(Medicare Claims Processing Manual)

250.13.5 - Claims Processing and Payment  (Rev. 2078, Issued: 10- 28-10, Effective: 04 -01-11, Implementation: 04- 04-11)  A. General Overview   The HPSA physician bonus program guidelines are contained in Publication 100- 04, Chapter 12, and Section 90.4.  Refer to that manual for payment and claims processing guidance for the HPSA physician bonus program that was established in 2005.  The following guidelines pertain only to qualifying 02-  general surgeons  who have reassigned their billing rights to CAHs paid under the optional method, and who are eligible to receive the additional 10 percent HSIP payment for major surgical procedures furnished  in HPSAs from January 1, 2011 through December 31, 2015.   Contractors shall only identify eligible services with a 10 -  or 90 -  day global period rendered in eligible zip code areas based on the HPSA physician bonus program ZIP code file for the appropriate date of service.   Providers may report modifier AQ when submitting claims for major surgical procedures that were furnished in approved HPSAs, where those HPSAs are not recognized for automatic payment.  The modifier must be appended to the major surgical procedure HCPCS co de in order for the CAH paid under the optional method to be paid the 10 percent additional incentive payment for the surgical procedure on behalf of the general surgeon.   B. Method of Payment:    Calculate and pay CAHs paid under the optional method on behalf of  02-  general surgeons furnishing  10 -  and 90 -  day global surgical procedures in a recognized HPSA an additional 10 percent incentive payment based on 115 percent of the amount that would be paid for the surgeons professional services under the PFS;    Calculate the payment based on the amount actually paid for the service, not the Medicare approved amount;    Combine the additional payment with the HPSA physician bonus payment;    Accept and pay services submitted with modifier AQ and;    Revise the special incentive remittance for CAHs that is forwarded with the incentive check so that physicians can identify which type of incentive payment (HPSA physician, HSIP, or PCIP) was paid for which service.   C. Changes for Contractor Systems   The Medicare Carrier System, (MCS), Common Working File (CWF,) and National Claims History (NCH) shall be modified to accept a new HSIP and a new PCIP indicator on the claim line.   Once the type of incentive payment has been identified by the shared systems, the shared system shall modify their systems to set the indicator on the claim line as follows:  1 = HPSA;  2 = PSA;  3 = HPSA and PSA;  4 = HSIP;  5 = HPSA and HSIP  6 = PCIP;  7 = HPSA and PCIP;  Space = Not Applicable.   The contractor shared system shall send the HIGLAS 810 invoice for incentive payment invoices, including the new HSIP payment.  The contractor shall also combine the practitioners HPSA physician bonus, Physician Scarcity (PSA) bonus (if it should become available at a later date), and HSIP payment invoice per practitioner.  The contractor shall receive the HIGLAS 835 payment file from HIGLAS showing a single incentive payment per practitioner.   250.14 - Payment of Licensed Clinical Social Workers (LCSWs) in a Method II CAH  (Rev. 2202, Issued: 04- 27-11, Effective: 10 -01-11, Implementation: 10- 03-11)  The services of a LCSW that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X, and/or 98X and the AJ modifier (clinical social worker).   Under Section 1834(g)(2)(B) of the Act, outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient CAH services.   Section 1833 (a)(1)(F) of the Act stipulates that payment for services performed by a LCSW shall be 80 percent of the lesser of the actual charges for the services or 75 percent of the amount determined for the payment of a psychologist.  Payment is calculated as follows:   ((Facility specific MPFS amount times the LCSW reduction (75%)) minus (deductible and coinsurance)) times 115%.  250.15 - Coding and Payment of Multiple Surgeries Performed in a Method II CAH  (Rev. 2333, Issued: 10- 28-11, Effective: 04 -01-12, Implementation: 04- 02-12)  Multiple surgeries rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co -surgeons, surgical teams, or assistants- at-surgery may participate in performing multiple surgeries on the same patient on the same day.   Medicare pays for multiple surgeries by ranking from the highest MPFS amount to the lowest MPFS amount. When the same physician performs more than one surgical service at the same session, the allowed amount is 100% for the surgical code with the highest MPFS amount. The allowed amount for the subsequent surgical codes is based on 50% of the MPFS amount.  In addition, special endoscopic pricing rules are applied prior to the multiple surgery rules, if applicable. CAH Method II providers may review the multi ple surgery and special endoscopic pricing rules in Pub. 100- 04, Chapter 12, Section 40.6.  In addition, section 40.6.D addresses rare situations where the above payment rules may be bypassed using modifier 22. Providers shall be aware that CAH claims billed with Modifier 22 may be subject to medical review .  