(Medicare Claims Processing Manual)

Co-surgeon services rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized for co -surgeons and is billed on type of bill 85X with revenue code (RC) 96X, 97X or 98X and the 62 modifier.   Under authority of 42 CFR 414.40, CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. This includes the use of payment modifiers for co -surgeon services.  250.10.1 - Use of Payment Policy Indicators for Determining Procedures Eligible for Payment of Co -surgeons  (Rev. 1781, Issued: 07- 29-09; Effective:  01 -01-08; Implementation:  07 -06-09)  Section 1862 of the Social Security Act (the Act) stipulates that no payment can be made for care that is not reasonable and necessary for the diagnosis and treatment of illness or injury.  Medicare uses the payment policy indicators on the Medicare Physician Fee Schedule Database (MPFSDB) to determine if co -surgeon services are reasonable and necessary for a specific HCPCS/CPT code. The MPFSDB is located at http://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/PFSlookup/ .  The A/B MACs (A) have access to the payment policy indicators via the Physician Fee Schedule Payment Policy Indicator File in the FISS.   See the Physician Fee Schedule Payment Policy Record Layout in 250.2 for a description of the co -surgeon payment policy indicators.   250.10.2 - Payment of Co -surgeon Services Rendered in a Method II CAH  (Rev. 1781, Issued: 07- 29-09; Effective:  01 -01-08; Implementation:  07 -06-09)  Under Section 1834(g)(2)(B) of the Act outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient CAH services.   Payment for co -surgeon services performed by a physician is based on the lesser of the actual charges or the reduced fee schedule amount (62.5%) and is calculated as follows:  ((facility specific MPFS amount times co -surgery reduction % (62.5%)) minus (deductible and coinsurance)) times 115%.   250.10.3 - Co-surgeon Services Medicare Summary Notice (MSN) and Remittance Advice (RA) Messages  (Rev. 3475, Issued: 03- 04-16, Effective: 06 -06-16, Implementation: 06- 06-16)  Contractors shall deny co -surgeon services for HCPCS/CPT codes with a payment policy indicator of 0.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 15.12  Contractors shall deny medically unnecessary co- surgeon services for HCPCS/CPT codes with a payment policy indicator of 1 when an Advance Beneficiary Notice (ABN) was issued.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR  CARC: 54  RARC: N/A  MSN: 36.1  Contractors shall deny medically unnecessary co- surgeon services for HCPCS/CPT codes with a payment policy indicator of 1 when an Advance Beneficiary Notice (ABN) was not issued.  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 36.2  Contractors shall deny co -surgeon services for HCPCS/CPT codes with a payment policy indicator of 2 when the co- surgeons each have the same specialty.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 54  RARC: N/A  MSN: 21.21  Contractors shall deny line items for co- surgeon services without the 62 modifier on claims with the same surgical procedure code and line item date of service on more than one line when only one line has the 62 modifier.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.  Group Code: CO  CARC: 4  RARC: N/A  MSN: 16.10  250.10.4 - Review of Supporting Documentation for Co-surgeon Services in a Method II CAH  (Rev. 1781, Issued: 07- 29-09; Effective:  01 -01-08; Implementation:  07 -06-09)  Given the absence of national policy on this provision, A/B MACs (A) have the authority to establish procedures to define the appropriate supporting documentation needed to establish medical necessity.  The A/B MACs (A) shall also determine if a clinician or non-clinician medical reviewer shall review co -surgeon services.  250.11 - Coding Bilateral Procedures Performed in a Method II CAH  (Rev. 1777; Issued:  07- 24-09; Effective Date:  01 -01-08; Implementation Date:  01-04-10)  Under authority of 42 CFR 414.40, CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. This includes the use of payment modifiers for bilateral procedures.  Bilateral procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is authorized as a bilateral procedure and is billed on type of bill 85X with revenue code (RC) 96X, 97X or 98X and the 50 modifier (bilateral procedure).   Modifier 50 applies to a bilateral procedure performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral, the 50 modifier is not reported.   If a procedure is authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 1), the procedure shall be reported on a single line item with the 50 modifier and one service unit.  Modifiers LT (left side) and RT (ri ght side) shall not be reported when the 50 modifier applies. See 20.6 in this chapter for more information on the use of the 50, LT and RT modifiers. See the Physician Fee Schedule Payment Policy Record Layout in 250.2 for a description of the bilateral  procedure payment policy indicators.  