(Medicare Claims Processing Manual)

The file of OPPS hospital upper limit CCRs and the file of Statewide CCRs are located on the CMS Web site at www.cms.hhs.gov/HospitalOutpatientPPS/  under Annual Policy Files.  A spreadsheet li sting the Statewide CCRs also  can be found in the file containing the preamble tables that appears in the most recent OPPS/ASC final rule.  The contractors must always use the most recent Statewide CCR.   The file of standard and nonstandard cost centers to be used in the calculation of hospital outpatient CCRs is also found on the CMS Web site at www.cms.hhs.gov/HospitalOutpatientPPS/ under Revenue Code to Cost Center Crosswalk.   10.11.11 - Reporting of CCRs for Hospitals Paid Under OPPS and for CMHCs (Rev.  2111, Issued: 12- 03-10, Effective: 04- 01-11, Implementation: 04- 04-11 )  The contractors shall report the OPPS hospital overall or CMHC CCR they calculate, or the Statewide CCR they sel ect, for each provider to the Outpatient Provider Specific File (OPSF; see 50.1 of this chapter) within 30 days after the date of the calculation or selection of the Statewide CCR for the provider.  If a cost report reopening results in adjustments that w ould change the CCR that is currently in effect, the contractor shall calculate and enter the CCR in the OPSF within 30 days of the date that the reopening is finalized.  In such an instance, contractors must create an additional record in the OPSF for the  provider.  The contractor entries in the OPSF shall include the effective date of the CCR being entered.  Entries in the OPSF shall not replace a pre- existing entry for the provider. The only instances a Medicare contractor retroactively changes a field i n the PSF is to update the CCR when using the FISS Lump Sum Utility for outlier reconciliation or otherwise specified by the CMS Regional Office or Central Office.   10.12 - Payment Window for Outpatient Services Treated as Inpatient Services  (Rev. 3238, Is sued: 04 -22-15,  Effective: 04 -01-15 Implementation: 04 -06-15)  The policy for the payment window for outpatient services treated as inpatient services is discussed in chapter 3  40.3 of this manual.  The policy requires payment for certain outpatient services provided to a beneficiary on the date of an inpatient admission or during the 3 calendar days (or 1 calendar day for a non-IPPS hospital) prior to the date of an inpatient admission to be bundled (i.e., included) with the Medicare Part A payment f or the beneficiarys inpatient admission if those outpatient services are provided by the admitting hospital or an entity that is wholly owned or wholly operated by the admitting hospital.  The policy applies to all diagnostic outpatient services (includin g non- patient laboratory tests) and non -diagnostic services (i.e., therapeutic) that are related to the inpatient stay.  Ambulance and maintenance renal dialysis services are not subject to the payment window.  All diagnostic services (including non- patien t laboratory tests) provided to a Medicare beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital) on the date of the beneficiarys inpatient admission or during the 3 calendar days (or, in the case of a non- subsection (d) hospital, 1 calendar day) immediately preceding the date of admission are required to be included on the Part A bill for the inpatient stay.   Outpatient non- diagnostic services that are related to an inpatient admission must be bundled with the Part A billing for the inpatient stay.  An outpatient service is related to the admission if it is clinically associated with the reason for a patients inpatient admission.  In accordance with section 102 of Pub. L. 111- 192, for services furnished on or after June 25, 2010, all outpatient non- diagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are de emed related to the admission, and thus, must be billed to Part A with the inpatient stay.  Also, outpatient non- diagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholl y operated by the hospital) on the first, second, and third calendar days for a subsection (d) hospital paid under the IPPS (first calendar day for non- subsection (d) hospitals) preceding the date of a beneficiarys inpatient admission are deemed related t o the admission, and thus, must be billed to Part A with the inpatient stay, unless the hospital attests to specific non -diagnostic services as being unrelated to the hospital claim (that is, the preadmission non- diagnostic services are clinically distinct  or independent from the reason for the beneficiarys admission).  Outpatient non- diagnostic services provided during the payment window that are unrelated to the admission, and are covered by Part B, may be separately billed to Part B.  The June 25, 2010 effective date of section 102 of Pub. L. 111- 192 applies to outpatient services provided on or after June 25, 2010.  In the event that there is no Part A coverage for the inpatient stay, the hospital may bill Part B for the services provided to the benefic iary prior to the point of inpatient admission (i.e., the time of formal  admission pursuant to the inpatient admission order) that would otherwise be included in the payment window for Part A payment, including services requiring an outpatient status.  Cer tain Part B inpatient services provided to the beneficiary after the point of inpatient admission (i.e., the time of formal admission pursuant to the inpatient admission order) may also be billed to Part B when Part A payment cannot be made.  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10 Medical and Other Health Services Furnished to Inpatients of Participating Hospital" for a full description of this policy.   