(Medicare Claims Processing Manual)

100.3 - Resident and Interns Not Under Approved Teaching Programs  (Rev. 1, 10-01-03)  A3-3669  A. - General   A provider's cost for the services furnished by residents and interns not under approved teaching programs (including physicians employed by the provider who are authorized to practice only in a provider setting) are covered under Part B.  (Part A covers only the costs of services performed for inpatients by residents and interns who are under approved teaching programs.) See the Medicare Benefit Policy Manual, Chapter 6 for further information on the coverage of these services.   The provider determines that part of the inpatient charges which represents the cost of the services of residents and interns who are not under approved teaching programs and bills these separately under Part B, using type of bill code 121 and revenue code 096X, 097X, or 098X as applicable.  B. - Provider Procedures   The cost of Part B residents' and interns' services to inpatients is calculated on a per diem basis by the hospital in consultation with its A/B MAC (A).  The A/B MAC (A) apportions the total cost of such services (including fringe benefits, etc.) between inpatient and outpatient services on the basis of the time spent on each.  It obtains the inpatient per diem figure by dividing the total annual inpatient cost for these services by the estimated annual number of inpatient days for all patients.  For the patients who are enrolled under Part B, regardless of whether Part A benefits are payable, the provider is reimbursed for 80 percent of the cost of providing these services.  The provider collects or bills the complementary insurer for 20 percent of the per diem rate for the services of residents and interns covered under Part B times the number of inpatient days provided.  The administrative cost of determining Part B deductible status involving the cost of query, response, recording, and accounting on an individual basis in the aggregate, exceeds the potential patient deductible obligation.  Therefore, as long as the patient is entitled to Part A benefits no determination of the patient's deductible liability need to be made for inpatient Part B interns' and residents' services.   Patients not enrolled under Part B are liable for the entire cost of intern and resident services.  The provider maintains a record of the inpatient days of these individuals so that this cost may be excluded from the amount of program obligation at the ti me of final cost settlement.   C. - A/B MAC (A) Procedures   Its A/B MAC (A) assists the provider in arriving at the inpatient per diem rate for the cost of services covered under Part B provided by residents and interns.  (See the Provider Reimbursement Manual, Part I, 2120 for apportioning costs between inpatient  and outpatient per diem and 2406 for establishing interim rates.) The normal interim reimbursement rate applied to other provider services applies to Part B residents' and interns' services.   100.4 - Billing for Services After Termination of Provider Agreement  (Rev. 1, 10- 01-03)  HO- 404, HH- 433  An agreement with a hospital is not time -limited and has no fixed expiration date.   A. - Part A Billing   A hospital whose provider agreement terminates (voluntarily or involuntarily), may be reimbursed for covered Part A inpatient services for up to 30 days for services furnished on or after the effective date of termination  for beneficiaries who were admitted prior to the termination date.   EXAMPLE:   Termination date:  6/30/01  Beneficiary admitted on or before 6/29/01  Payment can be made:  6/30/01, up to and including 7/29/01  B. - Assuring That Hospitals Continue to Bill for Covered Services   Upon cessation of a hospital's participation in the program, it supplies the Regional Office the names and HICNs of Medicare beneficiaries entitled to have payment made on their behalf, and continues to bill for covered services in accordance with subsecti on A.  It continues to submit "no- payment" death or discharge bills for Medicare beneficiaries admitted prior to the termination of the provider's agreement.  C. - Part B Billing   Following termination of its agreement, a hospital is considered to be a "nonparticipating hospital."  An inpatient of such a hospital who has Part B coverage, but for whom Part A benefits have been exhausted, or are otherwise not available, is entitled to  reimbursement for those services that are covered in a nonparticipating institution.  Services, if rendered, must be billed on Form CMS -1500 and sent to the A/B MAC (B).  If a hospital has been billing on the CMS -1554 for physician services, it continues to do so.  If a terminated hospital meets the necessary criteria, it may be certified to provide emergency services, and will be assigned an emergency provider number (E suffix).  This procedure is not automatic, however, and hospitals which are terminated for Life S afety Code violations may never be able to qualify as emergency providers.  Should a terminated hospital later qualify as an emergency provider, billings are handled by the designated emergency FI.   100.4.1 - Billing Procedures for a Provider Assigned Multiple Provider Numbers or a Change in Provider Number  (Rev. 267, Issued 07- 30-04, Effective: 10 -01-04, Implementation: 01- 03-05)  Where a multiple -facility provider is assigned separate provider numbers for each component facility or where a provider is assigned a different number, it is required to use the new number for all notices of admission, start of care notices, bills, etc., beginning with the date the new number is effective.  A. - Inpatient   The component provider to which the new number is assigned must apportion costs for all patients who are inpatients in that component as of the first day of the next fiscal period when the new provider number goes in effect.  The hospital must submit a dis charge bill with the old provider number and an admission notice with the new.  The date of discharge and the date of admission are the same date, which is the first day of the new fiscal period.  All subsequent billings are submitted under the new provide r number.  If a no -payment situation where the entire billing period represents charges for which no Part A payment can be made, it is not necessary to submit a discharge bill and admission notice.  In this situation, only a final no- payment bill with a discharge date is submitted under the old provider number.  Services furnished during the "no- payment" period may subsequently be determined to be covered.  Where such covered services were furnished before the date of change in provider number, the hospital  submits one corrected bill covering the entire period showing the old provider number.  