250.16 - Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Imaging Procedures Rendered by Physicians  (Rev. 3578, Issued:  08- 05 Effective:  01 -01-17, Implementation:  01- 03-17)  Diagnostic imaging procedures rendered by a physician that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedures are eligible and billed on type of bill 85x with revenue code (RC) 096x, 097x and/or 098x.   The MPPR on diagnostic imaging applies when multiple services are furnished by the same physician to the same patient in the same session on the same day. Full payment is made for each service with the highest payment under the MPFS.  Effective for dates of services on or after January 1, 2012, payment is made at 75 percent for each subsequent service; and effective for dates of services on or after January 1, 2017, payment is made at 95 percent for each subsequent service.   250.17  - Payment of Global Surgical Split Care in a Method II CAH Submitted with Modifier 54 and/or 55  (Rev. 2574, Issued: 10- 26-12 , Effective:01 -01-13 , Implementation:01- 07-13)  Global surgical procedures rendered by a physician that has reassigned their billing rights to a CAH Method II provider is payable by Medicare only when billed on an 85x type of bill (TOB) with revenue code (RC) 096x, 97x, and/or 98x and modifier 54 (surgical care only) and/or 55 (postoperative management only).   There are occasions when more than one physician provides services included in the global surgical period, i.e., when the physician who performs the surgical procedure does not furnish the follow -up care. If this occurs, payment for the postoperative or post -discharge care should be split between the physicians when they agree on the transfer of care.   When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative care, result in payment that is higher than the global allowed amount).   CAH Method II providers may review the Global Surgical pricing rules in Pub. 100- 04, Chapter 12, sections 40.1 -40.5.  260 - Outpatient Partial Hospitalization Services  (Rev. 1, 10- 03-03)  A3-3661, A -01-93  Medicare Part B coverage is available for outpatient partial hospitalization services provided by hospitals, CAHs, and CMHCs.  260.1 - Special Partial Hospitalization Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)   Medicare Part B coverage is available for hospital outpatient partial hospitalization services.    A. Billing Requirement     Section 1861 ( http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm)  of the Act defines the services under the partial hospitalization benefit in a hospital.   Section 1866(e)(2) of the Act (http://www.socialsecurity.gov/OP_Home/ssact/title18/1800.htm) recognizes CMHCs as providers of services but only for furnishing partial hospitalization or intensive outpatient services.  See 261.1.1 of this chapter for CMHC partial hospitalization bill review directions.    Hospitals and CAHs report condition code 41 in FLs 18- 28 (or electronic equivalent) to indicate the claim is for partial hospitalization services.  They must also report a revenue code and the charge for each individual covered service furnished.  In addit ion, hospital outpatient departments are required to report HCPCS codes.  CAHs are not required to report HCPCS code for this benefit.    Under component billing, hospitals are required to report a revenue code and the charge for each individual covered service furnished under a partial hospitalization program.  In addition, hospital outpatient departments are required to report HCPCS codes.   Component billing assures that only those partial hospitalization services covered under 1861(ff) of the Act are paid by the Medicare program.    Effective January 1, 2017, non- excepted off -campus provider -based departments of a hospital are required to report a PN modifier on each claim line for non -excepted items and services.  The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule.  We expect the PN modifier to be reported with each nonexcepted item and service including those for which paym ent will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.     Excepted off -campus provider -based departments of a hospital must continue to report existing modifier PO (Services, procedures and/or surgeries provided at off -campus provider -based outpatient departments) for all excepted items and services furnished. Use of the off -campus PBD modifier became mandatory beginning January 1, 2016.    All hospitals are required to report condition code 41 in FLs 18- 28 to indicate the claim is for partial hospitalization services.  Hospitals use bill type 13X and CAHs use bill type 85X.  The following special procedures apply.    Bills must contain an acceptable revenue code.  They are as follows:    Revenue Code Description   0250  Drugs and Biologicals   043X  Occupational Therapy   0900  Behavioral Health Treatment/Services   0904  Activity Therapy  0910  Psychiatric/Psychological Services (Dates of Service prior to October 16, 2003)   0914  Individual Therapy   0915  Group Therapy   0916  Family Therapy   0918  Behavioral Health/Testing   0942  Education/Training    Hospitals other than CAHs are also required to report appropriate HCPCS codes as follows: