(Medicare Claims Processing Manual)

The IHS CAHs ar e paid for covered inpatient Medicare Part B ancillary services based upon 101 percent of an all inclusive facility specific per diem rate that is established on a yearly basis from prior year cost report information. Medicare Part B deductible and coinsur ance amounts are applied to inpatient Medicare Part B ancillary services, but are waived by the IHS.   100.7.2.1 - A/B MAC (A) - CAH Ancillary Services - Medicare Part B - Claims Processing (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  All charges, except therapies, telehealth originating site facility fee , PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (all -inclusive ancillary) on TOB 12X (hospital inpatient Part B). The MSN is  suppressed.   See 100.10 and 100.11 of this chapter, for more information on the payment of vaccines and their administration and therapy services.   100.8 - A/B MAC (A) - CAH Swing -bed - Medicare Part A - Payment Policy (Rev. 1325; Issued:  08- 29-07; Eff ective:  01 -01-08; Implementation:  01 -07-08)  The IHS CAH swing -bed services are paid 101 per cent of an all inclusive facility specific per diem rate. Medicare Part A coinsurance is applied to IHS CAH swing -bed inpatient bills, but is waived by the IHS.   100.8.1 - A/B MAC (A) - CAH Swing-bed - Medicare Part A - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X (hospital swing -bed). Technical criteria for swing -bed admissions apply (i.e., 3 day qualifying hospital stay, 30 day transfer requirements, etc.) but CAH swing -bed providers are not required to report revenue code 0022 or HIPPS codes. The MSN is suppr essed.   For more information on the technical criteria for Medicare Part A coverage of SNF services see Chapter 8, 20 in Pub. 100- 02, Medicare Benefit Policy Manual.   100.8.2 - A/B MAC (A) - CAH Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Payment Policy  (Rev. 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  The IHS CAHs are paid for covered inpatient Medicare Part B ancillary services based upon 101 percent of an all inclusive facility specific per diem rate that is  established on a yearly basis from prior year cost report information. Medicare Part B deductible and coinsurance amounts are applied to inpatient Medicare Part B ancillary services, but are waived by the IHS.   100.8.2.1 - A/B MAC (A) - CAH Swing -bed - Inpatient Ancillary Claims - Medicare Part B - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS CAH swing -bed Medicare Part B inpatient ancillary bills revert to inpatient Medicare Part B ancillary bills  and are submitted under the regular hospital (or CAH) provider number (not the swing -bed provider number) with revenue code 0240 (all inclusive ancillary) on TOB 12X (inpatient Part B). The MSN is suppressed.  100.9 - A/B MAC (A) - CAH Outpatient - Medica re Part B - Payment Policy (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS CAHs are paid for covered outpatient services based on 101 percent of an all inclusive facility specific per visit rate that is established on a yearly basis from prior year cost report information for both facilities electing Standard Method I and Optional Method II billing.   For services provided in IHS CAHs, deductible and coinsurance amounts are applied by Medicare, but are waived by the IHS.   Third party payers may be billed for applicable deductible and coinsurance amounts.   See Chapter 4, 250.1 and 250.2 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on the payment of Method I and II CAH outpatient claims.  See  100.10 and 100.11 of this chapter, for more information on the payment of vaccines and their administration and therapeutic services.   100.9.1 - A/B MAC (A) - CAH Outpatient - Medicare Part B - Claims Processing  (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  All charges, except therapies, telehealth originating site facility fee , PPV, influenza virus vaccine, hepatitis B vaccine, and hospital -based ambulance services are combined and reported under revenue code 0510 (clinic  visit) on TOB 85X (CAH).   Non-patient lab specimens are billed on TOB 14X (hospital other).   The MSN is suppressed.   See Chapter18, 10 of Pub. 100- 04, Medicare Claims Processing Manual, for detailed billing instructions for vaccines. See Chapter 5 of Pub. 100- 04 for detailed billing instructions for therapy services. See Chapter15 of Pub. 100- 04 for detailed billing instructions for ambulance services.  100.9.1.1 - A/B MAC (A) - CAH Election of Method I or Method II (Rev. 1040, Issued: 08- 25-06, Effective : 09-11-06, Implementation: 09- 11-06)  See Chapter 4, 250 of Pub. 100- 04, Medicare Claims Processing Manual, for information on the election of Standard Method I or Optional Method II IHS CAH billing for professional services.   