(Medicare Claims Processing Manual)

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   Revenue Code 037X for CRNA technical service = cost reimbursement   Revenue Code 0964 for CRNA professional service = 115% times 80% (not medically directed) or 115% times 50% (medically directed) of allowed amount (Use Anesthesia formula) for outpatient CRNA professional services.   Providers 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 prior to July 1, 2007  Add the anesthesia code base unit and time units. The time units are calculated by dividing actual anesthesia time (Units field on the UB92) by 15. Multiply the sum of base and time units by the locality specific anesthesia conversion factor (file name below).   The Medicare program pays the CRNA 80% of this allowable charge when not medically directed. Deductible and coinsurance apply.   If the CRNA is medically directed, pay 50% of the allowable charge. Deductible and coinsurance apply.   Base Formula   Number of minutes divided by 15, plus the base units = Sum of base units and time  Sum of base units and time times the conversion factor = allowed amount   Source  Number of minutes = Number of units on the claim (Units field of the UB04) Base Units = Anesthesia HCPCS   Conversion Factor = File -  MU00.@BF12390.MPFS.CYXX.ANES.V1023      250.4 - CAH Outpatient Services Part B Deductible and Coinsurance  (Rev. 1070, Issued: 09- 29-06, Effective: 01 -01-07, Implementation: 01- 02-07)  Payment for outpatient services of a CAH is subject to applicable Medicare Part B deductible and coinsurance amounts unless waived based on statute.   For information on the application of deductible and coinsurance for screening and preventive services, see chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual.   Payments for clinical diagnostic laboratory tests furnished to CAH outpatients on or after November 29, 1999, are made on a reasonable cost basis with no beneficiary cost -sharing - no coinsurance, deductible, copayment, or any other cost -sharing.    250.5 - Medicare Payment for Ambulance Services Furnished by Certain CAHs  (Rev. 4390, Issued: 10- 07-19, Effective: 10 -01-19, Implementation: 10- 07-19)  Medically necessary ambulance services furnished for dates of service on or after December 21, 2000 and prior to January 1, 2004, by a CAH or by an entity that is owned and operated by the CAH are paid based on 100 percent of the reasonable costs if the 35 mile rule for reasonable cost -based payment is met.   For dates of service on or after January 1, 2004, medically necessary ambulance services furnished by a CAH or by an entity that is owned and operated by the CAH are paid based on 101 percent of the reasonable costs if the 35 mile rule for reasonable cost -based payment is met.   For dates of service on or after December 21, 2000 and prior to October 1, 2011, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located withi n a 35 mile drive of the CAH or the entity.   For dates of service on or after October 1, 2011 and prior to October 1, 2019, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH.  Additionally, if there is no provider or supplier of ambulance services located within a 35 mile drive of the CAH but there is an entity owned and operated by the CAH located more than a 35 mile drive from the CAH, that CAH -owned and operated entity can only be paid 101 percent of reasonable costs for its ambulance services if it is the closest provider or supplier of ambulance services to the CAH.   For dates of service on or after October 1, 2019, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH, e xcluding ambulance providers or suppliers that are not legally authorized to furnish ambulance services to transport individuals either to or from the CAH. Additionally, if there is no provider or supplier of ambulance services located within a 35 mile dri ve of the CAH but there is an entity owned and operated by the CAH located more than a 35 mile drive from the CAH, that CAH- owned and operated entity can only be paid 101 percent of reasonable costs for its ambulance services if it is the closest provider or supplier of ambulance services to the CAH.   Section 205 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 exempts certain CAHs from the current Medicare ambulance cost per trip payment limit as well as from the ambulance fee schedule. Section 205(a) of BIPA states:   The Secretary shall pay the reasonable costs incurred in furnishing ambulance services if such services are furnished (A) by a CAH (as defined in 1861(mm)(1)) , or (B) by an entity that is owned and operated by a CAH, but only if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35 -mile drive of such CAH.  Those CAHs and CAH -owned and operated entities that meet the 35 mile rule for reasonable cost -based payment shall report condition code B2 (CAH ambulance attestation) on their bills.   