(Medicare Claims Processing Manual)

PC/TC Indicator  Bonus Payment Policy  0 Physician services. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components.   ACTION: Pay the bonus  1 Globally billed. Only the professional component of this service qualifies for the bonus payment.  The bonus cannot be paid on the technical component of globally billed services.   ACTION: Return the service as unprocessable and notify the CAH that the professional component must be re -billed if it is performed within a qualifying bonus area. If the technical component is the only component of the service that was performed in the bonus area, there wouldnt be a qualifying service.  1 Professional Component (modifier 26).   ACTION: Pay the bonus.  1 Technical Component (modifier TC).   ACTION: Do not pay the bonus.  2 Professional Component only.   ACTION: Pay the bonus.  3 Technical Component only.   ACTION: Do not pay the bonus.  4 Global test only. Only the professional component of this service qualifies for the bonus payment.  ACTION: Return the service as unprocessable. Instruct the provider to re-bill the service as separate professional and technical component procedure codes.  5 Incident to codes.   ACTION: Do not pay the bonus.  6 Laboratory physician interpretation codes.   ACTION: Pay the bonus  7 Physical therapy service.   ACTION: Do not pay the bonus.  8 Physician interpretation codes.   ACTION: Pay the bonus.  PC/TC Indicator  Bonus Payment Policy  9 Concept of PC/TC does not apply.   ACTION: Do not pay the bonus.   NOTE:  Codes that have a status of X on the CORF extract Medicare Physician Fee Schedule Database (MFSDB) have been assigned PC/TC indicator 9 and are not considered physician services for MFSDB payment purposes. Therefore, neither the HPSA bonus nor the physician bonus payment (5 percent) will be paid for these codes.   250.3 - Payment for Anesthesia in a Critical Access Hospital (CAH)  (Rev 41, 12- 08-03)  Payment for anesthesia services is based on the HCPCS FILE, the Anesthesia Conversion Factor File, and the CORF extract of the MPFS Summary File.   250.3.1 - Anesthesia File  (Rev. 41, 12- 08-03) Conversion Factor File = MU00.@BF12390.MPFS.CY04.ANES.V1023   Record Layout for the Anesthesia Conversion Factor File  Data Element Name  Picture  Location  Length A/B MAC (B) Number  X (5)  1-5 5 Locality Number  X (2)  13-14 2 Locality Name  X (30)  19-48 30 Anesthesia CF 2002  99V99 74-77 4  250.3.2 - Physician Rendering Anesthesia in a Hospital Outpatient Setting  (Rev. 2452, Issued: 04- 26-12, Effective: 01 -10-12, Implementation: 10 -01-12)  When a medically necessary anesthesia service is furnished within a HPSA area by a physician, a HPSA bonus is payable. In addition to using the PC/TC indicator on the CORF extract of the MPFS Summary File to identify HPSA services, pay physicians the HPSA bonus when CPT codes 00100 through 01999 are billed with the following modifiers: QY, QK, AA, or GC and QB or QU in revenue code 963. Modifier QB or QU must be submitted to receive payment of the HPSA bonus for claims with dates of service prior to Jan uary 01, 2006. Effective for claims with dates of service on or after January 01, 2006, the modifier AQ, physician providing a service in a health professional shortage area, may be required to receive the HPSA bonus. Refer to 250.2.2 of this chapter for more information on when modifier AQ is required.   The modifiers signify that a physician performed an anesthesia service.  Using the Anesthesia File (See Section above) the physician service will be 115 percent times the payment amount to be paid to a CAH on Method II payment plus 10 percent HPSA bonus payment.   Anesthesiology modifiers:   AA = anesthesia services performed personally by anesthesiologist.  GC =service performed, in part, by a resident under the direction of a teaching physician.  QK = medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.  QY = medical direction of one CRNA by an anesthesiologist.   Modifiers AA and GC result in physician payment at 100% of the allowed amount. Modifiers QK and QY result in physician payment at 50% of the allowed amount.   Data elements needed to calculate payment:    HCPCS plus Modifier,   Base Units,   Time units, based on standard 15 minute intervals,   Locality specific anesthesia Conversion factor, and   Allowed amount minus applicable deductions and coinsurance amount.   Formula 1: Calculate payment for a physician performing anesthesia alone   HCPCS = xxxxx  Modifier = AA  Base Units = 4  Anesthesia Time is 60 minutes. Anesthesia time units = 4 (60/15)  Sum of Base Units plus Time Units = 4 + 4 = 8  Locality specific Anesthesia conversion factor = $17.00 (varies by localities)  Coinsurance = 20%   Example 1:   Physician personally performs the anesthesia case   Base Units plus time units -  4+4=8  Total units multiplied by the anesthesia conversion factor times .80  8 x $17= ($136.00 -  (deductible*) x .80 = $108.80  Payment amount times 115 percent for the CAH method II payment.  $108.80 x 1.15 = $125.12 (Payment amount)  $125.12 x .10 = $12.51 (HPSA bonus payment)  *Assume the Part B deductible has already been met for the calendar year   Formula 2:  Calculate the payment for the physicians medical direction service when the physician directs two concurrent cases involving CRNAs. The medical direction allowance is 50% of the allowance for the anesthesia service personally performed by the physician.   HCPCS = xxxxx  Modifier = QK  Base Units = 4  Time Units 60/15=4  Sum of base units plus time units = 8  Locality specific anesthesia conversion factor = $17(varies by localities)  Coinsurance = 20 %   (Allowed amount adjusted for applicable deductions and coinsurance and to reflect payment percentage for medical direction).   