(Medicare Claims Processing Manual)

Ambulance services which are subject to the ambulance fee schedule.   150 - Hospitals That Do Not Provide Outpatient Services  (Rev. 1, 10- 03-03) HO- 440.1, A -00-21, A -02-064  Covered Part B -only services furnished to inpatients when they are furnished by a hospital that does no Medicare billing for hospital outpatients services under Part B are excluded from OPPS.  The Part B -only services, which are payable for hospital inpati ents who have either exhausted their Part A benefits or who are not entitled to Part A benefits, are specified in Chapter 3.  These services include, but are not limited to, diagnostic tests; x-ray and radioactive isotope therapy; surgical dressings; limb braces and trusses; and artificial limbs and eyes.  Medicare payment for excluded Part B -only services furnished by these hospitals is determined using the method under which the hospital was paid prior to OPPS.    Hospitals must notify their A/B MAC (A) if they do not submit claims for outpatient Part B services, so that their claims can be excluded from the OPPS.  The hospital must also notify the A/B MAC (A) if it begins to furnish Part B outpatient services.  OPPS will apply at that time unless other excl usions are applicable.   160 - Clinic and Emergency Visits (Rev. 1445, Issued:  02- 08-08; Effective:  01- 01-08; Implementation:  03 -10-08)  CMS has acknowledged from the beginning of the OPPS that CMS believes that CPT Evaluation and Management (E/M) codes were designed to reflect the activities of physicians and do not describe well the range and mix of services provided by hospitals during visits of clinic and emergency department patients.  While awaiting the development of a national set of facility -specific codes and guidelines, providers should continue to apply their current internal guidelines to the existing CPT codes.  Each hospitals internal guidelines should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.  Hospitals should ensure that their guidelines accurately reflect resource distinctions between the five levels of codes.   Effective Januar y 1, 2007, CMS is distinguishing between two types of emergency departments: Type A emergency departments and Type B emergency departments.   A Type A emergency department is defined as  an emergency department that is available 24 hours a day, 7 days a week and is either licensed by the State in which it is located under applicable State law as an emergency room or emergency department or it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emerg ency medical conditions on an urgent basis without requiring a previously scheduled appointment.  A Type B emergency department is defined as an emergency department that meets the definition of a dedicated emergency department as defined in 42 CFR 489.24 under the EMTALA regulations.  It must meet at least one of the following requirements:    (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;    (2) It is held out to the public ( by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or    (3) During the calendar year immediately preceding the calendar  year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one -third of all of its outpatient visits for the  treatment of emergency medi cal conditions on an urgent basis without requiring a previously scheduled appointment.   Hospitals must bill for visits provided in Type A emergency departments using CPT emergency department E/M codes.  Hospitals must bill for visits provided in Type B emergency departments using the G -codes that describe visits provided in Type B emergency departments.   Hospitals that will be billing the new Type B ED visit codes may need to update their internal guidelines to report these codes.   Emergency department and  clinic visits are paid in some cases separately and in other cases as part of a composite APC payment.  See section 10.2.1 of this chapter for further details.   160.1 - Critical Care Services  (Rev. 2141, Issued: 01- 24-11, Effective: 01- 01-11, Implementation: 01 -03-11)  Hospitals should separately report all HCPCS codes in accordance with correct coding principles, CPT code descriptions, and any additional CMS guidance, when available.  Specifically with respect to CPT code 99291 (Critical care,  evaluation and management of the critically ill or critically injured patient; first 30 -74 minutes), hospitals must follow the CPT instructions related to reporting that CPT code.  Prior to January 1, 2011, any services that CPT indicates are included in the reporting of CPT code 99291 (including those services that would otherwise be reported by and paid to hospitals using any of the CPT codes specified by CPT) should not be billed separately by the hospital.  Instead, hospitals should report charges for any services provided as part of the critical care services. In establishing payment rates for critical care services, and other services, CMS packages the costs of certain items and services separately reported by HCPCS codes into payment for critical car e services and other services, according to the standard OPPS methodology for packaging costs.   Beginning January 1, 2011, in accordance with revised CPT guidance, hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care.  CMS will continue to recognize the existing CPT codes for critical care services and will establish payment rates based on historical data, into which the cost of the ancillary services is intrinsically packaged.  The I/OCE conditionally packages payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment.  The paym ent status of the ancillary services does not change when they are not provided in conjunction with critical care services.  Hospitals may use HCPCS modifier - 59 to indicate when an ancillary procedure or service is distinct or independent from critical ca re when performed on the same day but in a different encounter.    Beginning January 1, 2007, critical care services will be paid at two levels, depending on the presence or absence of trauma activation.  