(Medicare Claims Processing Manual)

Medicare Claims Processing Manual  Chapter 23 - Fee Schedule Administration and Coding Requirements    Table of Contents  (Rev. 12326; Issued:10- 26-23)  Transmittals for Chapter 23     10 - Reporting ICD Diagnosis and Procedure Codes  10.1 -  General Rules for Diagnosis Codes  10.2 -  Inpatient Claim Diagnosis Reporting  10.3 -  Outpatient Claim Diagnosis Reporting  10.4 -  ICD Procedure Code 10.5 -  Coding for Outpatient Services and Physician Offices  10.6 -  Relationship of Diagnosis Codes and Date of Service  20 - Description of Healthcare Common Procedure Coding System (HCPCS)  20.1 -  Use and Maintenance of CPT -4 in HCPCS  20.2 -  RESERVED  20.3 -  Use and Acceptance of HCPCS Codes and Modifiers  20.4 -  Deleted HCPCS Codes/Modifiers  20.5 -  The HCPCS Codes Training 20.6 -  Professional/Public Relations for HCPCS  20.7 -  Use of the American Medical Associations (AMAs) Physicians Current Procedural Terminology (CPT) Fourth Edition Codes, and Use of the Americian Dental Associationss (ADA) Current Dental Terminology- Fourth Edition (CDT) Codes on A/B MACs (A)s, (B)s, (HHH)s, and DME MACs Web Sites and Other Electronic Media   20.8 -  Payment, Utilization Review (UR), and Coverage Information on CMS Quarterly  HCPCS Codes Update File  20.9 -  National  Correct Coding Initiative ( NCCI)  20.9.1 -  Correct Coding Modifier Indicators (CCMI) and HCPCS Codes Modifiers  20.9.1.1 -  Instructions for Codes With Modifiers ( A/B MACs (B)  Only)  20.9.2 -  Limiting Charge and CCI Edits  20.9.3  Appeals                                                                                                                            20.9.3.1 Procedure -to-Procedure  (PTP) Edits                                                                            20.9.3.2 Medically Unlikely (MUEs) Edits                                                     20.9.4 -  Savings Report                                                                          20.9.4.1 -  Savings Record Format  20.9.5  Adjustments                                                                                   20.9.6 -  Correct Coding Edit (CCE) File Record Format  20.9.7  National Correct Coding Initiative (NCCI) Edits Quarterly Updates  30 - Services Paid Under the Medicare Physicians Fee Schedule  30.1 -  Maintenance Process for the Medicare Physician Fee Schedule Database (MPFSDB)  30.2 -  MPFSDB Record Layout  30.2.1 -  Payment Concerns While Updating Codes  30.2.2 -  MPFSDB Status Indicators  30.3 -  Furnishing Pricing Files  30.3.1 -  RESERVED  30.3.2 -  A/B MAC (A), (B), or (HHH) Furnishing Physician Fee Schedule Data for National Codes  30.3.3 -  Furnishing Other Fee Schedule, Prevailing Charge, and Conversion Factor Data  30.3.4 -  Responsibility to Obtain and Implement Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedules  30.3.5 -  File Specifications  30.5 -  Payment Amounts for Portable X -Ray Transportation Services  40 - Clinical Diagnostic Laboratory Fee Schedule  40.1 -  Access to Clinical Diagnostic Lab Fee Schedule Files  40.2 -  A/B MAC (B)  Record Layout for Clinical Laboratory Fee Schedule  40.3 -  Institutional Claim Record Layout for Clinical Laboratory Fee Schedule  40.4 -  Gap -Filled Fees Submitted to CMS by A/B MACs (B)  40.4.1 -  A/B MACs (B)  Forward HCPCS Gap Fill Amounts to A/B MACs (A)  and (HHH)  50 - Fee Schedules Used by Medicare A/B MACs (A) and (HHH) Processing Institutional Claims  50.1 -  Institutional Claim Record Layout for Hospice, Radiology and Other Diagnostic Prices and Local HCPCS Codes  50.2 -  Institutional Claim Record Layout for the Durable Medical Equipment, Prosthetic, Orthotic and Supply Fee Schedule  50.3 -  Institutional Claim Record Layout for the Outpatient Rehabilitation and CORF Services Fee Schedule 50.4 -  Institutional Claim Record Layout for the Skilled Nursing Facility Fee Schedule  50.5 -  RESERVED  50.6 -  Physician Fee  Schedule Payment Policy Indicator File Record Layout  50.7 -  Institutional Claim Record Layout for the Mammography Fee Schedule  50.8 -  Institutional Claim Record Layout for the Ambulance Fee Schedule  60 - Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule  60.1 -  Record Layout for DMEPOS Fee Schedule  60.2 -  Quarterly Update Schedule for DMEPOS Fee Schedule  60.3 -  Gap -filling DMEPOS Fees  60.3.1 -  Payment Concerns While Updating Codes  60.4 -  Process for Submitting Revisions to DMEPOS Fee Schedule to CMS  60.5  Rural ZIP Code Claim Record Layout for Medicare Contractors Processing Rural DMEPOS Fee Schedule Claims  70 - Parenteral and Enteral Nutrition (PEN) Fee Schedule  70.1-  Record Layout for PEN Fee Schedule  80 - Reasonable Charges as Basis for A/B MAC (B)/DME MAC  Payments  80.1 -  Criteria for Determining Reasonable Charge 80.2 -  Updating Customary and Prevailing Charges  80.3 -  The Customary Charge  80.3.1 -  Calculating Customary Charge  80.3.1.1 -  Equity Adjustments in Customary Charge Screens  80.3.2 -  Customary Charge Profile  80.4 -  Prevailing Charge  80.4.1 -  Rounding of Reasonable Charge Calculation 80.5 -  Filling Gaps in A/B MAC (B)  Reasonable Charge Screens  80.5.1 -  Use of Relative Value Scale and Conversion Factors for Reasonable Charge Gap -Filling  80.6 -  Inflation Indexed Charge (IIC) for Nonphysician Services  80.7 -  Determination of Comparable Circumstances  80.8 -  Applying Criteria for Reasonable Charge Determinations  80.8.1 -  Waiver of Deductible and Coinsurance  90 - Inherent Reasonableness Used for Payment of Nonphysician Services  100 -  Competitive Bidding Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Single Payment Amounts  100.1 -  Record Layout for Competitive Bidding HCPCS Category File  100.2 -  Record Layout for Competitive Bidding Pricing File  100.3 -  Record Layout for Competitive Bidding ZIP Code File s 100.4 -  Record Layout for Competitive Bidding Contract Supplier File  100.5 -  Adjustments to the Single Payment Amounts to Reflect Changes in HCPCS Codes  Addendum -  MPFSDB File Record Layout and Field Descriptions       10 - Reporting ICD Diagnosis and Procedure Codes  (Rev. 3081, Issued: 09 -26-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  Proper coding is necessary on Medicare claims because codes are generally used in determining coverage and payment amounts.  