(Medicare Claims Processing Manual)

 If a procedure is performed bilaterally and the HCPCS code descriptor does not state that it is a unilateral or bilateral procedure, report bilateral surgical procedures on a single claim line with modifier 50 and one (1) unit of service. For specific inst ructions for Ambulatory Surgical Centers, refer to Chapter 14, Section 40.5 of the "Medicare Claims Processing Manual" on the CMS website at: Regulations -and-Guidance.Ch14  When modifier - 50 is required by manual or coding instructions, claims submitted with 2 lines or 2 units and anatomic modifiers will be denied for incorrect coding. MACs may reopen or allow resubmission of those claims in accordance with their policies and with the policy in Chapter 34, Section 10.1, of the "Medicare Claims Processing Manual" on the CMS website at: Regulations -and-Guidance.Ch34    Clerical errors (which include minor errors and omissions) may be treated as reopenings.    Providers or suppliers may change and resubmit their own claims where possible but during reopening MACs may, when necessary, correct the claim to modifier - 50 from an equivalent 2 units of bilateral anatomic modifiers. The original submitted version of the claim is retained in the Medicare IDR (Integrated Data Repository).    Providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1- F9, TA, T1-T9, E1 -E4) and report procedures with differing modifiers on individual claim lines when appropriate. Many MUEs are based on the assumption that correct modifiers are used.   A/B MACs shall include with the review determination the more detailed explanation of the correct coding initiative edit, which can be found in the standard correspondence language for A/B MACs in the Correspondence Language Manual for Medicare Services .   MACs shall  assign MSN 15.6. CARC 151 with Group Code CO  for claims that fail the MUE edits, when the UOS on the claim exceeds the MUE value, and deny the entire claim line(s) for the relevant Healthcare Common Procedure Coding System  (HCPCS) code.    MACs shall assign CARC 236 with Group Code CO and MSN 16.8 for claims that fail the PTP edits, and deny when this procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the NCCI program or workers compensation state regulations/ fee schedule requirements.   20.9.4 Reserved for future use  (Rev. 4465; Issued: 11- 15-19, Effective: 01 -30-19, Implementation: 01- 30-19)  20.9.4.1 Reserved for future use  (Rev. 4465; Issued: 11- 15-19, Effective: 01 -30-19, Implementation: 01- 30-19)  20.9.5 - Adjustments  (Rev. 1, 10- 01-03)  A/B MACs (B) adjust for underpayment if the wrong, lower paying code is paid on the first of multiple claims submitted.  If the wrong, higher paying code is paid on the first of multiple claims submitted, A/B MACs (B) pay the subsequent claim(s) and initiate recovery action on the previously paid claim(s).   20.9.6 - Correct Coding Edit (CCE) File Record Format  (Rev. 10233; Issued: 07- 24-20, Effective: 06 -16-20, Implementation: 06- 16-20)  The following record layout for the Correct Coding Edit (CCE) File is available to the Shared Systems, A/B MACs (B), and the Regional Offices via Network Data Mover and CMS Data Center.   A/B MAC (B)/Shared Systems Record Format   Field  Type  Record Position  Length  Comprehensive Column 1 Code or  Mutually Exclusive Column 1 Code  Character  1 5 Component Column 2 Code or  Mutually Exclusive Column 2 Code  Character  6 5 Prior Rebundled Code Indicator  * rebundled prior to 1996 edits   rebundled 1/1/1996 or later  Character  11 1 Correspondence Language Reference  Character  12 12 Effective Date (4 position year followed by Julian day)  Numeric  24 7 Deletion Date (4 position year followed by Julian day)  Numeric  31 7 Modifier Indicators  0 No CCE modifier allowed  1 CCE modifier acceptable  9 Use of CCE modifier not specified  Numeric  38 1 Savings Type Indicator Edit  1 CCE  2 Mutually Exclusive  Character  39 1  20.9.7 - National  Correct Coding Initiative (NCCI) Edits Quarterly Updates  (Rev.  10878, Issued: 07- 15-2021, Effective:08 -16-2021; Implementation:08- 16-2021)           Medicare Administrative Contractors (MACs) receive quarterly updates to National Correct Coding Initiative (NCCI) edits, indicating the version and the effective date, through a recurring update notification. At this time, the official method for providers or suppliers to receive the National Correct Coding Initiative (NCCI) edits is through the CMS website.   30 - Services Paid Under the Medicare Physicians Fee Schedule  (Rev. 1717, Issued: 04- 24-09, Effective: 07 -01-09, Implementation: 07- 06-09)  Following is a general description of services paid under the Medicare Physicians Fee Schedule (MPFS).   A. Physicians Services   Effective with services furnished on or after January 1, 1992, A/B MACs (B) pay for physicians services based on the MPFS.  The Medicare allowed charge for such physicians services is the lower of the actual charge or the fee schedule amount.  The Medicare payment is 80 percent of the allowed charge after the deductible is met for most services paid based on the fee schedule.  Exceptions to the rule, e.g., services for which deductible is not applicable, are specifically identified for the service where t he exception applies.   The Physicians Fee Schedule is used when paying for the following physicians services.    Professional services (including attending physicians services furnished in teaching settings) of doctors of medicine and osteopathy (including osteopathic practitioners), doctors of optometry, doctors of podiatry, doctors of dental surgery and dental med icine, and chiropractors;    Services covered incident to physicians services other than certain drugs covered as incident to services;    Physical and occupational therapy, and speech- language pathology services furnished by physical therapists, occupational therapists, and speech -language pathologists in private practices;    Diagnostic tests other than clinical laboratory tests.  See chapter 16 for payment for clinical diagnostic laboratory tests;   Radiology services; and    Monthly capitation payment (MCP) for physicians services associated with the continuing medical management of end stage renal disease (ESRD) services.   