100.10 - A/B MAC (A) - Vacc ines and Vaccine Administration - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Effective January 1, 2006, IHS providers, including CAHs are paid separately from the AIR for certain vaccines and their administ ration. See Chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual for more information on the payment of PPV, influenza virus, and hepatitis B vaccines. The administration of vaccines is paid based on the MPFS.   The Medicare Part B deductible and co insurance does not apply to PPV and influenza vaccines. The Medicare Part B deductible and coinsurance are applied to the hepatitis B vaccine, but are waived by the IHS.   100.10.1 - A/B MAC (A) - Vaccines and Vaccine Administration - Claims Processing (Rev . 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  These vaccines are reported on TOB 12X, 13X, 83X, or 85X along with the appropriate revenue codes and HCPCS codes as found in billing instructions in Chapter 18, 10.2 of Pub. 100- 04, Medicare Claims Processing Manual.   No clinic visit shall be billed if vaccine and its administration are the only service received.  Vaccines and their administration may be billed with or without a clinic visit.   The MSN is suppressed.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs (TOB 83X).  All IHS ASC providers must submit their claims to the A/B MAC (B).   100.11 - A/B MAC (A) - Pulmonary Rehabilitation, Physical Therapy, Occupational Therapy, Speech -Language Pathology and Diagnostic Audiology Services -  Payment Policy  (Rev. 3897, Issued: 10- 27-17, Effective: 01- 01-10, Implementation: 04- 02-18)   Effective January 1, 2006, IHS providers are paid separately from the  AIR for physical therapy, OT, speech -language pathology and diagnostic audiology services. Payment for services to IHS providers on TOB 12X or 13X is made based on the MPFS. Payment for services to IHS CAHs on TOB 85X is made based on reasonable cost.  Effective January 1, 2010, IHS providers are paid separately from the AIR for Pulmonary Rehabilitation services. Payment for services to IHS providers on TOB 13X is made based on the MPFS. Payment for services to IHS CAHs on TOB 85X is made based on reasonabl e cost.  100.11.1 - A/B MAC (A) - Physical Therapy, Occupational Therapy, Speech -Language Pathology and Diagnostic Audiology Services - Claims Processing (Rev. 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  Therapy services and d iagnostic audiology services are reported on TOB 12X, 13X, 83X or 85X using the appropriate revenue code and HCPCS codes.   No clinic visit shall be billed if a therapy service or a diagnostic audiology service is the only service received. These services m ay be billed with or without a clinic visit.   The MSN is suppressed.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs (TOB 83X). All IHS ASC providers must submit their claims to th e A/B MAC (B).   100.11.2 - A/B MAC (A)   Pulmonary Rehabilitation Services - Claims Processing  (Rev. 3897, Issued: 10- 27-17, Effective: 01- 01-10, Implementation: 04- 02-18)  Pulmonary Rehabilitation services are reported on TOB 13X or 85X using revenue code 948 and HCPCS code G0424.   No clinic visit shall be billed if a pulmonary rehabilitation service is the only service received. These services may be billed with or without a clinic visit.   The MSN is suppressed.   Note:   See Medicare Claims Processing Manual, Chapter 32  Billing R equirements for Special Services, Section 140.4 for additional billing instructions, frequency editing and limitations.   100.12 - A/B MAC - Ambulance Services  (Rev. 2102, Issued: 11- 19-10, Effective: 04- 01-11, Implementation: 04- 04-11)  Section 630 of the MMA allows for the reimbursement of ambulance services provided by IHS hospital -based ambulance providers, CAHs, and entities owned and operated by a CAH, for the 5 year period beginning January 1, 2005. Section 2902 of the Affordable Care Act indefinitely  extends Section 630 of the MMA, retroactive to January 1, 2010. Effective January 1, 2005, claims for ambulance services submitted by hospital -based ambulance providers and CAHs shall be processed by the designated A/B MAC.   All claims processing requirements in Chapter 15 of Pub. 100- 04, Medicare Claims Processing Manual, shall apply to ambulance service claims submitted by IHS hospital -based ambulance providers and ambulance service claims submitted by IHS CAHs.  100.12.1 - A/B MAC (A) - Outpatie nt Hospital -Based Ambulance Services - Medicare Part B - Payment Policy (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Medically necessary ambulance services submitted by hospital -based ambulance providers are reimbursed base d on the ambulance fee schedule.   The Medicare Part B deductible and coinsurance apply to ambulance services, but are waived by the IHS.   See Chapter 15, 30.2.4 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on the payment of ambulance claims.   100.12.1.1 - A/B MAC (A) - Outpatient Hospital -Based Ambulance Services - Medicare Part B - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)