(Medicare Claims Processing Manual)

Application of the Outpatient Mental Health Treatment Limitation (A/B MACs (A))   In accordance with 1833 of the Act, payment is made at 62 percent of the approved amount for outpatient mental health treatment services.  This provision will continue to be implemented in accordance with the Act when these services are furnished to beneficiaries by CORFs.  The refore, make payment at 62 percent of 80 percent of the approved amount (or in effect 50 percent) for outpatient mental health treatment services.   D. SNF Services   Effective with services furnished on or after April 1, 2001, A/B MACs (A)  pay for Part B services furnished to SNF Part B inpatients and outpatients (22X and 23X types of bill) under the MPFS and other applicable fee schedules.  Thus, where a fee schedule exists for the type of service, the fee amount (or charge if less than the applicable fee amount) is paid.  Fee schedules made effective for SNF on this date include: Therapy, Lab, and DMEPOS.  Effective for services furnished by a SNF on and after January 1, 2002, A/B MACs (A)  pay SNFs for radiology, other diagnostic, and other services under the MPFS.  Payment is the lower of billed charges or the fee schedule amount.  In either case, any applicable deductible and coinsurance amounts are subtracted from the payment amount prior to payment.  Coinsurance is calculated on the Medicare payment amount after the subtraction of any applicable deductible amount.  If there is no fee schedule for the service or item being billed, A/B MACs (A) and (HHH) are to make payment based on cost.  Consequently, all services billed under Part B are to be billed using HCPCS codes, whether the beneficiary resides in a certified b ed or a noncertified bed.   30.1 - Maintenance Process for the Medicare Physician Fee Schedule Database (MPFSDB)  (Rev. 1, 10- 01-03)  The CMS calculates the fee schedule payment amounts and releases them to the A/B MACs (B) in the Medicare Physician Fee Schedule Database (MPFSDB).  A/B MACs (B) implement those payment amounts on January 1 of each year.  The CMS maintains the payment file s centrally and is responsible for recalculating any revised payment amounts.  Any revisions initiated by Central Office (fee schedule amounts or payment policy indicators) are issued to the A/B MACs (B) on a quarterly basis.   The information for the ongoing maintenance of the MPFSDB is stated below.   CMS calculates the new fee schedule amounts.  The CMS Central Office issues the revised data to the ROs in the same format of the MPFSDB.    A/B MACs (B) receive a file containing data with revisions for the quarter.  This file is released electronically via CMS Mainframe Telecommunications System.    A/B MACs (B) must allow providers 30 days notification before revised payment amounts are implemented.  The revised payment amounts are implemented the beginning of the following quarter.    CMS furnishes the recalculated payment amounts to the A/B MACs (B) in data files to ensure accuracy.  A/B MACs (B) overlay these files into their existing file, to eliminate the potential for errors.    A/B MACs (B) must make adjustments on those claims that were processed incorrectly if the adjustment is requested by the physician/supplier.  Adjustments are made retroactively to January 1 of the current year, unless otherwise specified.  This directive a pplies in all instances unless the situation requires special consideration.  In those instances, instructions on handling adjustments will be provided on a case -by-case basis.   Separate instructions are issued describing the data exchange for the A/B MACs (A) and (HHH)    .In summary, A/B MACs (A) and (HHH) receive the revised payment amounts two to three weeks after the A/B MACs (B) receive the data from CMS.  A/B MACs (A) and (HHH) do not implement the revised payment amounts prior to the A/B MACs (B)s implementation date.    A/B MACs (B) are required to furnish the revised payment information to the State Medicaid Agencies upon their request one month following receipt of the data from CMS.  Those State agencies with Internet access capability will download the data directly f rom CMS Web site.   The CMS publishes a schedule for Medicare Physician Fee Schedule updates and participation physician enrollment procedures annually for all MACs.  30.2 - MPFSDB Record Layout  (Rev. 4298, Issued: 05- 03-19, Effective: 01 -01-19, Implementation 10- 07-19)  The CMS MPFSDB includes the total fee schedule amount, related component parts, and payment policy indicators.  The record layout is provided in the Addendum below.  30.2.1 - Payment Concerns While Updating Codes  (Rev. 1, 10- 01-03)  The following instructions apply in situations where the CMS CO does NOT provide pricing guidance via the Medicare Physician Fee Schedule Database (MPFSDB) for physicians services.   If a new code appears, A/B MACs (B) make every effort to determine whether the procedure, drug or supply has a pricing history and profile.  If there is a pricing history, map the new code to previous customary and prevailing charges or fee schedule amount s to ensure continuity of pricing.  Since there are different kinds of coding implosions and explosions, the way the principle is applied varies.  For example, when the code for a single procedure is exploded into several codes for the components of that procedure, the total of the separate relative value unit or other charge screens established for the components must not be higher than the relative value units or other charge screens for the original service.  However, when there is a single code that describes two or more distinct complete  services (e.g., two different but related or similar surgical procedures), and separate codes are subsequently established for each, continue to apply the payment screens that applied to the single code to each of the services described by the new codes.   