(Medicare Claims Processing Manual)

This section contains the listing of payer codes designated by the National Uniform Billing Committee to be assigned by payers only.  Providers shall not submit these codes on their claims forms.  The definitions indicating Medicares usage for these syste matically assigned codes are indicated next to each code value.   Condition Codes   12-14 - Not currently used by Medicare.   15  Clean claim is delayed in CMS Processing System.   16  SNF Transition exception.  60  Operating Cost Day Outlier.   61  Operating Cost Outlier.   62  PIP Bill.   63  Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.   64  Other Than Clean Claim.   65  Non -PPS Bill.   98  Data Associated With DRG 468 Has Been Validated.   EY  Lung Reduction Study Demonstration Claims.  M0  All -Inclusive Rate for Outpatient -  Used by a Critical Access Hospital electing to be paid an all -inclusive rate for outpatient services.   M1  Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV). Code indicates the influenza virus vaccine or pneumonia vaccine (PPV) is being billed via the roster billing method by providers that mass immunize.   M2  Allows Home Health claims to process if provider reimbursement > $150,000.00. HHA Payment Significantly Exceeds Total Charges. Used when payment to an HHA is significantly in excess of covered billed charges.   M3  SNF 3 Day stay bypass for NG/Pioneer ACO waiver.   M4  Presence of infected wound or wound with morbid obesity    M5  Not currently used by Medicare   M6  PA Rural Health Model   M7-M9  Not currently used by Medicare.  MA  GI Bleed. (Bill Type 72x)   MA  Managed Care Enrollee (Bill Type 12x, 13x, and 76x)   MB  Pneumonia. (Bill Type 72x)   MC  Pericarditis. (Bill Type 72x)   MD -  Myelodysplastic Syndrome. (Bill Type 72x)   ME -  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 72x)   MF -  Monoclonal Gammopathy. (Bill Type 72x)   MG  Grandfathered Tribal Federally Qualified Health Centers.   MH-MO  Not currently used by Medicare.   MP  PHP claim contains initial admit week   MQ  PHP claim contains final discharge week    MR-MW  Not currently used by Medicare.   MX  Wrong Surgery on Patient (Inpatient)   MY  Surgery Wrong Body Part (Inpatient)   MY  Outlier Cap Bypass (CMHC)   MZ  Surgery Wrong Patient (Inpatient)   MZ  IOCE error code bypass   UU  Not currently used by Medicare.   Occurrence Codes   23 - Date of Cancellation of Hospice Election period.  48 - Date hospice face- to-face encounter was untimely   49  Original Notice of Election (NOE) receipt date  Occurrence Span Codes   79 - Verified non- covered stay dates for which the provider is liable.   Value Codes   17- Operating Outlier Amount  The A/B MAC (A) reports the amount of operating outlier payment amount made (either cost or day (day outliers have been obsolete since 1997)) in CWF with this code.  It does not include any capital outlier payment in this entry.  18  Operating Disproportionate Share Amount  The A/B MAC (A) REPORTS THE OPERATING DISPROPORTIONATE SHARES AMOUNT APPLICIALBE.  It uses the amount provided by the disproportionate share field in PRICER.  It does not include any PPS capital IME adjustment  entry.   19  The Medicare shared system will display this payer only code on the claim for low volume providers to identify the amount of the low volume adjustment being included in the providers reimbursement.  This payer only code 19 is also used for IME on hos pital claims.  This instruction shall only apply to ESRD bill type 72x and must not impact any existing instructions for other bill types.   19 - Operating Indirect Medical Education Amount  The A/B MAC (A) reports operating indirect medical education amount applicable.  It uses the amount provided by the indirect medical education field in PRICER.  It does not include any PPS capital IME adju stment in this entry.   20  Total payment sent provider for capital under PPS, including HSP, FSP, outlier, old capital, DSH adjustment, IME adjustment, and any exception amount.  62   On Type of Bill 032x:  HH Visits -  Part A -  The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Securi ty Act.  On Type of Bills 081x 0r 082x: Number of High Routine Home Care Days -  Days that fall within the first 60 days of a routine home care hospice claim.  63  On Type of Bill 032x:  HH visits  Part B -  The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Securit y Act.  On Type of Bills 081x 0r 082x: Number of Low Routine Home Care Days -  Days that come after the first 60 days of a routine home care hospice claim.  63  On Type of Bills 081x 0r 082x: Number of Low Routine Home Care Days - Days that come after the first 60 days of a routine home care hospice claim.   64 - HH Reimbursement  Part A -  The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount.  This Part A payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3)  of the Social Security Act.   65 - HH Reimbursement  Part B -  The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount.  This Part B payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   70 - Interest Amount -  The contractor reports the amount of interest applied to this Medicare claim.   