(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 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: 96  RARC: M28  MSN: 21.21   Hospitals are required to report HCPCS codes that identify the services rendered. Allowed Revenue Codes  0240  0274  0275  0276  0278  030x  031x  032x  0333  034x  035x,  040x,  042x  043x  044x  046x  0471  0482  0483  054x  061x  0623  073x  074x  0771  078x*  080x  086x  092x  0942*  0964*    *Billed prior to admission or on the day of discharge.  * 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.   Additional Allowed services that are be identified by HCPCS, not identified by Revenue Codes  Other Diagnostic services: (A MAC maintained)  Preventive services:  COVID -19, Influenza, pneumococcal pneumonia, and hepatitis B vaccines  Colorectal screening  Screening glaucoma services  Bone mass measurements  Prostate screening  Covered drugs:  Hemophilia clotting factors  Immunosuppressive drugs  Oral anti- cancer drugs  Oral anti- emetic  Non -ESRD Epoetin Alfa (EPO)   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 ser vice when the inpatient admission is determined not reasonable and necessary and the beneficiary 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 circumstances 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 Par t A, has exhausted his 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 services 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 i s 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 separate 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 payable 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 D MEPOS fee schedule where there 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 lesser 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 establ ish a payment amount that is 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 appli cable 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 coins urance).   In setting a contractor 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 would 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 applicable 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. In 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 replac ement 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 Benefit Policy Manual, chapter 6, 10.2 (Other Circums tances 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., reasonable 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 (AI/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, Medicare 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 differe nt 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 Cannot 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) and 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 bill 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)