When the 35 mile  rule for reasonable cost -based payment is not met, the CAH ambulance service or the ambulance service furnished by the entity that is owned and operated by the CAH, is paid based on the ambulance fee schedule.  250.6 - Clinical Diagnostic Laboratory Tests Furnished by CAHs  (Rev. 1782; Issued:  07- 30-09; Effective Date:  07 -01-09; Implementation Date:  07-06-09)  Medicare beneficiaries are not liable for any coinsurance, deductible, copayment, or other cost sharing amount for clinical diagnostic laboratory services furnished as a CAH outpatient service.   For dates of service prior to July 1, 2009, payment for clinical diagnostic laboratory tests furnished by a CAH is made at 101 percent of reasonable cost only if the patient is an outpatient of the CAH and is physically present in the CAH at the time the s pecimen is collected -  (Type of Bill (TOB), 85x).   For dates of service on or after July 1, 2009, an individual is no longer required to be physically present in a CAH at the time the specimen is collected.  However, the individual must be an outpatient of the CAH, as defined at 42 CFR 410.2 and be receiv ing services directly from the CAH.  In order for the individual to be receiving services directly from the CAH, the individual must either be receiving outpatient services in the CAH on the same day the specimen is collected, or the specimen must be colle cted by an employee of the CAH.   Tests for non- patients are billed on TOB 14x, and are paid under the lab fee schedule.   250.7 - Payment for Outpatient Services Furnished by an Indian Health Service (IHS) or Tribal CAH  (Rev. 231, Issued 07- 23-04, Effective: 01 -01-04/Implementation: 01- 03-05)  The IHS or Tribal CAHs are paid for outpatient services based on a facility specific visit rate that is established on a yearly basis from prior year cost report information.  Payment for outpatient IHS or Tribal CAH services is paid at 80% of the facility specific outpatient visit rate for both facilities electing Standard Method (I) and Optional Method (II) billing.  IHS or Tribal CAHs will follow the billing methodology for t he billing method that is chosen.  Standard Method (I) is found in 250.1 and Optional Method (II) is found in 250.2 of this chapter.  Facilities billing under the Optional Method (II) will follow the methodology for HPSA and Scarcity payments as outlined in 250.2 of this chapter.  Outpatient services provided at IHS or Tribal CAHs should be billed on an 85X type of bill.  Effective for cost reporting periods beginning on or after January 1, 2004, payment for outpatient IHS or Tribal CAH outpatient services will be made at 101% of the facility specific outpatient visit rate less applicable Part B deductible and coinsurance amounts.   250.8 - Coding for Administering Drugs in a Method II CAH  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)  This section provides billing guidance and payment instructions for hospitals when providing drugs and drug administration services in a Method II CAH.    250.8.1 - Coding for Low Osmolar Contrast Material (LOCM)  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)  Method II CAHs bill the outpatient physician involvement (professional component) for the administration of Low Osmolar Contrast Material (LOCM) with revenue code 96X, 97X or 98X on type of bill (TOB) 85X.  Bills must include an appropriate outpatient hospital visit CPT code for evaluation and management (E & M).   The technical component for LOCM may be billed by both Method I and Method II CAHs with revenue code 636 and one of the following HCPCS codes as appropriate:   HCPCS Code  Descriptor  Q9945  Low osmolar contrast material (up to 149 mg/ml iodine concentration, per ml) Q9946  Low osmolar contrast material (150 - 199 mg/ml iodine concentration, per ml) Q9947  Low osmolar contrast material (200 - 249 mg/ml iodine concentration, per ml) Q9948  Low osmolar contrast material (250 - 299 mg/ml iodine concentration, per ml) Q9949  Low osmolar contrast material (300 - 349 mg/ml iodine concentration, per ml) Q9950  Low osmolar contrast material (350 - 399 mg/ml iodine concentration, per ml) Q9951  Low osmolar contrast material (400 or greater mg/ml iodine concentration, per ml)   250.8.2 - Coding for the Administration of Other Drugs and Biologicals  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)  Outpatient physician involvement for hydration; therapeutic or diagnostic injections and intravenous (IV) infusions (other than hydration); and chemotherapy administration in a Method II CAH is included in the physicians evaluation and management (E & M) services. Bills must include an appropriate outpatient hospital visit E & M CPT code with revenue code 96X, 97X or 98X on TOB 85X.   See 250.2 for information on fee schedule payment for professional services.   250.9 - Coding Assistant at Surgery Services Rendered in a Method II CAH  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)