(Medicare Claims Processing Manual)

In general, payment for professional medical services, under the cost -based CAH payment plus professional services billed to the A/B MAC (B)  method should be made on the same basis as would apply if the services had been furnished in the outpatient department of a hospital.   Bill type 85X is used for all outpatient services including services approved as ASC services. Non-patient laboratory specimens (those not meeting the criteria for reasonable cost payment in 250.6) will be billed on a 14X type of bill.   (See Section 250.6 -  Clinical Diagnostic Laboratory Tests Furnished by CAHs.)   250.1.1 - Special Instructions for Non -covered Time Increments in Standard Method Critical Access Hospitals (CAHs)  (Rev. 1921, Issued: 02- 19-10, Effective: 04 -01-10, Implementation: 04- 05-10)  CAHs sometimes bill outpatient therapy services using HCPCS that by definition give specific time increments like those discussed in Chapter 5, sections 20 and 40.  However, standard method CAHs are not subject to payment on a fee basis under the Medicare Physician Fee Schedule, therefore these CAHs should follow the instructions below if there is a need to bill non- covered increments.   When HCPCS codes required for reporting do not specify an increment of billing in their definition (i.e., 15 minute intervals), the unit for the line item is 1, and CAHs should follow the general instructions given for billing non- covered charges in Chapter 1, section 60, either by the line item or on no payment claims.  Several of the outpatient therapy HCPCS codes, however, are defined in specific time increments, and units reported on line items should be consistent with these definitions. In such cases, when both covered and non- covered increments are provided in the s ame visit on the same date of service, CAHs should bill as follows:    Report covered and non- covered units in separate line items, even when part of the same visit, with one line item for all covered and non- covered increments in a visit, and another for all non- covered increments in that same visit;   Use ABN- related modifiers when appropriate to explain non- coverage and payment liability of specific lines (i.e., - GY, see Chapter 1, section 60 for details on these modifiers);    Do not report non- covered line items that are part of a partially covered service on a separate no payment claim (i.e., using condition code 21).  Instead, always report them on the same claim with the separate lines for the covered portion of the service.  No payment claims received for the same date, same beneficiary, same provider and same therapy service as a for -payment claim will be rejected. A distinct reason code will make providers aware of the reason for the rejection, and they can correct their bi lling to have covered and non- covered portions of the same service on the same claim;    Do not report non- covered line items as part of the required reporting of value codes 50, 51 and 52 for covered visits (i.e., where all increments are non- covered and there are no covered charges for the line item, since these line items are either part of an already counted partially covered visit, or an entirely non- covered visit); and    Never split a single increment into a covered and non- covered portion.   250.2 - Optional Method for Outpatient Services:  Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional Services  (Rev. 3019, Issued: 08- 07-14, Effective: 01 -01-12, ICD -10: Upon Implementation of ICD-  10, Implementation: 09 -08-14, ICD -10: Upon Implementation of ICD - 10)  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  A CAH may elect to be paid for outpatient services in any cost re porting period under this method by filing a written election with the A/B MAC (A) on an annual basis at least 30 days before start of the Cost Reporting period to which the election applies.  An election of this payment method, once made for a cost report ing period, remains in effect for all of that period for the CAH.   Effective for cost reporting periods beginning on or after October 1, 2010 if a CAH elected the optional method for its most recent cost reporting period beginning before October 1, 2010 or chooses to elect the optional method on or after October 1, 2010, that election remains in place until it is terminated, an annual election is no longer required.  If a CAH elects the optional method on or after October 1, 2010, it must submit its request in writing to its A/B MAC (A) at least 30 days before the start of  the first cost reporting period for which the election is effective.  That election will not terminate unless the CAH submits a termination request to its A/B MAC (A) at least 30 days before the start of its next cost reporting period.   The Medicare Prescription Drugs, Improvement, and Modernization Act (MMA) of 2003, changed the requirement that each practitioner rendering a service at a CAH that has elected the optional method, reassign their billing rights to that CAH.  This provision allows each practitioner to choose whether to reassign billing rights to the CAH or file claims for professional services through their A/B MAC (B).  The reassignment will remain in effect for that entire cost reporting period.  The individual practitioner must certify, using the Form CMS -855R, if he/she wishes to reassign their billing rights.  The CAH must then forward a copy of Form CMS -855R to the A/B MAC (A), and the A/B MACs (B) must have the practitioner sign an attestation  that clearly states that the practitioner will not bill the A/B MAC (A) or A/B MAC (B) for any services rendered at the CAH once the reassignment has been given to the CAH.  This attestation will remain at the CAH.   