(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 4 - Part B Hospital  (Including Inpatient Hospital Part B and OPPS)  Table of Contents  (Rev. 12421; Issued : 12-21-23) (Rev. 12423; Issued:12- 20-23)     Transmittals for Chapter 4   10 - Hospital Outpatient Prospective Payment System (OPPS)  10.1 -  Background  10.1.1 -  Payment Status Indicators  10.2 -  APC Payment Groups  10.2.1 -  Composite APCs  10.2.2 -  Cardiac Resynchronization Therapy  10.2.3 -  Comprehensive APCs   10.2.4. -  Reporting for Certain Outpatient Department Services (That Are Similar to Therapy Services) (Non -Therapy Outpatient Department Services) and Are Adjunctive to Comprehensive APC Procedures  10.3 -  Calculation of APC Payment Rates  10.4 -  Packaging  10.4.1 -  Combinations of Packaged Services of Different Types That are Furnished on the Same Claim  10.5 -  Discounting 10.6 -  Payment Adjustments  10.6.1 -  Payment Adjustment for  Rural  Sole Community  Hospitals  10.6.2 -  Payment Adjustment for Failure to Meet the Hospital Outpatient Quality Reporting Requirements  10.6.2.1 -  Hospitals to which the Payment Reduction Applies  10.6.2.2 -  Services to which the Payment Reduction Applies  10.6.2.3 -  Contractor Responsibilities  10.6.2.4 -  Application of the Payment Reduction Factor in Calculation of the Reduced Payment and Reduced Copayment  10.6.3 -  Payment Adjustment for Certain Cancer Hospitals  10.6.3.1 -  Payment Adjustment for Certain Cancer Hospitals for CY 2012 and CY 2013 10.6.3.2 -  Payment Adjustment for Certain Cancer Hospitals for CY 2014  10.6.3.3 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2015 10.6.3.4 -  Payment Adjustment for Certain Cancer Hospitals   Beginning CY 2016 10.6.3.5 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2017 10.6.3.6 -  Payment Adjustment for Certain Cancer Hospitals Beginning CY 2018        10.6.3.7 -  Payment Adjustment for Certain Cancer Hospitals         Beginning CY 2019        10.6.3.8 -  Payment Adjustment for Certain Cancer Hospitals         Beginning CY 2020   10.6.4 -  Payment Adjustment for Rural Emergency Hospitals   10.7 -  Outliers  10.7.1 -  Outlier Adjustments  10.7.2 -  Outlier Reconciliation  10.7.2.1 -  Identifying Hospitals and CMHCs Subject to Outlier Reconciliation  10.7.2.2 -  Reconciling Outlier Payments for Hospitals and CMHCs  10.7.2.3 -  Time Value of Money  10.7.2.4 -  Procedures for Medicare Contractors to Perform and Record Outlier Reconciliation Adjustments  10.8 -  Geographic Adjustments  10.8.1 -  Wage Index Changes  10.9 -  Updates  10.10 -  Biweekly Interim Payments for Certain Hospital Outpatient Items and Services That Are Paid on a Cost Basis, and Direct Medical Education Payments, Not Included in the Hospital Outpatient Prospective Payment System (OPPS)  10.11 -  Calculation of Overall Cost to Charge Ratios (CCRs) for Hospitals Paid Under the Outpatient Prospective Payment System (OPPS) and Community Mental Health Centers (CMHCs) Paid Under the Hospital OPPS  10.11.1 -  Requirement to Calculate CCRs for Hospitals Paid Under OPPS and for CMHCs  10.11.2 -  Circumstances in Which CCRs are Used  10.11.3 -  Selection of the CCR to be Used 10.11.3.1 -  CMS Specification of Alternative CCR  10.11.3.2 -  Hospital or CMHC Request for Use of a Different CCR  10.11.3.3 -  Notification to Hospitals Paid Under the OPPS of a Change in the CCR  10.11.4 -  Use of CCRs in Mergers, Acquisitions, Other Ownership Changes , or Errors Related to CCRs  10.11.5 -  New Providers and Providers with Cost Report Periods Less Than a Full Year  10.11.6 -  Substitution of Statewide CCRs for Extreme OPPS Hospital Specific CCRs  10.11.7 -  Methodology for Calculation of Hospital Overall CCR for Hospitals that Do Not Have Nursing and Paramedical Education Programs  for Cost Reporting Periods Beginning Before  May 1, 2010, Under Cost Report Form 2552- 96 10.11.7.1 -  Methodology for Calculation of Hospital Overall CCR for Hospitals That Do Not Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning On or After May 1, 2010, Under Cost Report 2552- 10 10.11.8 -  Methodology for Calculation of Hospital Overall CCR for Hospitals That Have Nursing and Paramedical Education Programs  for Cost Reporting Periods Beginning Before  May 1, 2010, Under Cost Report Form 2552- 96 10.11.8.1 -  Methodology for Calculation of Hospital Overall CCR for Hospitals That Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning On or After May 1, 2010, Under Cost Report 2552- 10 10.11.9 -  Methodology for Calculation of CCR for CMHCs  10.11.10 -  Location of Statewide CCRs, Tolerances for Use of Statewide CCRs in Lieu of Calculated CCRs and Cost Centers to be Used in the Calculation of CCRs  10.11.11 -  Reporting of CCRs for Hospitals Paid Under OPPS and for CMHCs  10.12 -  Payment Window for Outpatient Services Treated as Inpatient Services  20 - Reporting Hospital Outpatient Services Using Healthcare Common Procedure Coding System (HCPCS)  20.1 -  General  20.1.1 -  Elimination of the 90 -day Grace Period for HCPCS (Level I and Level II)  20.2 -  Applicability of OPPS to Specific HCPCS Codes  20.3 -  Line Item Dates of Service  20.4 -  Reporting of Service Units  20.5 -  Clarification of HCPCS Code to Revenue Code Reporting 20.6 -  Use of Modifiers  20.6.1 -  Where to Report Modifiers on the Hospital Part B Claim  20.6.2 -  Modifiers - 50 20.6.3 -  Modifiers - LT and -RT 20.6.4 -  Modifiers 73 and 74 20.6.5 -  Modifiers 76 and 77 20.6.6 -  Modifiers for Radiology Services  20.6.7 -  Modifier  CA 20.6.8 -  HCPCS Level II Modifiers  20.6.9 -  Modifier  FB 20.6.10 - Modifier FC  20.6.11 -  Modifier PO  20.6.12 - Modifier PN   20.6.13 -  Modifier CT  20.6.14 -  Modifier FX  20.6.15 -  Modifier FY  20.6.16-  Modifier JG  20.6.17-  Modifier TB  20.6.18-  Modifier ER  20.6.19 -  Modifier CG  20.7 -  Billing of C HCPCS Codes by Non- OPPS Providers  30 - OPPS Coinsurance  30.1 -  Coinsurance Election 30.2 -  Calculating the Medicare Payment Amount and Coinsurance  40 - Outpatient Code Editors (OCEs)  40.1 -  Integrated OCE (July 2007 and Later)  40.1.1 -  Patient Status Code and Reason for Patient Visit for the Hospital OPPS  40.2 -  Outpatient Prospective Payment System (OPPS) OCE (Prior to July 1, 2007)  40.2.1 -  Patient Status Code and Reason for Patient Visit for the Hospital OPPS  40.3 -  Non -OPPS OCE (Rejected Items and Processing Requirements) Prior to July 1, 2007 40.4 -  Paying Claims Outside of the IOCE  40.4.1 -  Requesting to Pay Claims Without IOCE Approval  40.4.2 -  Procedures for Paying Claims Without Passing through the IOCE  40.5 -  Transitional Pass -  Throughs for Designated Drugs or Biologicals