(Medicare Claims Processing Manual)

8. Court/Law Enforcement -The patient was referred to this facility for outpatient or referenced diagnostic services upon the direction of a court of law, or upon the request of a law enforcement agency representative.   9. Information not available.  10. Transfer from a CAH -  The patient was referred to this facility for outpatient or referenced diagnostic services by (a physician of) the CAH were the patient is an inpatient.   The hospital must determine the proper source of admission code based on the patients response and/or any other information the hospital may have available from its preregistration records or scheduling data.  The hospital must enter the proper source of admission code on the claim.  NOTE:  Information regarding the form locator number that corresponds to the source of admission code and a table to crosswalk its CMS -1450 form locator to the 837 transaction is found in Chapter 25.   If the patient was referred for services by a physician at:    This hospital, the hospital enters codes 2 or 7;    Another hospital, the hospital enters code 4; or    Some other source, the hospital enters codes 1, 3, 5, 6, 8, 9, or A, as appropriate.   If the hospital is sure the admission source is not from its hospital or another hospital but cannot determine which of the codes apply, the hospital will enter code 1 on Medicare claims.  However, incorrect reporting where services were referred by staff at its own hospital or another hospital (codes 2, 4, or 7 are applicable) is considered program abuse and subject to applicable sanctions.  90.4 - Type of Bill  (Rev. 2971, Issued: 05- 23-14, Effective: 07 -01-14, Implementation, 07- 07-14)  To properly bill, hospitals other than CAHs assign type of bill (TOB) 13X to all bills for outpatient hospital services and TOB 14X for non -patient (referred) laboratory specimens.  A n on-patient is defined as a beneficiary that is neither an inpatient nor an outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital and the beneficiary is not physically present at the hospital.  TOB 14X should only be billed for non- patient lab specimens, which are paid under the clinical laboratory fee schedule at the lesser of the actual charge, the fee schedule amount, or the National Limitation Amount (NLA), (including CAHs and MD Waiver hospitals).  Part B deductible and coinsurance do not apply for laboratory tests payable on the laboratory fee schedule.   TOB 14X should no longer be used for referred diagnostic services other than laboratory services.   CAHs should bill TOB 85X for outpatient services (including outpatient labs), and TOB 14X for non- patient laboratory specimen tests.   90.5 - Definition of Diagnostic Services  (Rev. 1, 10- 01-03) HO- 350.E   A service is diagnostic if it is an examination or procedure to which the patient is subjected, or which is performed on materials derived from a hospital outpatient to obtain information to aid in the assessment of a medical condition or the identification of a disease.  Among these examinations and tests are diagnostic laboratory services such as hematology and chemistry, diagnostic x- rays, isotope studies, EKGs, pulmonary function tests, psychological tests, and other tests given to determine the natur e and severity of an ailment or injury.  Hospitals may determine whether services are diagnostic from their internal systems as appropriate.   90.6 - Definition of Encounter  (Rev. 1, 10- 01-03) HO- 350F   The term encounter means a direct personal contact in the hospital between a patient and a physician, or other person who is authorized by State law and, if applicable, by hospital staff bylaws to order or furnish services for diagnosis or treatment of the patient.  Direct personal contact does not include telephone contacts between a patient and physician.  Nor is the compensation arrangement between the physician and the hospital relevant to whether an encounter has occurred.  Patients will be treated as hospital outpatients for purposes of billing for certain diagnostic services that are ordered during or as a result of an encounter that occurred while such patients are in  an outpatient status at the hospital.  If a Medicare outpatient is referred to another provider or supplier for further diagnostic testing or other diagnostic services as a result of an encounter that occurs in this hospital, the hospital is responsible f or arranging with the other entity for the furnishing of services.  Hospitals are not required to verify that all ordered services are furnished but only to assure that, when it is necessary to refer a patient to an outside entity, the referral is made to a provider or supplier with which the referring hospital an arrangement.  This requirement is necessary to assure that billing for services that are furnished is processed through the servicing hospital.  When a patient has follow -up visits with a physician in the hospital following an initial encounter, each subsequent visit to the physician will be treated as a separate encounter for billing.  100 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  100.1 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  110 - ESRD Method Selection  (Rev. 1, 10- 01-03)  See chapter 8, for instructions for completing the ESRD Method Selection Form.   110.1 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  120 - Reserved  (Rev. 3441, Issued: 01- 15-16, Effective; 12 -31-13; ASC X12: 01- 01-12, MAC Implementation: 02 -16-16; ASC X12: 02- 16-16)  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12423CP   12/20/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024 13222 R4247CP  03/01/2019 Update to Publication 100- 04 Chapters 2, 6, and 18 to Provide Language -Only Changes for the New Medicare Card Project  04/01/2019 11155 R3441CP  01/15/2016 Update to Pub. 100- 04, Chapter 02 Admission and Registration Requirements, for Provider Verification of Beneficiary Eligibility and Entitlement 02/16/2016 9457 R2971CP  05/23/2014 July 2014 Update of the Hospital Outpatient Prospective Payment System (OPPS)  07/07/2014 8776 R1472CP  03/06/2008 Update of Institutional Claims References  04/07/2008 5893 R1421CP  01/25/2008 Update of Institutional Claims References  Rescinded and Replaced by Transmittal 1472 04/07/2008 5893 R1257CP  05/25/2007 Important Message From Medicare (IM) and Expedited Determination Procedures for Hospital Discharges  07/02/2007 5622 R980CP  06/14/2006 Changes Conforming to CR 3648 Instructions for Therapy Services -  Replaces Rev. 941  10/02/2006 4014 R941CP  05/05/2006 Changes Conforming to CR 3648 Instructions for Therapy Services  10/02/2006 4014 R851CP  02/10/2006 Revisions to Instructions for Contractors Other Than the Religious Nonmedical Health Care Institutions Specialty Contractor Regarding Claims for Beneficiaries with RNCHI Elections  05/11/2006 4218 R795CP  12/30/2005 Redefined Type of Bill 14X For Non -Patient Laboratory Specimens -CR 3835 Manualization  04/03/2006 4208 R001CP  10/01/2003 Initial Publication of Manual  NA NA Back to top of Chapter