If there is no pricing history or coding implosion and explosion, A/B MACs (B) must make an individual consideration determination for pricing and payment of a covered service.   Conversely, when the codes for the components of a single service are combined in a single global code, A/B MACs (B) establish the payment screens for the new code by totaling the screens used for the components (i.e., use the total of the customary charge s for the components as the customary charge for the global code; use the total of the prevailing charges for the components adjusted for multiple surgical rules if applicable as the prevailing charge for the global code, etc.).  However, when the codes for several different services are imploded into a single code, A/B MACs (B) set the payment screens at the average (arithmetic mean), weighted by frequency, of the payment screens for the formerly separate codes.   30.2.2 - MPFSDB Status Indicators  (Rev. 4418, Issued: 10- 18- 19, Effective: 01 -01- 20 Implementation: 11-  19 19)   A = Active code.  These codes are separately paid under the physician fee schedule if covered.  There will be RVUs and payment amounts for codes with this status.  The presence of an A indicator does not mean that Medicare has made a national coverage determ ination regarding the service; A/B MACs (B) remain responsible for coverage decisions in the absence of a national Medicare policy.  B = Payment for covered services are always bundled into payment for other services not specified.  There will be no RVUs or payment amounts for these codes and no separate payment is ever made.  When these services are covered, payment for them is subsumed by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse regarding care of a patient).  C = A/B MACs (B) price the code.  A/B MACs (B) will establish RVUs and payment amounts for these services, generally on an individual case basis following review of documentation such as an operative report.  D =*  Deleted/discontinued codes.  E = Excluded from physician fee schedule by regulation.  These codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation.  No RVUs or payment amounts are shown and no payment may be made under the fee schedule fo r these codes.  Payment for them, when covered, continues under reasonable charge procedures.  F = Deleted/discontinued codes.  (Code not subject to a 90 day grace period.) These codes are deleted effective with the beginning of the year and are never subject to a grace period.  This indicator is no longer effective beginning with the 2005 fee schedule as of January 1, 2005. G = Not valid for Medicare purposes.  Medicare uses another code for reporting of, and payment for, these services.  (Code subject to a 90 day grace period.)  This indicator is no longer effective beginning with the 2005 fee schedule as of January 1, 2005.  H =*  Deleted modifier.  For 2000 and later years, either the TC or PC component shown for the code has been deleted and the deleted component is shown in the data base with the H status.  I = Not valid for Medicare purposes.  Medicare uses another code for reporting of, and payment for, these services.  (Code NOT subject to a 90 day grace period.)  J= Anesthesia services (no relative value units or payment amounts for anesthesia codes on the database, only used to facilitate the identification of anesthesia services.)  L = Local codes.  A/B MACs (B) will apply this status to all local codes in effect on January 1, 1998 or subsequently approved by central office for use.  A/B MACs (B) will complete the RVUs and payment amounts for these codes.  M= Measurement codes, used for reporting purposes only.  N = Non-covered service.  These codes are carried on the HCPCS tape as noncovered services.  P = Bundled/excluded codes.  There are no RVUs and no payment amounts for these services.  No separate payment is made for them under the fee schedule.  If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident (an example is an elastic bandage furnished by a physician incident to a physician service).  If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (for example, colostomy supplies) and is paid under the other payment provision of the Act.  Q =  Therapy functional information code (used for required reporting purposes only). This indicator is no longer effective beginning with the 2020 fee schedule as of January 1, 2020.  R = Restricted coverage.  Special coverage instructions apply.  T = There are RVUs and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider.  If any other services payable under the physician fee sched ule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made.  X = Statutory exclusion.  These codes represent an item or service that is not in the statutory definition of physician services for fee schedule payment purposes.  No RVUs or payment amounts are shown for these codes and no payment may be made under the phy sician fee schedule.  (Examples are ambulances services and clinical diagnostic laboratory services.)  *Codes with these indicators had a 90 day grace period before January 1, 2005 30.3 - Furnishing Pricing Files  (Rev. 1, 10- 01-03)  The CMS provides a schedule for activities related to furnishing these pricing files in advance each year.  The CMS will provide the completed physician fee schedule, the Durable Medical Equipment and Prosthetics and Orthotics and Supplies (DMEPOS) fee schedules and clinical lab data to United Mine Workers and Indian Health Services.  A/B MACs (A), (B), (HHH), and DME MACs are informed where to access the files for FTP (File Transfer Protocol) download.  30.3.1 - RESERVED  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  30.3.2 - A/B MAC (A), (B), or (HHH) Furnishing Physician Fee Schedule Data for National Codes  (Rev. 4131, Issued: 09- 14-18, Effective: 12 -17-18, Implementation: 12 -17-18)