A hospital may attest to specific non -diagnostic services as being unrelated to  the hospital Part A claim (that is, the preadmission non- diagnostic services are clinically distinct or independent from the reason for the beneficiarys admission) by adding a condition code 51 (definition 51 -  Attestation of Unrelated Outpatient Non-diagnostic Services) to the separately billed outpatient non- diagnostic services claim.  Providers may submit outpatient claims with condition code 51 starting April 1, 2011, for outpatient claims that have a date of service on or after June 25, 2010.  Outpatient claims with a date of service on or after June 25, 2010, that did not contain condition code 51 received prior to April 1, 2011, will need to be adjusted by the provider if they were rejected by FISS or CWF.   20 - Reporting Hospital Outpatient Services Using Healthcare Common Procedure Coding System (HCPCS)  (Rev. 1, 10- 03-03) A3-3626.4, HO -442.6  20.1 - General  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Reporting of HCPCS codes is required of acute care hospitals including those paid under alternate payment systems, e.g., Maryland, long -term care hospitals.  HCPCS codes are also required of rehabilitation hospitals, psychiatric hospitals, hospital -based RHCs, hospital -based FQHCs, and CAHs reimbursed under Method I I (HCPCS required to be billed for fee reimbursed services).  This also includes all -inclusive rate hospitals.  HCPCS includes the American Medical Associations Current Procedural Terminology, 4th Edition, (CPT -4) for physician services and CMS develope d codes for certain nonphysician services.  All of the CPT-4 is contained within HCPCS, and is identified as Level I CPT codes consist of five numeric characters.  The CMS developed codes are known as Level II.  Level II codes are five- character codes that  begin with an alpha character that is followed by either numeric or alpha characters.   Hospital -based and independent ESRD facilities must use HCPCS to bill for blood and blood products, and to bill for drugs and clinical laboratory services paid outside the composite rate.  In addition, the hospital is required to report modifiers as applicable and as described in 20.6.   The CAHs are required to report HCPCS only for Part B services not paid to them on a reasonable cost basis, e.g., screening mammographies and bone mass measurements.   The HCPCS codes are required for all outpatient hospital services unless specifically excepted in manual instructions.  This means that codes are required on surgery, radiology, other diagnosti c procedures, clinical diagnostic laboratory, durable medical equipment, orthotic -prosthetic devices, take -home surgical dressings, therapies, preventative services, immunosuppressive drugs, other covered drugs, and most other services.  When medical and s urgical supplies (other than prosthetic and orthotic devices as described in the Medicare Claims Processing Manual, Chapter 20, 10.1) described by HCPCS codes with status indicators other than H or N are provided incident to a physician's service by a hospital outpatient department, the HCPCS codes for these items should not be reported because these items represent supplies.  Claims containing charges for medical and surgical supplies used in providing hospital outpatient services are submitted to the  Medicare contractor providing OPPS payment for the services in which they are used.  The hospital should  include charges associated with these medical and surgical supplies on claims so their costs are incorporated in ratesetting, and payment for the supplies is packaged into payment for the associated procedures under the OPPS in accordance with 42 CFR 419.2(b)(4).   For example, if the hospital staff in the emergency department initiate the intravenous administration of a drug through an infusion pump des cribed by HCPCS code E0781 (Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient), complete the drug infusion, and discontinue use of the infusion pump before the patient leaves  the hospital outpatient department, HCPCS code E0781 should not be reported because the infusion pump was used as a supply and would be paid through OPPS payment for the drug administration service.  The hospital should include the charge associated with the infusion pump on the claim.  In another example, if hospital outpatient staff perform a surgical procedure on a patient in which temporary bladder catheterization is necessary and use a catheter described by HCPCS code A4338 (Indwelling catheter; Foley  type, two -way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each), the hospital should not report A4338 because the catheter was used as a supply and would be paid through OPPS payment for the surgical procedure.  The hospital should include the charge associated with the urinary catheter on the claim.   When hospital outpatient staff provide a prosthetic or orthotic device, and the HCPCS code that describes that device includes the fitting, adjustment, or other services necessary for the patients use of the item, the hospital should not bill a visit or procedure HCPCS code to report the charges associated with the fitting, adjustment, or other related services.  Instead, the HCPCS code for the device already includes the fitting, adjustment or other similar services.  For example, if the hospital outpatient staff provides the orthotic device described by HCPCS code L1830 (KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment), the hospital should only bill HCPCS code L1830 and should not bill a visit or procedure HCPCS code to describe the fitting and adjustment.  Claims with required HCPCS coding missing will be returned to the hospital for correction.   Future updates will be issued in a Recu rring Update Notification.   20.2 - Applicability of OPPS to Specific HCPCS Codes (Rev. 1536, Issued:  06- 19-08; Effective:  07- 01-08; Implementation: 07 -07-08)