(Medicare Claims Processing Manual)

EXAMPLE C:   Same as Example B except that the claim from the radiologist uses modifier  -77 and indicates that, while the ER physicians finding that the patient did not have pneumonia was correct, there was also a suspicious area of the lung suggesting a tumor that required further testing.  In such situations, the A/B MAC (B) pays for both claims under the fee schedule.   EXAMPLE D:   The A/B MAC (B) receives separate claims for CPT code 71010 -26 from a radiologist and a physician who treated that patient in the ER, both with a date of service of January 1.  The first claim processed in the system is paid and the second claims will be i dentified and denied as a duplicate.  If the denied provider is the radiologist and he raises an issue the A/B MAC (B) will develop the claim to determine whether the findings of the radiologists interpretation were conveyed to the treating physician (orally or in writing) in time to contribute to the diagnosis and treatment of the patient. If the radiologists interpretation was furnished in time to serve this purpose, that claim should be paid, and the claim from the other physician should be denied as  not reasonable and necessary.   110 - Special Billing Instructions for Claims Submitted to A/B MACs (A) (Rev. 1, 10- 01-03)  Transmittal 368 (CR 1323 issued May 24- 01) which revised the following SNF sections of the manual but not incorporated in the master manual.  SNF-533.1, SNF -533.1.A, SNF -533.1.B, SNF -533.1.C, SNF -533.1.D, SNF -533.1.E   For billing instructions, see chapter 25.   110.1 - Aborted Procedure  (Rev. 1, 10- 01-03)  When a procedure is not completed, the SNF should bill an unlisted code (e.g., CPT code ending in 99) and show the actual charges for the procedure.  The A/B MAC (A)  will request additional data from the SNF to determine applicable payment.  Deductible and coinsurance apply based on fee schedule rules.   110.2 - Combined Procedures (Radiology)  (Rev. 1, 10- 01-03)  There are no separate codes covering certain combined procedures, e.g., a hand and forearm included in a single x- ray.  The code with the higher fee schedule amount should be used.   110.2 - Combined Procedures (Radiology)  (Rev. 1, 10- 01-03)  There are no separate codes covering certain combined procedures, e.g., a hand and forearm included in a single x- ray.  The code with the higher fee schedule amount should be used.   110.3 - Payment for Radiopharmaceuticals (Rev. 1, 10- 01-03)  Radiopharmaceuticals are not subject to the fee schedule, but are paid based on reasonable cost when given in a SNF.  SNFs report HCPCS codes 79900, A4641, A4642, A9500, A9503, and A9505, as appropriate, with revenue codes 0333, 034X, or 0636.   NOTE:  The correct code to report is A4641.  It replaced HCPCS code 78990.  HCPCS code 78990 should not be reported because this code is not valid for Medicare purposes.   EXCEPTION: HCPCS codes 77781, 77782, 77783, and 77784 include payment for the radiopharmaceutical in the technical component.  When these procedures are performed, SNFs do not report radiopharmaceutical codes 79900, A4641, A4642, A9500, A9503, and A9505.  The A/B MAC (A)  will reject codes 79900, A4641, A4642, A9500, A9503, and A9505 when they are billed for supplies used in conjunction with procedure codes 77781, 77782, 77783, and 77784.  120 - Radiology or Other Diagnostic Unlisted Service or Procedure Billing Instructions for A/B MAC (A)  Claims  (Rev. 1, 10- 01-03)  Some radiology and other diagnostic services may not have a corresponding HCPCS code.  This is because these are typically services that are rarely provided, unusual, or new.  The provider should assign the appropriate unlisted procedure code to any such service. The following list contains the unlisted procedure codes along with the suggested revenue code for billing.  These services are paid on a fee schedule if one exists or cost if a fee has not been established for SNFs. However, before billing any of these codes the provider needs to furnish a complete description of the radiology procedure to the A/B MAC (A)  for review and analysis.  The description should include a narrative definition of the procedure and a description of the nature, extent and need for the procedure and the time, effort, and equipment necessary.  The A/B MAC (A)  will determine if the provider has correctly identified the procedure as unlisted.  If the procedure is not identified correctly, the A/B MAC (A) will inform the provider of the correct HCPCS code to assign to the procedure. If there is no fee schedule amount established, these services are paid based on cost to SNFs.   For Radiology:   Revenue Code  HCPCS  Definition  032x 76499 Unlisted diagnostic radiologic procedure  0402 76999 Unlisted ultrasound procedure  0333 77299 Unlisted procedure, therapeutic radiology clinical treatment planning  0333 77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices  0333 77499 Unlisted procedure, therapeutic radiology clinical treatment management  0333 77799 Unlisted procedure, clinical brachytherapy  034x 78099 Unlisted endocrine procedure, diagnostic nuclear medicine  034x 78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine  034x 78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine  034x 78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine  Revenue Code  HCPCS  Definition  034x 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine  034x 78599 Unlisted respiratory procedure, diagnostic nuclear medicine  034x 78699 Unlisted nervous system procedure, diagnostic nuclear medicine  034x 78799 Unlisted genitourinary procedure, diagnostic nuclear medicine  034x 78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine  034x 79999 Unlisted radiopharmaceutical therapeutic procedure  For Other Diagnostic Procedures:   Revenue Code  HCPCS  Definition  075x 91299 Unlisted diagnostic gastroenterology procedure  047x 92599 Unlisted otorhinolaryngological service or procedure  048x 93799 Unlisted cardiovascular service or procedure  073x 93799 Unlisted cardiovascular service or procedure  0921 93799 Unlisted cardiovascular service or procedure  046x 94799 Unlisted pulmonary service or procedure  074x 95999 Unlisted neurological or neuromuscular diagnostic procedure  0922 95999 Unlisted neurological or neuromuscular diagnostic procedure   130 - EMC Formats (Rev. 3227, Issued: 04- 02-15, Effective; ASC -X12: January 1, 2012 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  June 11, 2013, ICD -10: Upon Implementation of ICD -10 Implementation: ASC X12: November 10, 2014 Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors:  May 19, 2014 -  MAC Non -Shared System Edits; July 7, 2014 -  CWF development/testing, FISS requirement development; October 6, 2014 -  CWF, FISS, MCS Shared System Edits), ICD -10: Upon Implementation of ICD -10)  Billing instructions for the ASC X12 837 institutional claim format can be found in chapter 24 of this manual or, for Form CMS -1450 can be found in chapter 25 of this manual.  Each revenue code requires a HCPCS code, modifier if applicable, units, line -item date of service, and charge.   Billing instructions for the ASC X12 837 professional claim format can be found in chapter 24 of this manual or for Form CMS -1500 can be found in this manual, Chapter 26, Instructions for Completing Form CMS -1500."   140 - Bone Mass Measurements (BMMs)  (Rev. 1416; Issued:  01- 18-08; Effective:  01 -01-07; Implementation:  02 -20-08)  Sections 1861(s)(15)  and (rr)(1) of the Social Security Act (the Act) (as added by 4106 of the Balanced Budget Act (BBA) of 1997) standardize Medicare coverage of medically necessary bone mass measurements by providing for uniform coverage under Medicare Part B.  This coverage is effect ive for claims with dates of service furnished on or after July 1, l998.  Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of beneficiaries qualifying for BMM by reducing the dosage requirement for glucocorticoid (steroid) therapy from 7.5 mg of predni sone per day to 5.0 mg.  It also changed the definition of BMM by removing coverage for a single- photon absorptiometry as it is not considered reasonable and necessary under section 1862 (a)(1)(A) of the Act.  Finally, it required that in the case of monit oring and confirmatory baseline BMMs, they be performed with a dual -energy x-ray absorptiometry (axial) test.  Conditions of Coverage for BMMs are located in Pub.100- 02, Medicare Benefit Policy Manual, chapter 15   140.1 - Payment Methodology and HCPCS Coding (Rev.  4150, Issued: 10- 26-2018, Effective: 04 -01-19, Implementation: 04- 01-19)  A/B MACs (B) pay for BMM procedures based on the Medicare physician fee schedule.  Claims from physicians, other practitioners, or suppliers where assignment was not taken are subject to the Medicare limiting charge.  The A/B MACs (A) pay for BMM procedures under the current payment methodologies for radiology services according to the type of provider. Do not pay BMM procedure claims for dual photon absorptiometry, CPT procedure code 78351. Deductible and coinsurance do not apply.  Any of the following CPT procedure codes may be used when billing for BMMs through December 31, 2006.  All of these codes are bone densitometry measurements except code 76977, which is bone sonometry measurements.  CPT procedure codes are applicable to billing A/B MACs (A and B).  76070 76071 76075 76076 76078 76977 78350 G0130  Effective for dates of services on and after January 1, 2007, the following changes apply to BMM:   New 2007 CPT bone mass procedure codes have been assigned for BMM.  The following codes will replace current codes, however the CPT descriptors for the services remain the same:  77078 replaces 76070  77079 replaces 76071  77080 replaces 76075  77081 replaces 76076  77083 replaces 76078  Effective for dates of service on and after January 1, 2015, contractors shall pay for bone mass procedure code 77085 ( Dual -energy X -ray absorptiometry (DXA), bone density study, 1 or more sites, axial skeleton, (e.g., hips, pelvis, spine), including vertebral fracture assessment.)   Certain BMM tests are covered when used to screen patients for osteoporosis subject to the frequency standards described in chapter 15, section 80.5.5 of the Medicare Benefit Policy Manual. Contractors will pay claims for screening tests when coded as follows:   Contains CPT procedure code 77078, 77079, 77080, 77081, 77083, 76977 or  G0130, and