For CAHs that elected the optional method before November 1, 2003, the provision is effective beginning on or after July 1, 2001.  For CAHs electing the optional method on or after November 1, 2003, the provision is effective for cost reporting periods beginning on or after July 1, 2004.  Under this election, a CAH will receive payment from their A/B MAC (A) for professional services furnished in that CAHs outpatient department. Professional services are those furnished by all licensed professionals who ot herwise would be entitled to bill the A/B MAC (B) under Part B.  Payment to the CAH for each outpatient visit (reassigned billing) will be the sum of the following:    For facility services, not including physician or other practitioner services, payment will be based on 101 percent of the reasonable costs of the services.  List the facility service(s) rendered to outpatients using the appropriate revenue code.  The A/B MAC will pay 101 percent of  the reasonable costs for the outpatient services less applicable Part B deductible and coinsurance amounts, plus:    Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.   The A/B MAC (A) uses the Medicare Physician Fee Schedule (MPFS) amounts to pay for all the physician/nonphysician practitioner services rendered in a CAH that elected the optional method.  Payment is based on the lesser of the actual charge or the facility -specific MPFS amount less deductible and coinsurance times 1.15; and    AK -  Service rendered in a CAH by a non -participating physician   For a non -participating physician service, a CAH must place modifier AK on the claim.  Payment is based on the lesser of the actual charge or a reduced fee schedule amount of 95 percent. Payment is calculated as follows:    [(facility -specific MPFS amount times the non -participating physician reduction (0.95) minus (deductible and coinsurance] times 1.15.   GF -  Services rendered by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA)   GF - Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA).  (The GF modifier is not to be used for CRNA services.  If a claim is received and it has the GF  modifier for certified registered nurse anesthetist (CRNA) services, the claim is returned to the provider.)  Also, while this national GF modifier includes CRNs, there is no benefit under Medicare law that authorizes payment to CRNs for their services .  Accordingly, if a claim is received and it has the GF modifier for CRN services, no Medicare payment should be made.   Services billed with the GF modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent.  Payment is calculated as follows:    [(facility -specific MPFS amount times the nonphysician practitioner services reduction (0.85) minus (deductible and coinsurance)] times 1.15.   SB - Services rendered in a CAH by a certified nurse- midwife  For dates of service prior to January 1, 2011, certified nurse -midwife services billed with the SB modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 65 percent.  Payment is calculated as follows:   For dates of service on or after January 1, 2011, Medicare covers the services of a certified nurse- midwife.  The SB modifier is used to bill for the services and payment is based on the lesser of the actual charge or 100 percent of the MPFS.  MPFS Payme nt is calculated as follows :   [(facility -specific MPFS amount) minus (deductible and coinsurance)] times 1.15.  AH -  Services rendered in a CAH by a clinical psychologist  Payment for the services of a clinical psychologist is based on the lesser of the actual charge or 100 percent of the MPFS.   Payment is calculated as follows:    [(facility -specific MPFS amount) minus (deductible and coinsurance)] times 1.15.   AE -  Services rendered in a CAH by a nutrition professional/registered dietitian.  Services billed with the AE modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:    [(facility -specific MPFS amount times the registered dietitian reduction (0.85) minus (deductible and coinsurance)] times 1.15. Outpatient services, including ASC type services, rendered in an all -inclusive rate provider should be billed using the 85X type of bill (TOB).  Non- patient laboratory specimens are billed on TOB 14X.  MPFS rates contained in the HHH abstract file are used for payment of all physician/professional services rendered in a CAH that has elected the optional method.  If a HCPCS code has a facility rate and a non -facility rate, the facility rate is paid.  See Chapter 23 of Pub. 100- 04, section 50.1 for the record layout for the HHH abstract file.   Physician Fee Schedule Payment Policy Indicator File  The information on the Physician Fee Schedule Payment Policy Indicator file is used to identify endoscopic base codes, payment policy indicators, global surgery indicators, diagnostic imaging family indicators, or the preoperative, intraoperative and postoperative percentages that are needed to determine if payment adjustment rules apply to a specific CPT code and the associated pricing modifier(s). See Chapter 12 of Pub. 100-04 for more information on payment policy indicators and payment adjustment rules.  See Chapter 23 of Pub. 100- 04, section 50.6 for the record layout of the Payment Policy Indicator file.   Health Professional Shortage Area (HPSA) Incentive Payments for Physicians   Section 1833 (m) of the Social Security Act, provides incentive payments for physicians who furnish services in areas designated as HPSAs under section 332(a)(1)(A) of the Public Health Service (PHS) Act.  This statute recognizes geographic -based, primary medical care and mental health HPSAs, are areas for receiving a 10 percent bonus payment.  The Health Resources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas.