(Medicare Claims Processing Manual)

NOTE: Providers submitting an 837I are instructed to place the appropriate Prior Authorization code above into Loop 2300 REF02 (REF01 = G1) as follows: REF*G1*A/B REBILLING~ For DDE or paper Claims, "A/B Rebilling" will be added in FL 63. NOTE: Providers submitting an 837I are instructed to place the DCN in the Billing Notes loop 2300/NTE in the format: NTE*ADD*ABREBILL12345678901234~ For DDE or paper Claims, Providers are instructed to use the word "ABREBILL" plus the denied inpatient DCN/CCN/I CN shall be added to the Remarks Field (form locator #80) on the claim using the following format: "ABREBILL12345678901234". (The numeric string (12345678901234) is meant to represent original claim DCN/ICN numbers from the inpatient denial.)  Not Allowed Revenue Codes  The claims processing system shall set edits to prevent payment on Type of Bill 012x for claims containing the revenue codes listed in the table below.  010x  011x  012x  013x  014x  015x  016x  017x  018x  019x  020x  021x  022x  023x  029x  0390  0399  045x  050x  051x  052x  054x  055x  056x  057x  058x  059x  060x  0630  0631  0632  0633  0637  064x  065x  066x  067x  068x  072x  0762  082x  083x  084x  085x  088x  089x  0905  0906  0907  0912  0913  093x  0941  0943  0944  0945  0946  0947  0948  095x  0960  0961  0962  0963  0964*  0969  097x  098x  099x  100x  210x  310x           * In the case of Revenue Code 0964, this is used by hospitals that have a CRNA exception.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR  CARC: 96  RARC: M28  MSN: 21.21  CWF shall edit to ensure that DSMT services are not billed on a 012x claim.   Hospitals are required to report HCPCS codes that identify the services rendered.  ort HCPCS codes that identify the services rendered. 240.2 - Editing Of Hospital Part B Inpatient Services:  Other Circumstances in Which Payment Cannot Be Made under Part A  (Rev.:11685, Issued:11- 09-22, Effective: 07 -01-22, Implementation: 12- 12-22)  When Medicare pays under Part B for the limited set of non-physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, chapter 6, 10.2 (that is, when furnished by a participating hospital to an inpatient of the hos pital who is not entitled to benefits under Part A, has exhausted his or her Part A benefits, or receives services not covered under Part A), the contractor shall set revenue code edits to prevent payment on Type of Bill 012x for claims containing the reve nue codes listed in the table below with exceptions as noted.  For the exceptions noted, contractors shall ensure that only the exceptions identified are allowed to process with the revenue code.  Not Allowed Revenue Codes   010x  011x  012x  013x  014x  015x  016x  017x  018x  019x  020x  021x  022x  023x  0250  0251  0252  0253  0256  0257  0258  0259  026x  0270  0271  0272  0273  0277  0279  028x  029x  036x  0370  0374  0379  038x  039x  041x  045x  0470  0472  0479  0480  0481  0489  049x  050x  051x  052x  053x  0541  0542  0543  0544  0546  0547  0548  0549  055x  056x  057x  058x  059x  060x  0620  0624  063x  064x  065x  066x  067x  068x  069x  070x  071x  072x  075x  076x  079X  081x  082x  083x  084x  085x  087x  088x  089x  090x  091x  093x  0940  0941  0942*  0943  0944  0945  0946  0947  0948  0949  095x  0960  0961  0962  0963  0964*  0969  097x  098x  099x  100x  210x  310x          * In the case of Revenue Code 0964, this is used by hospitals that have a CRNA exception.  * In the case of Revenue Code 0942, this is used by rural hospitals for kidney disease education (KDE) services.  The actual geographic location, core based statisti cal area (CBSA) is used to identify facilities located in rural areas. In addition, KDE services are covered when claims are received from section 401 hospitals.  Additionally, models may allow this Revenue Code.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR  CARC: 96  RARC: M28  MSN: 21.21   Hospitals are required to report HCPCS codes that identify the services rendered. Allowed Revenue Codes  0240  0274  0275  0276  0278  030x  031x  032x  0333  034x  035x,  040x,  042x  043x  044x  046x  0471  0482  0483  054x  061x  0623  073x  074x  0771  078x*  080x  086x  092x  0942*  0964*    *Billed prior to admission or on the day of discharge.  * In the case of Revenue Code 0964, this is used by hospitals that have a CRNA exception.  * In the case of Revenue Code 0942, this is used by rural hospitals for kidney disease education (KDE) services.  The actual geographic location, core based statisti cal area (CBSA) is used to identify facilities located in rural areas. In addition, KDE services are covered when claims are received from section 401 hospitals.  Additionally, models may allow this Revenue Code.   Additional Allowed services that are be identified by HCPCS, not identified by Revenue Codes  Other Diagnostic services: (A MAC maintained)  Preventive services:  COVID -19, Influenza, pneumococcal pneumonia, and hepatitis B vaccines  Colorectal screening  Screening glaucoma services  Bone mass measurements  Prostate screening  Covered drugs:  Hemophilia clotting factors  Immunosuppressive drugs  Oral anti- cancer drugs  Oral anti- emetic  Non -ESRD Epoetin Alfa (EPO)   240.3 - Implantable Prosthetic Devices  (Rev. 2877, Issued: 02- 07-14, Effective: 10 -01-13, Implementation: 04- 07-14)  Under 42 CFR 419.2(b)(11), implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of these devices, are paid under the OPPS, and are therefore packaged with the surgical  implantation procedure unless the device has pass -through payment status.  This payment provision applies when such a device is billed as a Part B outpatient service, or as a Part B inpatient ser vice when the inpatient admission is determined not reasonable and necessary and the beneficiary should have been treated as a hospital outpatient (see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 6, 10.1).  In these circumstances, hospitals should submit the usual HCPCS code for Part B payment of the device.   In the other circumstances in which a beneficiary does not have Part A coverage of inpatient services on the date that such a device is implanted (that is, when furnished by a participating hospital to an inpatient who is not entitled to benefits under Par t A, has exhausted his or her Part A benefits, or receives services not covered under Part A), hospitals paid under the OPPS should report HCPCS code, C9899, Implanted Prosthetic Device, Payable Only for Inpatients who do not Have Inpatient Coverage, that is effective for services furnished on or after January 1, 2009.  This code allows an alternative Part B inpatient payment methodology for the device as discussed in this section, and may be reported only on claims with TOB 12X when the prosthetic device i s implanted on a day on which the beneficiary does not have coverage under Part A because he or she is not entitled to Part A benefits, has exhausted his or her Part A benefits, or receives services not covered under Part A.  The line containing this new code will be rejected if it is reported on a claim that is not a TOB 12X or if it is reported with a line item date of service on which the beneficiary has coverage of inpatient hospital services.  By reporting C9899, the hospital is reporting that the item  is eligible for separate OPPS payment because the primary procedure is not a payable Part B inpatient service under Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10.2 (Other Circumstances in Which Payment Cannot Be Made under Part A).   If C9899 is a separately payable Part B inpatient service, the contractor shall determine the payment amount as follows.  If the device has pass through status under the OPPS, the contractor shall establish the payment amount for the device at the product of the charge for the device and the hospital specific cost to charge ratio.  Where the device does not have pass through status under the OPPS, the contractor shall establish the payment amount for the device at the amount for a comparable device in the D MEPOS fee schedule where there is such an amount.  Payment under the DMEPOS fee schedule is made at the lesser of charges or the fee schedule amount and therefore if there is a fee for the specific item on the DMEPOS fee schedule, the payment amount for the item will be set at the lesser of the actual charges or the DMEPOS fee schedule amount.  Where the item does not have pass through payment status and where there is no amount for a comparable device in the DMEPOS fee schedule, the contractor shall establ ish a payment amount that is specific to the particular implanted prosthetic device for the applicable calendar year.  This amount (less applicable unpaid deductible and coinsurance) will be paid for that specific device for services furnished in the appli cable calendar year unless the actual charge for the item is less than the established amount). Where the actual charge is less than the established amount, the contractor will pay the actual charge for the item (less applicable unpaid deductible and coins urance).   In setting a contractor established payment rate for the specific device, the contractor takes into account the cost information available at the time the payment rate is established.  This information may include, but is not limited to, the amount of devi ce cost that would be removed from an applicable APC payment for implantation of the device if the provider received a device without cost or a full credit for the cost of the device.