(Medicare Claims Processing Manual)

A.  Scope of this Subsection  The instructions in this subsection apply to demand bills other than for HH PPS and apply with some modification for Part A SNF services.  Demand bills for those services are subject to special instructions that are cited below.   1. HH PPS Demand Bills. There are special instructions for HH PPS demand bills. Such special instructions must be followed if:   (a) An HHABN is required, or  (b) If a beneficiary requests demand billing when receiving care from a home health agency (HHA) in an HH PPS episode. Instructions for such bills can be found at:    50 of Chapter 10 (Home Health) of the Medicare Claims Processing Manual; and   Note these HH PPS demand bills use frequency code 9.   2. SNF Demand Bills . There are special instructions relating to collection of funds from patients for inpatient Part A SNF demand bills, which can be found in Chapter 30, 70 of the Medicare Claims Processing Manual.  In all other respects, the instructions below apply to SNF Part A services also.   B.  General Instructions   Inpatient and outpatient providers are required to submit demand bills using condition code 20 when requested by beneficiaries.  Billing with condition code 20 is ONLY in case when an ABN is not given/not appropriate for billing related to doubtful liabili ty (for ABN instructions, see 60.4.1 below).  Medicare contractors perform review of demand bills with condition code 20, to assure compliance with codified Medicare medical necessity, coverage and payment liability policy.  Other covered services may appear on demand bills, but not other non-covered charges, as all non -covered charges on demand bills will be considered in dispute and in need of review. Allowing covered and non-covered services to come in on demand bills will allow all services provided in the statement covers period to be billed simultaneously, though payment of the covered services will be delayed by the review and development of the non-covered charges when not split to a separate claim. For this reason, providers should break out demand billed services to separate claims for discrete time periods with all non-covered charges whenever possible.  Demand bills must contain at least one non-covered charge, the coverage of which is at issue, when the Medicare contractor receives them from the provider, or claims with condition code 20 will be returned to the provider.  No payment bills using condition code 21 are only used for services that are not in dispute, as opposed to non-covered charges on demand bills.  Therefore, Condition Code 21 claims can be simultaneously submitted with such bills.   No claims seeking payment and submitted with all covered charges may be submitted by the same provider simultaneously with a demand bill for the same beneficiary.  This restriction is required because some services on demand bills may be found covered upon review.  If such overlapping claims with covered services are received, the incoming claim will be processed to completion as a rejection, with a unique reason code explaining the reason for the rejection. Providers can then correct and re- submit the claim assuming the overlap in periods was a billing error.  Providers should be aware CMS may require development of any non-covered charge on traditional demand bills. Such services will then be paid, RTPed, rejected or denied in accordance with other instructions/edits applied in processing to completion.  C.  Final Summary  In summary, other general requirements for demand bills are:    Condition Code 20 must be used;   All charges associated with Condition Code 20 must be submitted as non-covered;   All non-covered services on the demand bill must be in dispute;   At least one non- covered line must appear on the claim related to the services in dispute;  Unrelated covered charges are allowed on the same claim;   Unrelated non-covered charges not in dispute, if any, would be billed on a no payment claim using Condition Code 21;   Frequency code zero should be used if  all services on the claim are non -covered;   Occurrence code 32 (i.e., ABN) is NEVER submitted on a claim using condition code 20; and   Basic required claim elements must be completed.   Claims not meeting these requirements will be returned to providers.  60.4 - Noncovered Charges on Outpatient Bills  (Rev. 2694, Issued: 05- 03-13, Effective: 10-01-13, Implementation: 10-07-13)  The term outpatient is often used very generally.  In this section, the term outpatient uses the designation of types of bill as inpatient or outpatient as defined in the National Uniform Billing Committee.   TABLE:  Original Medicare Types of Bill  Inpatient or Outpatient.   Designation  Types of Bill  Paid by Original Medicare  Medicare Trust Fund Payment Inpatient  11x  Hospital 18x  Swing Bed 21x  Skilled Nursing Facility (SNF)  41x  RNHCI  Religious Non- Medical Health Care Institution  Part A  Outpatient  81x, 82x  Hospice  Part A  32x,  Home Health (HH) Services under a Plan of Treatment  Part A and Part B  12x, 13x, 14x  Hospital 22x, 23x  SNF  34x  HH Services not under a Plan of Treatment  71x  RHC  Rural Health Clinic  72x  RDF  Renal Dialysis Facility  74x  OPT  Outpatient Physical Therapy (Rehabilitation Agency) 75x  CORF  Comprehensive Outpatient Rehabilitation Facility  76x  CMHC  Community Mental Health Center  77x  FQHC  Federally Qualified Health Center  85x  Critical Access Hospital (CAH)  Part B   Note that under these designations, types of bill 12X and 22X which are referred to as inpatient Part B, are designated as outpatient.  Also, hospice claims are designated as outpatient while they can report both inpatient and outpatient levels of care.  60.4.1 - Outpatient Billing with an ABN (Occurrence Code 32)  (Rev. 1921, Issued: 02- 19-10, Effective: 04-01-10, Implementation: 04-05-10)  The billing instructions in this subsection apply to payment condition 2.  If an ABN is given, the billing procedures in this subsection must be used, rather than traditional demand billing.  Using an ABN is frequently required, and is also allowed on a voluntarily basis when a provider sees fit.  It is used more often than traditional demand billing.   