However, where services subsequently determined to be covered were furnished after the date of change, the hospital submits a corrected discharge bill with the old provider number and a new admission notice and billing with the new provider number.   Effective October 1, 2004, there are new rules pertaining to long term care hospitals.  (See section 150.14.1).   B. - Outpatient Services, Part B Ancillary Services and Home Health Agency Services   For outpatient services and Part B ancillary services, and home health agency services, the provider uses the old provider number for services provided up through the day before the effective date of the new provider number.  Thereafter, it uses the new number when submitting bills.   100.5 - Review of Hospital Admissions of Patients Who Have Elected Hospice Care  (Rev. 1, 10- 01-03)  HO- 418  Review of admissions to inpatient general hospitals of beneficiaries who have elected hospice care assures that:    Nonhospice Medicare coverage is provided to those beneficiaries only when the hospitalization was for a condition not related to the terminal illness, and    When inpatient hospital services were provided as a hospice benefit, the services rendered were stipulated in the individual's plan of care as established by the hospice's interdisciplinary group.  A. - Review for Nonrelated Hospital Admissions   To assure that nonhospice Medicare coverage is provided to beneficiaries who have elected hospice care only when hospitalization was for a condition not related to the terminal illness, the medical review agent reviews all inpatient hospital claims for the se beneficiaries.  Appropriate medical records will be requested and a determination made as to whether or not services were related to the individual's terminal illness.   Many illnesses may occur when an individual is terminally ill which are brought on by the patient's underlying condition.  For example, it is not unusual for a terminally ill patient to develop pneumonia or some other illness as a result of a weakened condition.  Similarly, the setting of bones after fractures which occur in a bone cancer patient would be treatment of a related condition.   If the review reveals hospitalization to be unrelated to the individual's terminal illness, a determination as to the medical necessity and appropriateness of the admission is made.  Payment will be totally denied or totally approved based on the finding.  If, after review, the admission should have been totally denied, consideration under the limitation of liability provision ( 1879 of the Act) applies.   If the review of medical records reveals hospitalization to be related to the individual's terminal illness, the claim is denied as services waived through the hospice election.  Limitation on liability provision does not apply.  B. - Review for Related Hospital Admissions   To assure that beneficiaries who have elected hospice care are receiving services as provided in the plans of care established by the hospice's interdisciplinary groups, the medical review agent reviews all inpatient hospital claims submitted by the hospic e for these beneficiaries.  Appropriate medical records (including the plans of care) are requested and a determination made as to whether or not services provided were related to the individual's terminal illness and stipulated in the plan of care.   If the review reveals that services provided were medically necessary and appropriate for the control of pain or acute or chronic symptom management as outlined in the individual's plan of care, the claim is approved.   If the review reveals that services provided to the hospice beneficiary were not stipulated in the plan of care as established by the hospice's interdisciplinary group, the claim is denied.  Limitation on liability does not apply.   100.6 - Inpatient Renal Services  (Rev. 1, 10-01-03)  HO-E400  Section 405.103l of Subpart J of Regulation 5 stipulates that only approved hospitals may bill for ESRD services.  Hence, to allow hospitals to bill and be reimbursed for inpatient dialysis services furnished under arrangements, both facilities participating in the arrangement must meet the conditions of 405.2120 and 405.2160 of Subpart U of Regulation 5.  In order for renal dialysis facilities to have a written arrangement with each other to provide inpatient dialysis care both facilities must meet the minimum utilization rate requirement, i.e., two dialysis stations with a performance capacity of at least four dialysis treatments per week.   Dialysis may be billed by an SNF as a service if: (a) it is provided by a hospital with which the facility has a transfer agreement in effect, and that hospital is approved to provide staff-assisted dialysis for the Medicare program; or (b) it is furnished directly by an SNF meeting all nonhospital maintenance dialysis facility requirements, including minimum utilization requirements.  (See 1861(h)(6), 1861(h)(7), title XVIII.)  100.7 - Lung Volume Reduction Surgery  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD -10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)   Lung Volume Reduction Surgery (LVRS) (also known as reduction pneumoplasty, lung shaving, or lung contouring) is an invasive surgical procedure to reduce the volume of a hyperinflated lung in order to allow the underlying compressed lung to expand, and thus, establish improved respiratory function.  Effective for discharges on or after January 1, 2004, Medicare will cover LVRS under certain conditions as described in 240 of Pub. 100- 03, National Coverage Determinations.   The Medicare Code Editor (MCE) creates a Limited Coverage edit for ICD -9-CM procedure code 32.22.  This procedure code has limited coverage due to the stringent conditions that must be met by hospitals.  Where this procedure code is identified by MCE, the A/B MAC (A) shall determine if coverage criteria is met and override the MCE if appropriate.   Effective with the implementation of ICD -10 there will not be an MCE edit for lung volume reduction surgery.  The LVRS can only be performed in the facilities listed on the following Web site:  http://www.cms.gov/Medicare/Medicare- General -Information/MedicareApprovedFacilitie/Lung -Volume -Reduction- Surgery -LVRS.html Medicare previously only covered LVRS as part of the National Emphysema Treatment Trial (NETT).  The study was limited to 18 hospitals, and patients were randomized into two arms, either medical management and LVRS or medical management.  The study was conducted by The National Heart, Lung, and Blood Institute of the National Institutes of Health and coordinated by Johns Hopkins University (JHU).  Hospital claims for patients in the NETT were identified by the presence of Condition Code EY.  The JHU instructed hospitals of the correct billing procedures for billing claims under the NETT.