(Medicare Claims Processing Manual)

* In the case of Revenue Code 0964, this is used by hospitals that have a CRNA exception.   * In the case of Revenue Code 0942, this is used by rural hospitals for kidney disease education (KDE) services.  The actual geographic location, core based statisti cal area (CBSA) is used to identify facilities located in rural areas. In addition, KDE services are covered when claims are received from section 401 hospitals.  Additionally, models may allow this Revenue Code.  The contractor shall use the following rem ittance 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: 96  RARC: M28  MSN: 21.21   Hospitals are required to report HCPCS codes that identify the services rendered.   240.3 - Implantable Prosthetic Devices  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)  Under 42 CFR 419.2(b)(11), implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of these devices, are paid under the OPPS, and are therefore packaged with the surgical  implantation procedure unless the device has pass -through payment status.  This payment provision applies when such a device is billed as a Part B outpatient service, or as a Part B inpatient service when the inpatient admission is determined not reasonable and necessary and the b eneficiary should have been treated as a hospital outpatient (see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 6, 10.1).  In these circumstances, hospitals should submit the usual HCPCS code for Part B payment of the device.   In the other circumst ances in which a beneficiary does not have Part A coverage of inpatient services on the date that such a device is implanted (that is, when furnished by a participating hospital to an inpatient who is not entitled to benefits under Part A, has exhausted hi s or her Part A benefits, or receives services not covered under Part A), hospitals paid under the OPPS should report HCPCS code, C9899, Implanted Prosthetic Device, Payable Only for Inpatients who do not Have Inpatient Coverage, that is effective for serv ices furnished on or after January 1, 2009.  This code allows an alternative Part B inpatient payment methodology for the device as discussed in this section, and may be reported only on claims with TOB 12X when the prosthetic device is implanted on a day on which the beneficiary does not have coverage under Part A because he or she is not entitled to Part A benefits, has exhausted his or her Part A benefits, or receives services not covered under Part A.  The line containing this new code will be rejected if it is reported on a claim that is not a TOB 12X or if it is reported with a line item date of service on which the beneficiary has coverage of inpatient hospital services.  By reporting C9899, the hospital is reporting that the item is eligible  for sepa rate OPPS payment because the primary procedure is not a payable Part B inpatient service under Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10.2 (Other Circumstances in Which Payment Cannot Be Made under Part A).   If C9899 is a separately pa yable Part B inpatient service, the contractor shall determine the payment amount as follows.  If the device has pass through status under the OPPS, the contractor shall establish the payment amount for the device at the product of the charge for the device and the hospital specific cost to charge ratio.  Where the device does not have pass through status under the OPPS, the contractor shall establish the payment amount for the device at the amount for a comparable device in the DMEPOS fee schedule where th ere is such an amount.  Payment under the DMEPOS fee schedule is made at the lesser of charges or the fee schedule amount and therefore if there is a fee for the specific item on the DMEPOS fee schedule, the payment amount for the item will be set at the l esser of the actual charges or the DMEPOS fee schedule amount.  Where the item does not have pass through payment status and where there is no amount for a comparable device in the DMEPOS fee schedule, the contractor shall establish a payment amount that i s specific to the particular implanted prosthetic device for the applicable calendar year.  This amount (less applicable unpaid deductible and coinsurance) will be paid for that specific device for services furnished in the applicable calendar year unless the actual charge for the item is less than the established amount). Where the actual charge is less than the established amount, the contractor will pay the actual charge for the item (less applicable unpaid deductible and coinsurance).   In setting a cont ractor established payment rate for the specific device, the contractor takes into account the cost information available at the time the payment rate is established.  This information may include, but is not limited to, the amount of device cost that woul d be removed from an applicable APC payment for implantation of the device if the provider received a device without cost or a full credit for the cost of the device.   If the contractor chooses to use this amount, see www.cms.hhs.gov/HospitalOutpatientPPS/  for the amount of reduction to the APC payment that would apply in these cases.  From the OPPS webpage, select Device, Radiolabeled Product, and Procedure Edits from the list on the left side of the page.  Open the file Procedure to Device edits to determine the HCPCS code that best describes the procedure in which the device would be used.  Then identify the APC to which that procedure code maps from the most recent Addenda B on the OPPS webpage and open the file FB/FC Modifier Procedures and Devices .  Select the applicable years file of APCs subject to full and partial credit reductions (for example: CY 2008 APCs Subject to Full and Partial Credit Reduction Policy).  Select the Full offset reduction amount that pertains to the APC that is most a pplicable to the device described by C9899.  It would be reasonable to set this amount as payment for the device.  