Claim level coding  When a provider determines the beneficiarys services for certain benefits should be terminated, the provider must follow the ED instruction requirements located at section 150.3 below.  If the beneficiary chooses to receive non- covered services after the date the provider believes covered services are terminated, the provider must also issue an ABN to the beneficiary.  In using the ABN, beneficiaries select only one option on the ABN notice prior to billing, after they have been told that the provider anticipates Medicare will not cover a service.  Claims, other than HHPPS claims, billed in association with an ABN never use condition code 20 or 21, and will be returned to providers if received with those codes. Instead, the claims:   Must use occurrence code 32 to signify all services on the claim are associated with one particular ABN given on a specific date, unless the use of modifiers makes clear that not every line on the claim is linked to the ABN;   Must provide the date the ABN was signed by the beneficiary in association with the occurrence code;    Must use occurrence code 32 and the accompanying date multiple times if more than one ABN is tied to a single claim for services that must be bundled/billed on the same claim;    Must submit all ABN -related services as covered charges (note GA modifier exception, below); and   Must complete all the same basic required claim elements as comparable claims for covered services.  Providers should be aware CMS may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN.   If claims using occurrence code 32 remain covered, they will be paid, RTPed, rejected or denied in accordance with other instructions/edits applied in processing.  Denials made through automated medical review of service submitted as covered are still per mitted after medical review, and the Medicare contractor will determine if additional documentation requests or manual development of these services are warranted. For all denials of services associated with the ABN, the beneficiary will be liable.   Line level coding  The GA modifier is used when provider must bill some services which are related and some which are not related to a ABN on the same claim.  The GA modifier is used when both covered and non-covered service appear on an ABN- related claim.  Occurrence code 32 must still be used on claims using the GA modifier, so that these services can be linked to specific ABN(s). In such cases, only the line items using the GA modifier are considered related to the ABN and must be covered charges, other line items on t he same claims may appear as covered or non -covered charges.   60.4.2 - Line -Item Modifiers Related to Reporting of Non -covered Charges When Covered and Non -covered Services Are on the Same Outpatient Claim  (Rev. 2783, Issued: 09- 10-13, Effective: 09-30-13, Implementation: 09-30-13)   Several Healthcare Common Procedural Coding System (HCPCS) modifiers are used to signify a specific line item is either not covered or not payable by Medicare, for many different reasons.  The chart immediately below lists those modifiers, many more commonly used on professional claims, for services not covered or not payable by Medicare.  Modifiers not payable on professional claims are also not payable on institutional claims and will be denied if submitted on such claims.  Providers are liable for these denials, UNLESS a specific modifier (see second table in this section) or indicator on the claim (i.e., occurrence code 32) specifically assigns liability to the beneficiary .  NOTE:   This table does not include ambulance origin and destination modifiers, which may fall into the ranges of modifiers values below, but are NOT non -covered by definition.   Source of the Modifier List  Non-covered Modifiers  Claims Processing Instructions  Definition Source  HCPCS Modifiers Not Covered  or Not  Payable by Medicare by HCPCS Definition  (HCPCS Administrative Instruction) -A1 through -A9,  -GY, - GZ, -H9,  -HA through - HZ,  -SA through - SE,  -SH, -SJ, - SK, - SL,  -ST, - SU, - SV, - SY, -TD through - TR,   -TT through - TW, - U1 through -U9, - UA through UD, UF through - UK Institutional standard systems will deny all line items on all TOBs using these modifiers in all cases as part of processing claims; provider liability is assumed EXCEPT when noted as beneficiary liable in accordance with the chart below (of the total set to the left:- GY) Use as defined by publication of HCPCS codes by CMS CPT/HCPCS Modifiers Permitted on OPPS Claims  See current OPPS instructions  Institutional standard systems accept these modifiers for processing on OPPS claims (TOBs: 12x, 13x, 14x) in accordance with HCPCS/CPT definitions  CPT numerical modifiers defined in publication of CPT Manual by the American Medical Association; HCPCS codes as defined by publication of HCPCS codes by CMS  Modifiers Used in Billing Ambulance Non-covered  Charges  -GY, -QL, -QM* or -QN*, - TQ, alpha origin/destination modifiers*  Applicable TOBs for ambulance billing: 12x, 13x, 22x, 23x, 83x, 85x See ambulance instructions and chart immediately below  Specific HCPCS Modifiers to Consider Related to Non -covered Charges or ABNs  -EY, -GA, -GK, -GL, -GY,  - GZ, -KB,  Institutional standard systems accept some of these modifiers for processing as specified on the chart below  See chart immediately below   * These modifiers are not non-covered by definition, but rather are commonly used on non-covered lines   In the past, modifiers were more frequently used to qualify procedure codes submitted on professional billing formats.  Use of modifiers has increased in institutional billing over time, though institutional claims do not always require the use of procedure codes in addition to revenue codes.  Institutional shared systems require procedure codes to be present any time a modifier is used, whether the line is covered or not.  Providers should use explicit procedure or HCPCS coding to describe services and items they deliver, even when submitting t hese items as non -covered.  In cases in which providers need to submit a non- covered service for which Medicare institutional claims have not required HCPCS coding in the past, such as with drugs or supplies, the following HCPCS code can be used with the appropriate revenue code in order to employ a modifier:  A9270 Non-covered item or service