Example 2:   Physician medically directs two concurrent cases involving CRNAs Base units plus time -  4+4=8  Total units multiplied by the anesthesia conversion factor times. 50 equal allowed amount minus any remaining deductible  8 x $17 = $136 x .50 = $68.00 - (deductible*) = $68.00  Allowed amount Times 80 percent times 1.15  $68.00 x .80 = $54.40 x 1.15 = 62.56 (Payment amount)  $62.56 x .10 = $6.26 (HPSA bonus payment)  *Assume the deductible has already been met for the calendar year.   NOTE:   For specific guidance on payment for Anesthesia and Teaching Services please review the following sections:   -   Payment for Anesthesiology Services Pub.100- 04, Chapter 12, Section 50   - Teaching Physician Services Pub.100- 04, Chapter 12, Section 100.1.2 (4) Anesthesia.   250.3.3 - Anesthesia and CRNA Services in a Critical Access Hospital (CAH)  (Rev. 616, Issued: 07- 22-05, Effective: 10 -01-02, Implementation: 01- 03-06)  250.3.3.1 - Payment for CRNA Pass -Through Services  (Rev.4295, Issued: 05- 03-19, Effective: 08 -27-19, Implementation: 08- 27-19)  CAHs are eligible to receive CRNA pass -through payments (pass -through exemption) for both inpatient and outpatient services if they meet criteria discussed at 42 CFR  412.113(c) of the regulations. CRNA pass -through payments and the Method II election for outpatient CAH services are applied as described below. Note that for CAHs that have a CRNA pass -through exemption, all CRNA services provided to CAH swing- bed patients must be included on the CAH swing- bed bill. (See MCPM, Ch. 3, 60 and 100.2 for more information)   If a CAH meets the criteria for a pass -through exemption and is interested in selecting Method II for its physicians and/or other practitioners, it can choose Method II for all outpatient professionals except the CRNA, and still retain the approved CRNA pa ss-through exemption for both inpatient and outpatient CRNA professional services.   Alternatively, a CAH, with an approved pass -through exemption, can choose to give up its pass -through exemption for both inpatient and outpatient CRNA professional services in order to include its CRNA outpatient professional services under Method II. By c hoosing to include the CRNA under Method II for outpatient services, the CAH loses its CRNA pass -through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case the CAH would have to bill the A/B MAC (B) for the CRNA inpatient professional services. All A/B MAC (A) payments for CRNA services are subject to cost settlement.   Provider Billing Requirements for CRNA Pass -Through   TOBs = 11X and 18X   Revenue Code 037X for CRNA technical services Revenue Code 0964 for Professional services  Reimbursement  Revenue Code 37X, CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)   Revenue Code 0964, CRNA professional service = Cost Reimbursement (100 percent of reasonable cost) for both inpatient (including swing- bed) and outpatient   Deductible and coinsurance apply.   Provider Billing Requirements for CRNA Pass -Through   TOB = 85X   Revenue Code 037X for CRNA technical services Revenue Code 0964 for Professional services  Anesthesia HCPCS codes and for any HCPCS codes for services the CRNA is legally authorized to perform in the state in which the services are furnished.   The appropriate HCPCS should be included when required for the applicable TOB and or revenue code.   Reimbursement  Revenue Code 37X, CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)   Revenue Code 0964, CRNA professional service = Cost Reimbursement (100 percent of reasonable cost) for both inpatient (including swing -bed) and outpatient   Deductible and coinsurance apply.    Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass - through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.                         .      250.3.3.2 - Payment for Anesthesia Services by a CRNA (Method II CAH only)  (Rev. 4157, Issued: 11- 02-18, Effective: 04 -01-19, Implementation: 04- 01-19)  Provider Billing Requirements for Method II CRNA -  Gave up Pass -Through Exemption (or never had exemption)   TOB = 85X   Revenue Code = 037X for CRNA technical service   Revenue Code = 0964 for CRNA professional service   HCPCS Code for services the CRNA is legally authorized to perform in the state in which the services are furnished   Reimbursement -  For dates of service on or after July 1, 2007  Revenue Code 037X for CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)   Revenue Code 0964 for CRNA professional service = Based on 100 percent of the allowed amount when not medically directed or 50 percent of the allowed amount when medically directed.   Providers bill a QZ modifier for non- medically directed CRNA services. Deductible and coinsurance apply.   How to calculate payment for anesthesia claims based on the formula -  For dates of service on or after July 1, 2007  Identify anesthesia claims by HCPCS code range from 00100 through 01999 Non-medically directed CRNA   (Sum of base units plus time (anesthesia time divided by 15)) times conversion factor minus (deductible and coinsurance) times 1.15  Medically directed CRNA   (Sum of base units plus time (anesthesia time divided by 15)) times conversion factor times medically directed reduction (50 %) minus (deductible and coinsurance) times 1.15   Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass -through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.  Reimbursement -  For dates of service prior to July 1, 2007