CMS accepts only HIPAA approved ICD -9-CM or ICD -10-CM/ICD -10-PCS codes, depending on the date of service.  The official ICD-9-CM co des which were updated annually through October 1, 2013 are posted at http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html    The official annual updates and effective dates for any changes to ICD -10-CM and ICD -10-PCS codes are posted at http://www.cms.gov/Medicare/Coding/ICD10/index.html  .  See the following sections (10.1 -  10.6) for additional instructions about coding ICD diagnoses for inpatient, outpatient, and other services.   10.1 - General Rules for Diagnosis Codes (Rev. 3081, Issued: 09 -26-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  The Official ICD -9-CM Coding Guidelines can be found at http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm    The Official ICD -10-CM and ICD -10-PCS Coding Guidelines can be found with the annual ICD -10-CM and ICD -10-PCS updates at http://www.cms.gov/Medicare/Coding/ICD10/index.html   The CMS understands that physicians may not always provide suppliers of DMEPOS with the most specific diagnosis code, and may provide only a narrative description.  In those cases, suppliers may choose to utilize a variety of sources to determine the most specific diagnosis code to include on the individual line items of the claim.  These sources may include, but are not limited to: coding books and resources, contact with physicians or other health profess ionals, documentation contained in the patients medical record, or verbally from the patients physician or other healthcare professional.   Beneficiaries are not required to submit diagnosis codes on beneficiary -submitted claims.  Beneficiary -submitted claims are filed on Form CMS -1490S.  For beneficiary- submitted claims, the A/B MAC (B)  must develop the claim to determine a current and valid diagnosis code and may enter the code on the claim.  10.2 - Inpatient Claim Diagnosis Reporting (Rev. 3081, Issued: 09 -26-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  On inpatient claims providers must report the principal diagnosis.  The principal diagnosis is the condition established after study to be chiefly responsible for the admission.  Even though another diagnosis may be more severe than the principal diagnosis, the principal diagnosis, as defined above, is entered.  Entering any other diagnosis may result in incorrect assignment of a Medicare Severity -  Diagnosis Related Group (MS -DRG) and an incorrect payment to a hospital under PPS.  See Chapter 25, Completing and Processing the Form CMS -1450 Data Set, for instructions about completing the claim.  Other diagnoses codes are required on inpatient claims and are used in determining the appropriate MS -DRG.  The provider reports the full codes for up to twenty four additional conditions if they coexisted at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay.  The principal diagnosis should not under any circumstances be duplicated as an additional or secondary diagnosis.  If the provider reports duplicate diagnoses they are eliminated in Medicare Code Editor (MCE) before GROUPER.   The Admitting Diagnosis Code is required for inpatient hospital claims subject to A/B MAC (A)  review.  The admitting diagnosis is the condition identified by the physician at the time of the patients admission requiring hospitalization.  For outpatient bills, the field defined as Patients Reason for Visit is not required by Medicare but may be used by providers for nonscheduled visits for outpatient bills.   10.3 - Outpatient Claim Diagnosis Reporting  (Rev. 3081, Issued: 09 -26-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly responsible for the outpatient services.  For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported.  If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported.  If the patient arrives at the hospital for examination or testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital reports the encounter code that most accurately reflects the reason for the encounter.   Examples include:   Z00.00 Encounter for general adult medical examination without abnormal findings   Z00.01 Encounter for general adult medical examination with abnormal findings   Z01.10 Encounter for examination of ears and hearing without abnormal findings   Z01.118 Encounter for examination of ears and hearing with other abnormal findings   For outpatient claims, providers report the full diagnosis codes for up to 24 other diagnoses that coexisted in addition to the diagnosis reported as the principal diagnosis.  For instance, if the patient is referred to a hospital for evaluation of hyperte nsion and the medical record also documents diabetes, diabetes is reported as another diagnosis.  Additional information and training is available on CMS Web site: http://www.cms.gov/Medicare/Coding/ICD10/index.html   10.4 - ICD Procedure Codes  (Rev. 3081, Issued: 09 -26-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)