If a procedure can be billed as bilateral, but is not authorized for the 150 percent bilateral adjustment (payment policy indicator 3), the procedure shall be reported on a single line item with the 50 modifier and one service unit.   250.11.1 - Use of Payment Policy Indicators for Determining Bilateral Procedures Eligible for 150 Percent Payment Adjustment  (Rev. 1777; Issued:  07- 24-09; Effective Date:  01 -01-08; Implementation Date:  01-04-10)  Medicare uses the payment policy indicators on the Medicare Physician Fee Schedule Database (MPFSDB) to determine if a bilateral procedure is authorized for a specific HCPCS/CPT code. The MPFSDB is located at http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/PhysicianFeeSched/index.html .  The A/B MACs (A) have access to the payment policy indicators via the Physician Fee Schedule Payment Policy Indicator File in the FISS.   See the Physician Fee Schedule Payment Policy Record Layout in 250.2 for a description of the bilateral procedure payment policy indicators.   250.11.2 - Payment of Bilateral Procedures Rendered in a Method II CAH  (Rev. 1777; Issued:  07- 24-09; Effective Date:  01 -01-08; Implementation Date:  01-04-10)  Under Section 1834(g)(2)(B) of the Act, outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient CAH services.   Payment for bilateral procedures with a payment policy indicator of 1 and the 50 modifier is based on the lesser of the actual charges or the 150 percent payment adjustment for bilateral procedures and is calculated as follows:    (facility specific MPFS amount times payment adjustment for bilateral procedures (150%) minus (deductible and coinsurance)) times 115%   Payment for bilateral procedures with the 50 modifier and a payment policy indicator of 3 is based on the lesser of the actual charges or 100% of the MPFS for each  side of the body (200%) and is calculated as follows:   (facility specific MPFS amount times 200% minus (deductible and coinsurance)) times 115%   250.12 - Primary Care Incentive Payment Program (PCIP) Payments to Critical Access Hospitals (CAHs) Paid Under the Optional Method  (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  Section 5501(a) of the Affordable Care Act revises section 1833 of the Social Security Act by adding a new paragraph, (x), Incentive Payments for Primary Care Services.  Section 1833(x) of the Act states that in the case of primary care services furnished on or after January  1, 2011, and before January 1, 2016, there shall be a 10 percent incentive payment for such services under Part B when furnished by a prim ary care practitioner.   250.12.1 - Definition of Primary Care Practitioners and Primary Care Services  (Rev. 2169, Issued: 03- 03-11, Effective: 04 -01-11, Implementation: 04- 04-11)  Primary care practitioners are defined as:   (1) A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital i npatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary; or   (2) A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary.   Primary care services are defined as CPT Codes:   (1) 99201 through 99215 for new and established patient office or outpatient evaluation and management (E/M) visits;   (2) 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home or custodial care E/M services; and domiciliary, rest home or home care plan oversight services; and   (3) 99341 through 99350 for new and established patient home E/M visits.   250.12.2 - Identifying Primary Care Services Eligible for the PCIP  (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)  CAHs paid under the optional method billing on TOB 85X for professional primary care services (revenue code 96X, 97X or 98X) furnished by primary care physicians and nonphysician practitioners who have reassigned their billing rights to the CAH are eligible for PCIP payments.   The National Provider Identifier (NPIs) of  primary care practitioners eligible for PCIP payment in a given calendar year (CY) are posted on Medicare contractor Web sites in the Primary Care Incentive Payment Program Eligibility File by January 31 of  the applicable incentive payment CY.   Eligible practitioners for PCIP payment in a given calendar year who were newly enrolled in Medicare in the year immediately preceding the PCIP payment year will be identified later in the payment year and posted on their  Medicare contractors Web site at that point in time.  CAHs paid under the optional method should contact their contractor with any questions regarding the eligibility of physician and nonphysician practitioners for PCIP payments.  Primary care practitioners furnishing primary care services will be identified on CAH claims by the NPI of the rendering practitioner as follows:    Line level Rendering Provider field when populated or,