For example, if C9899 is reporting insertion of a single chamber pacemaker (C1786 or equivalent narrative description on the claim in remarks) the file of procedure to device edits shows that a single chamber pacemaker is the dominant device for APC 0090 (APC  0089 is for insertion of both pacemaker and electrodes and therefore would not apply if electrodes are not also billed).  The table of offset reduction amounts for CY 2008 shows that the estimated cost of a single chamber pacemaker for APC 0090 is $4881.77.  It would therefore be reasonable for the contractor/MAC to set the payment rate for a single chamber pacemaker to $4881.77. I n this case the coinsurance would be $936.75 (20 percent of $4881.77, which is less than the inpatient deductible).   The beneficiary coinsurance is 20 percent of the payment amount for the device (i.e. the pass through payment amount, the DMEPOS fee schedule amount, the contractor established amount, or the actual charge if less than the DMEPOS fee schedule amount or the contractor established amount for the specific device), not to exceed the Medicare inpatient deductible that is applicable to the year in which the implanted prosthetic device is furnished.  When a hospital that is not paid under the OPPS furnishes an implantable prosthetic device other than dental), which replaces all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such a device, to an inpatient who has coverage under Part B but does not have Part A coverage, and the primary procedure is not a payable Part B inpatient service under Pub. 100-02, Medicare Be nefit Policy Manual, chapter 6, 10.2 (Other Circumstances in Which Payment Cannot Be Made under Part A), payment for the implantable prosthetic device is made under the payment mechanism that applies to other hospital outpatient services (e.g., reasonab le cost, all inclusive rate, waiver).   240.4 - Indian Health Service/Tribal Hospital Inpatient Social Admissions  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)  There may be situations when an American Indian/Alaskan Native (A I/AN) beneficiary is admitted to an IHS/Tribal facility for social reasons. These social admissions are for patient and family convenience and are not billable to Medicare.  There are also occasions where IHS/Tribal hospitals elect to admit patients prior to a scheduled day of surgery, or place a patient in a room after an inpatient discharge. These services are also considered to be social admissions as well.  For patients in a social admission status requiring outpatient services at another facility, Medi care disallows payment for inpatient Part B ancillary services, Type of Bill (TOB) 12X during a social admission stay when there is another bill from a different facility for an outpatient service, TOB 13X or 72X. The Common Working File (CWF) returns an A/B crossover edit and creates an unsolicited response (IUR) in this situation.  The CWF also creates an IUR when a line item date of service on TOB 12X is equal to or one day following the discharge date on TOB 11X for the same provider.   The CWF bypasses both of these edits when the beneficiary is not entitled to Medicare Part A at the time the services on TOB 12X are rendered.    240.5 - Payment of Part B Services in the Payment Window for Outpatient Services Treated as Inpatient Services When Payment Canno t Be Made Under Part A  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals) an d Pub 100- 04, Medicare Claims Processing Manual, Chapter 4,  10.12 (Payment Window for Outpatient Services Treated as Inpatient Services) regarding  services bundled into the original Part A claim under the 3 -day (1 -day for non -IPPS hospitals) payment window prior to the inpatient admission, that may be billed to Part B when Part A payment cannot be made.  Hospitals should use the following type of bi ll to report these services:    13X TOB (85X for a CAH) - Hospital outpatient services included in the payment window for outpatient services treated as inpatient services    14X TOB - Laboratory tests that are paid under the clinical laboratory fee schedule (see chapter 16, 40.3 of this manual), and included in the payment window for outpatient services treated as inpatient services   240.6 - Submitting Provider -Liable No- Pay Part A Claims  and Beneficiary Liability  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)  When Part A payment cannot be made for a hospital inpatient admission and the hospital, not the beneficiary, is liable under section 1879 of the Act for the cost of the Part A items and services, the hospital must submit a provider -liable no pay Part A claim (110 TOB) (see chapter 3 40.2.2,  Charges to Beneficiaries for Part A Services of this manual) .  Submission of this claim cancels  any claim that may have already been submitted by the hospital for payment under Part A.  When a Medicare review contractor denies a Part A claim for medical necessity, the claims system converts the originally submitted 11X claim to a 110 TOB on behalf of the hospital.   When the hospital and not the beneficiary is liable for the cost of the Part A services (pursuant to the limitation on liability provision in Section 1879 of the Social Security Act), the beneficiary is not responsible for paying the deduc tible and coinsurance charges related to the denied Part A claim and the beneficiarys Medicare utilization record is not charged for the services and items furnished.  The hospital must refund any payments (including coinsurance and deductible) made by the beneficiary or third party for a denied Part A claim when the provider is held financially liable for that denial (see section 1879(b) of the Act; 42 CFR  411.402; and chapter 30  30.1.2, Beneficiary Determined to Be Without Liability and 30.2.2, P rovider/Practitioner/Supplier is Determined to Be Liable of this manual).    Medicare beneficiaries are liable for their usual Part B financial liability for services covered under Part B when Part A payment cannot be made, including Part B copayments for e ach payable Part B inpatient or Part B outpatient service.  The beneficiary is also liable for the cost of services not covered under Part B.