(Medicare Claims Processing Manual)

Rules for completing a Form CMS -1500 and electronic formats are in Chapter 26.  Instructions in 10.1, 20.1, 20.2, 20.3 and 20.4 above also apply.   30.1 -  Determining Payment Amounts  (Rev. 1, 10- 01-03)  A/B MACs (B)  use the MPFS to determine payment for outpatient rehabilitation services.  Payment rules are the same as those for other services paid on the MPFS.   Assignment is mandatory.   See chapter 23, for a description of the MPFS.  30.2 -  Applicable A/B MAC (B)  CWF Type of Service Codes  (Rev. 1, 10- 01-03)  The A/B MAC (B) assigns the type of service code before submitting the claim record to CWF.     U = Occupational therapy  W= Physical therapy   40 - Special Claims Processing Rules for Institutional Outpatient Rehabilitation Claims  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Implementation: 04- 05-10)  40.1 -  Determining Payment Amounts  Institutional Claims  (Rev. 3367 Issued: 10- 07-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Institutional outpatient rehabilitation claims are paid under the Medicare Physician Fee Schedule (MPFS), except for claims from CAHs and hospitals in Maryland.  Medicare contractors should see 100.2 for details on obtaining the correct fee amounts.  40.2 - Applicable Types of Bill  (Rev. 2736, Issued: 06 -28-13, Effective: 10 -01-12, Implementation: 10- 07-13)  The appropriate types of bill for submitting outpatient rehabili tation services are: 12X, 13X, 22X, 23X, 34X, 74X, 75X, and 85X.   40.3 - Applicable Revenue Codes  (Rev. 2044, Issued: 09- 03-10, Effective: 09- 30-10, Implementation: 09- 30-10)  The appropriate revenue codes for reporting outpatient rehabilitation services are   0420 -  Physical Therapy Services  0430 -  Occupational Therapy Services  0440  Speech -language pathology services   The general classification of revenue codes is all that is needed for billing.  If, however, providers choose to use more specific revenue code classifications, the A/B MAC (A) should accept them.  Reporting of services is not limited to specific revenue c odes; e.g., services other than therapy may be included on the same claim.   Many therapy services may be provided by both physical and occupational therapists.  Other services may be delivered by either occupational therapists or speech -language pathologis ts.  Therefore, providers report outpatient rehabilitation HCPCS codes in conjunction with the appropriate outpatient rehabilitation revenue code based on the type of therapist who delivered the service, or, if a therapist does not deliver the service, the n on the type of therapy under the plan of care (POC) for which the service is delivered.   40.4 -  Edit Requirements for Revenue Codes  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Implementation: 04- 05-10)    Medicare contractors edit to assure the pres ence of a HCPCS code when revenue codes 0420, 0430, 0440, or 0470 are reported.  However, Medicare contractors do not edit the matching of revenue code to certain HCPCS codes or edit to limit provider reporting to only those HCPCS listed in section 20.  40.5 -  Line Item Date of Service Reporting  (Rev. 2044, Issued: 09- 03-10, Effective: 09- 30-10, Implementation: 09- 30-10)  Providers are required to report line item dates of service per revenue code line for outpatient rehabilitation services.  CORFs are also  required to report their full range of CORF services by line item date of service.  This means each service (revenue code) provided must be repeated on a separate line item along with the specific date the service was provided for every occurrence.   Contr actors will return claims that span two or more dates if a line item date of service is not entered for each HCPCS reported.  Line item date of service reporting became effective for claims with dates of service on or after October 1, 1998.   Services that do not require line item date of service reporting may be reported before or after those services that require line item reporting.   40.6 - Non-covered Charge Reporting  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Implementation: 04- 05-10)  Institutional outpatient therapy claims may report non- covered charges when appropriate according to the instructions provided in of this manual. Outpatient therapies billed as non-covered charges are not counted toward the financial limitation described above, when that limitation is in effect, unless the charges are subject to review after they are submitted and found to be covered by Medicare.  Modifiers associated with non- covered charges that are presented in Chapter 1, section 60 can be used on claim lines for  therapy services, in addition to the use of modifiers -GN, - GO and - GP.  40.7 - Billing for Biofeedback Training for the Treatment of Urinary Incontinence  (Rev. 2736, Issued: 06 -28-13, Effective: 10 -01-12, Implementation: 10- 07-13)  Medicare covered biofeedback training for the treatment of urinary incontinence may be provided by physical therapists in facility settings. For information regarding the coverage of this service, see the Medicare National Coverage Determinations Manual, Chapter 1, Section 30.1.1. Medicare pays for this service under the Medicare Physician Fee Schedule.   Providers bill this service on one of the types of bill listed in section 40.2 using revenue code 042X and one of the following HCPCS codes:    90901 -  Biofeedback training by any modality      90911 -  Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry   40.8  Rebilling Therapy Services for Hospital Inpatients  (Rev. 2868, Issued: 02- 06-14, Effective: 07 -01-14, Implementation: 0 7-07-14)  If a beneficiary receives therapy services during an inpatient hospital stay which was denied because the stay was not medically necessary, the therapy services may be rebilled under Medicare Part B coverage.  