71 - Funding of ESRD Networks -  The A/B MAC (A) reports the amount the Medicare payment was reduced to help fund ESRD networks.   72- Flat Rate Surgery Charge -  The standard charge for outpatient surgery where the provider has such a charging structure.   73- Sequestration adjustment amount.  74  Low volume hospital payment amount   75- Prior covered days for an interrupted stay.   76  Providers Interim Rate Providers percentage of billed charges interim rate during this billing period.  This applies to all outpatient hospital and skilled nursing facility (SNF) claims and home health agency (HHA) claims to which an interim rate is applicable.  The contractor reports to the left of the dollar/cents delimiter. An interim rate of 50 percent is entered as follows: 50.00.  77 - Medicare New Technology Add- On Payment -  Code indicates the amount of Medicare additional payment for new technology.  78  Off-site Zip Code - When the facility zip (Loop 2310E N403 Segment) is present for the following bill types: 12X, 13X, 14X, 22X, 23X, 34X, 72X, 74X, 75X, 81X, 82X, and 85X.  The ZIP code is associated with this value and is used to price MPFS HCPCS and Anesthesia Services for  CAH Method II.   79  Total payments for services applicable to the ESRD -  The Medicare shared system will display this payer only code on the claim.  The value represents the dollar amount for Medicare allowed payments applicable for the calculation in determining an outlier payment.   Q0  Pioneer Accountable Care Organization (ACO) non-model payment or Next Generation ACO non- model payment   Q1  Pioneer ACO model payment amount including reduction or NG ACO payment amount including reduction   Q2  Hospice claim paid from Part B Trust Fund   Q3  Prior Authorization 25% Penalty  Q4  PA Rural Model Exclusion - Physician Service Claim Reimbursement   Q5  EHR   Q6  PQRS               Q7  Islet Isolation Add -on payment amount   Q8 - Transitional Drug Add- On Payment Adjustment (TDAPA)   Q9  Medicare Performance Adjustment (MPA)   QA-QC  Not used by Medicare   QD  Device Credit   QE-QL  Not used by Medicare   QM  MIPS adjustment amount   QN  First APC pass- through device offset   QO  Second APC pass -through device offset   QP  Third APC pass -through device offset   QQ  Terminated procedure with device offset   QR  First APC pass- through drug or biological offset   QS  Second APC pass -through drug or biological offset   QT  Third APC pass -through drug or biological offset   QU Device credit with device offset   QV  Value -based purchasing adjustment amount   QW  Placeholder reserved for future use   QX-QZ  Not used by Medicare   200 - Special Services for OPPS Billing  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  200.1 - Billing for Corneal Tissue  (Rev. 3425, Issued: 12- 18-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Corneal tissue will be paid on a cost basis, not under OPPS, only when it is used in a corneal transplant procedure described by one of the following CPT codes: 65710, 65730, 65750, 65755, 65756, 65765, 65767, and any successor code or new code describing a new type of corneal transplant procedure that uses eye banked corneal tissue.  In all other procedures cornea tissue is packaged.  To receive cost based reimbursement hospitals must bill charges for corneal tissue using HCPCS code V2785.   200.2 - Hospital Dialysis Services For Patients With and Without End Stage Renal Disease (ESRD)  (Rev.  2455, Issued: 04- 26-12, Effective: 10 -01-12, Implementation; 10- 01-12)  Effective with claims with dates of service on or after August 1, 2000, hospital -based End Stage Renal Disease (ESRD) facilities must submit services covered under the ESRD benefit in 42 CFR 413.174 (maintenance dialysis and those items and services direct ly related to dialysis such as drugs, supplies) on a separate claim from services not covered under the ESRD benefit.  Items and services not covered under the ESRD benefit must be billed by the hospital using the hospital bill type and be paid under the O utpatient Prospective Payment System  (OPPS) (or to a CAH at reasonable cost).  Services covered under the ESRD benefit in 42 CFR 413.174 must be billed on the ESRD bill type and must be paid under the ESRD PPS.  This requirement is necessary to properly pay only unrelated ESRD services (thos e not covered under the ESRD benefit) under OPPS (or to a CAH at reasonable cost).   Medicare does not allow payment for routine or related dialysis treatments, which are covered and paid under the ESRD PPS, when furnished to ESRD patients in the outpatient department of a hospital. However, in certain medical situations in which the ESRD outpatient cannot obtain her or his regularly scheduled dialysis treatment at a certified ESRD facility, the OPPS rule for 2003 allows payment for non- routine dialysis treatments (which are not covered under the ESRD benefit) furnished to ESRD outpatients in the outpatient department of a hospital.  Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances:    Dialysis performed following or in connection with a dialysis -related procedure such as vascular access procedure or blood transfusions;    Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or