The fee schedule is not used to pay for direct medical and surgical services of teaching physicians in hospitals that have elected cost payment under 1861(b)(7)  of the Act.   When processing a claim, A/B MACs (B) continue to determine if a service is reasonable and necessary to treat illness or injury.  If a service is not reasonable and necessary to treat illness or injury for any reason (including lack of safety and efficacy because it is an experimental procedure, etc.), A/B MACs (B) consider the service noncovered notwithstanding the presence of a payment amount for the service in the Medicare fee schedule.  The presence of a payment amount in the MPFS and the Medicare physi cian fee schedule database (MPFSDB) does not imply that CMS has determined that the service may be covered by Medicare.  The nature of the status indicator in the database does not control coverage except where the status is N for noncovered.   A/B MACs (B) pay the above -mentioned physician services according to the physician fee schedule when billed by the following entities:    A physician or physician group including optometrists, dentists, oral and maxillofacial surgeons, podiatrists, and chiropractors;    A privately practicing physical therapist, (for outpatient physical therapy services);    A privately practicing speech -language pathologist (for outpatient speech- language services);    A privately practicing occupational therapist (for outpatient occupational therapy services);    A nonphysician practitioner including a nurse practitioner, a physician assistant, and a clinical nurse specialist beginning January 1, 1998, with respect to services these practitioners are authorized to furnish under state law: payment is equal to 85 percent of the participating physician fee schedule amount for the same service;    A nurse midwife:  payment is equal to 65 percent of the participating physician fee schedule amount for the same service;    A registered dietitian  or nutrition professional, for medical nutrition therapy services provided as of January 1, 2002: payment is equal to 85 percent of the participating physician fee schedule amount for the same service ;   An audiologist, for services rendered to beneficiaries not in a skilled nursing facility (SNF) Part A covered stay;    A clinical psychologist who renders services in community mental health centers (CMHCs) on or after July 1, 1988, and in all settings on or after July 1, 1990;    A clinical social worker: The fee schedule for CSW services is set at 75 percent of the fee schedule for comparable services furnished by clinical psychologists;    Another entity that furnishes outpatient physical therapy, occupational therapy, and speech - language pathology services.  This could be a rehabilitation agency, a public health agency, a clinic, a skilled nursing facility, a home health agency (for benefi ciaries who are not eligible for home health benefits because they are not home bound beneficiaries entitled to home health benefits), hospitals (when such services are provided to an outpatient or to a hospital inpatient who is entitled to benefits under Part A but who has exhausted benefits during a spell of illness, or who is not entitled to Part A benefits) and comprehensive outpatient rehabilitation facilities (CORFs).  The fee schedule also applies to outpatient rehabilitation services furnished under  an arrangement with any of the enumerated entities that are to be paid on the basis of the physician fee schedule;    The supplier of the technical component of any radiology or diagnostic service;    An independent laboratory doing anatomic pathology services; and    Services billed by entities authorized to bill for physicians, suppliers, etc.  under the reassignment rules.   B. Hospice Services   The Physicians Fee Schedule is used when paying for hospice physicians services by the A/B MAC (HHH).  Regular hospice services are paid under the hospice rate schedule (see chapter 11.)   C. Outpatient Rehabilitation Services   Effective with services furnished on or after January 1, 1999, A/B MACs (A) pay for outpatient rehabilitation services based on the MPFS.  Services included are physical therapy, speech- language pathology, occupational therapy, and certain audiology and CORF services.   Effective with services furnished on or after July 1, 2000, A/B MACs (A)  pay for all CORF services under the MPFS.  Effective with claims with dates of service on or after July 1, 2003, OPTs/Outpatient Rehabilitation Facilities (ORFs), (74X bill type) are required to report all their services utilizing HCPCS.  A/B MACs (A) are required to make payment for these services under the MPFS unless the item or service is currently being paid under the orthotic fee schedule or the item is a drug, biological, supply or vaccine.  The MPFS applies when these services are furnished by rehabilitation agencies, (outpatient physical therapy providers and CORFs), hospitals (to outpatients and inpatients who are not in a covered Part A stay), SNFs (to residents not in a covered Part A stay and to nonresidents who receive outpatient rehabilitation services from the SNF), and HHAs (to individuals who are not homebound or otherwise are not receiving services under a home health plan of treatment).  The MPFS is used as a method of payment for outpatient rehabilitation services furnished under arrangement with any of these providers.  The MPFS allowed charge for these services is the lower of the actual charge or the fee schedule amount.  The Medicare payment for the services is 80 percent of the allowed charge after the Part B deductible is met.  This is a final payment.  The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs).  CAHs are paid on a reasonable cost basis.   Application of the Outpatient Mental Health Treatment Limitation (A/B MACs (A))   In accordance with 1833 of the Act, payment is made at 62 percent of the approved amount for outpatient mental health treatment services.  This provision will continue to be implemented in accordance with the Act when these services are furnished to beneficiaries by CORFs.  The refore, make payment at 62 percent of 80 percent of the approved amount (or in effect 50 percent) for outpatient mental health treatment services.   D. SNF Services