Providers will receive one payment rate for critical care without trauma activation and will receive additional payment when critical care is associated with trauma activation.   To determine whether trauma activation occurs, follow the National Uniform Billing Committee (NUBC) guidelines in the Claims Proces sing Manual, Pub 100- 04, Chapter 25, 75.4 related to the reporting of the trauma revenue codes in the 68x series.  The revenue code series 68x can be used only by trauma centers/hospitals as licensed or designated by the state or local government authorit y authorized to do so, or as verified by the American College of Surgeons.  Different subcategory revenue codes are reported by designated Level 1 -4 hospital trauma centers. Only patients for whom there has been prehospital notification based on triage inf ormation from prehospital caregivers, who meet either local, state or American College of Surgeons field triage criteria, or are delivered by inter -hospital transfers, and are given the appropriate team response can be billed a trauma activation charge.   When critical care services are provided without trauma activation, the hospital may bill CPT code 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30 -74 minutes (and 99292, if appropriate).  If trauma activation occurs under the circumstances described by the NUBC guidelines that would permit reporting a charge under 68x, the hospital may also bill one unit of code G0390, which describes trauma activation associated with hospital critical care services.  Revenue code 68x must be reported on the same date of service.  The OCE will edit to ensure that G0390 appears with revenue code 68x on the same date of service and that only one unit of G0390 is billed.  CMS believes that trauma activation is a one -time occurrence in association with critical care services, and therefore, CMS will only pay for one unit of G0390 per day.   The CPT code 99291 is defined by CPT as the first 30- 74 minutes of critical care.  This 30 minute minimum has always applied under t he OPPS.  The CPT code 99292, Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes, remains a packaged service under the OPPS, so that hospitals do not have the ongoing administrative burden of reporting precisely the time for each critical service provided.  As the CPT guidelines indicate, hospitals that provide less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines.  Under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face- to-face critical care of a critically ill or critically injured patient.  If the physician and hospital staff or multiple hospital staff members are simultaneously engaged in this active face- to-face care, the time involved can only be counted once.   Beginning in CY 2007 hospitals may continue to report a charge with RC 68x without any  HCPCS code when trauma team activation occurs.  In order to  receive additional payment when critical care services are associated with trauma activation, the hospital must report G0390 on the same date of service as RC 68x, in addition to CPT code 99291 ( or 99292, if appropriate.)    Beginning in CY 2007 hospitals should continue to report 99291 (and 99292 as appropriate) for critical care services furnished without trauma team activation.  CPT 99291 maps to APC 0617 (Critical Care).  (CPT 99292 is packaged and not paid separately, but should be reported if provided.)   Critical care services are paid in some cases separately and in other cases as part of a composite APC payment.  See Section 10.2.1 of this chapter for further details.  Future updates will be issued in a Recurring Update Notification.   170 - Hospital and CMHC Reporting Requirements for Services Performed on the Same Day  (Rev. 763, Issued: 11- 25-05, Effective/Implementation Dates:  N/A)   When reporting a HCPCS code for a separately payable, non- repetitive hospital OPPS service, report charges for all services and supplies associated with that service, that were furnished on the same date (services subject to the 3- day payment window are an exception to this OPPS policy).   When a hospital provides electroconvulsive therapy (ECT) on the same day as partial hospitalization services, both the ECT and partial hospitalization services should be reported on the same hospital claim.  In this instance, the claim should contain condition code 41.  As noted above, report charges for all services and supplies associated with the ECT service, which were furnished on the same date(s) on the same claim.   NOTE:   For a list of revenue codes that are considered repetitive services, see Chapter 1, 50.2.2.  EXAMPLE 1   If a patient receives a laboratory service on May 1st and has an emergency room (ER) visit on the same day, one bill may be submitted since the laboratory service is paid under the clinical diagnostic laboratory fee schedule and not subject to O PPS.  In this situation, the laboratory service was not related to the ER visit or done in conjunction with the ER visit.   EXAMPLE 2   If the patient receives physical therapy on July 7th, 29th, and 30th, and receives services in the ER on July 28th, the pr ovider shall submit separate claims since the isolated individual service (ER visit) did not occur on the same day as the repetitive service (physical therapy).    EXAMPLE 3   If a patient has an ER visit (OPPS service) on May 15th and also receives a physica l therapy visit (repetitive, non -OPPS service) on the same day (as well as other physical therapy visits provided May 1st through May 31st) the services shall be billed on separate claims.  The provider would bill the ER service on one claim and the therap y services on the monthly repetitive claim.  Please note, as stated above, the procedures for billing repetitive services remains in effect under OPPS.  Therefore, in this example, it would not be appropriate to submit one therapy claim for services provid ed May 1st through May 15th, a second claim for the ER visit provided on May 15th, and a third claim for therapy visits provided on May 16th through May 31st.  Providers shall not split repetitive services in mid -month when another outpatient service occur s.  EXAMPLE 4