If the therapy would have been reasonable and necessary as hospital outpatient services, and provided the beneficiary has Part B entitlement, the services can be billed using Type of Bill 012x.  All payment and billing requirements for outpatient therapy (including therapy caps, functional r eporting and other instructions in this chapter) apply to these claims.  50 - CWF and PS&R Requirements - A/B MAC (A)  (Rev. 2044, Issued: 09- 03-10, Effective: 09- 30-10, Implementation: 09- 30-10)  The A/B MAC (A)  reports the procedure codes in the financial  data section (field 65a -65j) of the PS&R record.  It includes revenue code, HCPCS, units, and covered charges in the record.  Where more than one HCPCS procedure is applicable to a single revenue code, the provider reports each HCPCS and related charge on a separate line.  The A/B MAC (A)  reports the payment amount before adjustment for beneficiary liability in field 65g Rate and the actual charge in field 65h Covered Charges.  The PS&R system includes outpatient rehabilitation, and CORF services liste d in subsections E and F on a separate report from cost based payments.  See the PS&R guidelines for specific information.  100 - Special Rules for Comprehensive Outpatient Rehabilitation Facilities (CORFs)  (Rev. 1, 10- 01-03)  100.1 -  General  (Rev. 3220, Issued: 03 -16-15, Effective: ICD -10: Upon Implementation of ICD -10, ASC- X12: 01- 01-12, Implementation: 10- 01-14, ICD -10: Upon Implementation of ICD- 10 ASC X12: 09 -16-14)  The Omnibus Reconciliation Act of 1980 (Public Law 96- 499, Section 933) defines CORFs  (Comprehensive Outpatient Rehabilitation Facilities) as a distinct type of Medicare provider and adds CORF services as a benefit under Medicare Part B.  The Balance Budget Act (P.L.105 -33) requires payment under a prospective system for all CORF services.   See C hapter 1, for the policy on A/B MAC (A)  designations governing CORFs.    See the Medicare Benefit Policy Manual, C hapter 12, for a description of covered CORF services.   Physicians diagnostic and therapeutic services furnished to a CORF patient are n ot considered CORF physicians services.  The physician must bill the area A/B MAC (B) for these services.  If they are covered, the A/B MAC (B) reimburses them via the MPFS.   However, other services are considered CORF services to be billed by the CORF to  the A/B MAC (A), and are also considered included in the fee amount under the MPFS.  These services include such services as administrative services provided by the physician associated with the CORF, examinations for the purpose of establishing and revie wing the plan of care, consultation with and medical supervision of nonphysician staff, team conferences, case reviews, and other facility staff medical and facility administration activities relating to the services described in Medicare Benefit Policy Manual, chapter 12.  Related supplies are also included in the MPFS fee amount.   The CORFs bill Medicare with the ASC X12 837 institutional claim or Form CMS -1450 using HCPCS codes and Revenue Codes.  Usually the zero level revenue code is used.  Payment is based on the HCPCS code and related MPFS amount.  Requirements in 10 -  50 apply to CORF billing.  In addition the following requirements apply.   100.1.1 - Allowable Revenue Codes on CORF 75X Bill Types (Rev. 2736, Issued: 06- 28-13, Effective: 10- 01-12, Implementation: 10- 07-13)  Effective October 1, 2012, the following revenue codes are allowable for reporting CORF services on 75X bill types:   0270  0274  0279  029X  0412  0419  042X  0410  044X  0550  0559  043X  0636  0771  0911  0569  0942      NOTE:   Billed revenue codes not listed in the above list will be returned to the provider by Medicare systems.  See Chapter 25, Completing and Processing the CMS -1450 Data Set, for revenue code descriptions.  100.2 -  Obtaining Fee Schedule Amounts  (Rev. 1, 10- 01-03)  The CMS furnishes A/B MACs (A) with an annual therapy abstract file and a CORF supplemental file through the Medicare Telecommunications System.  The CMS notifies A/B MACs (A) when new files are availab le.  A/B MACs (A)  are responsible for informing CORFs of new fee schedule amounts.    Payment is calculated at 80 percent of the allowed charge after deductible is met.  The allowed charge is the lower of billed charges or the fee schedule amount.  Unmet deductible is subtracted from the allowed charge, and payment is calculated at 80 percent of the result.   EXAMPLE:   $120 Provider charge;  $100 MPFS amount. Payment is 80 percent of the lower of the actual charge or fee schedule amount, which in this case is $80.00.  ($100.00 (MPFS) X 80 percent.)   The remaining 20 percent or $20 is the patient s coinsurance liability.   These codes are updated as needed by CMS.   If the A/B MAC (A) receives a claim for a Medicare covered CORF service with dates of service on or  after July 1, 2000, that does not appear on its fee schedule abstract file, it has two options for obtaining pricing information:   1. It is provided with a therapy abstract file or CORF supplemental file that contains all therapy services and their related prices.  This supplemental file contains approximately a million records, and may be used as a resource to extract pricing data as needed.  The data in the supplemental file is in the same format as the MPFS abstract file in exhibit 1, but the fields defin ing the fee and outpatient hospital indicators are not populated, instead they are space -filled.