryland Hospitals  Payment is based according to the Health Services Cost Review Commission (HSCRC). That is 94% of submitted charges subject to any unmet deductible, coinsurance, and non- covered charges policies.   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.