(Medicare Claims Processing Manual)

EXAMPLE:   $120 Provider charge;  $100 MPFS amount. Payment is 80 percent of the lower of the actual charge or fee schedule amount, which in this case is $80.00.  ($100.00 (MPFS) X 80 percent.)   The remaining 20 percent or $20 is the patient s coinsurance liability.   These codes are updated as needed by CMS.   If the A/B MAC (A) receives a claim for a Medicare covered CORF service with dates of service on or  after July 1, 2000, that does not appear on its fee schedule abstract file, it has two options for obtaining pricing information:   1. It is provided with a therapy abstract file or CORF supplemental file that contains all therapy services and their related prices.  This supplemental file contains approximately a million records, and may be used as a resource to extract pricing data as needed.  The data in the supplemental file is in the same format as the MPFS abstract file in exhibit 1, but the fields defin ing the fee and outpatient hospital indicators are not populated, instead they are space -filled.   2. It can contact the local A/B MAC (B)  to obtain the price.  When requesting the pricing data, it advises the A/B MAC (B)  to provide the nonfacility  fee from the MPFS.  The MPFS supplemental file of physician fee schedule services is available for retrieval through CMS Mainframe Telecommunications System.  The A/B MAC (A)  is notified yearly of the file retrieval names and dates by a program memorandum or other communication.  100.3 - Proper Reporting of Nursing Services by CORFs - A/B MAC (A)  (Rev. 1459; Issued:  02- 22-08; Effective:  07- 01-08; Implementation:  07 -07-08)  Nursing services performed in the CORF shall be billed utilizing the following H CPCS code:   G0128  Direct (Face to Face w/ patient) skilled nursing services of a registered nurse provided in a CORF, each 10 minutes beyond the first 5 minutes.  In addition, HCPCS G0128 is billable with revenue codes 0550 and 0559 only.     100.4 - Outpatient Mental Health Treatment Limitation  (Rev. 2736, Issued: 06- 28-13, Effective: 10- 01-12, Implementation: 10- 07-13)  The Outpatient Mental Health Treatment Limitation (the limitation) is not applicable to CORF services because CORFs do not provide service s to treat mental, psychoneurotic and personality disorders that are subject to the limitation in section 1833(c) of the Act.  For dates of service on or after October 1, 2012, HCPCS code G0409 is the only code allowed for social work and psychological ser vices furnished in a CORF.  This service is not subject to the limitation because it is not a psychiatric mental health treatment service.   For additional information on the limitation, see Publication 100- 01, Chapter 3, section 30 and Publication 100- 02, Chapter 12, sections 50- 50.5.  100.5 -  Off-Site CORF Services  (Rev. 3220, Issued: 03- 16-15, Effective: ICD -10: Upon Implementation of ICD -10, ASC- X12: 01- 01-12, Implementation: 10- 01-14, ICD -10: Upon Implementation of ICD- 10 ASC X12: 09 -16-14)  The CORFs may provide physical therapy, speech -language pathology and occupational therapy off the CORFs premises in addition to the home evaluation.  Services provided offsite are billed separately and identified as offsite on the claim in remarks.  The charges for offsite visits include any additional charge for providing the services at a place other than the CORF premises.  There is no change in the payment method for offsite services.   100.6 - Notifying Patient of Service Denial  (Rev. 3220, Issued: 03- 16-15, Effective: ICD -10: Upon Implementation of ICD -10, ASC- X12: 01- 01-12, Implementation: 10- 01-14, ICD -10: Upon Implementation of ICD- 10 ASC X12: 09 -16-14)  Services may be noncovered because they are statutorily excluded from coverage under Medicare, or becau se they are not medically reasonable and necessary.   If a service is excluded by statute, the CORF may submit a claim for them to Medicare to obtain a denial prior to billing another insurance carrier .  It shows the charges as noncovered, and includes Condition Code 21. It may bill the beneficiary for the excluded services, and need not issue an advance beneficiary notice (ABN).  However, when providing therapy services under the financial limitations, the CORF should provide the beneficiary with the Notice  of Exclusion of Medicare Benefits (NEMB). The Medicare Claims Processing Manual, Chapter 30, Limitation on Liability, discusses ABNs for A/B MAC (A) processed claims for Part B services.   If, after reviewing the plan of care, the CORF determines that th e services to be furnished to the patient are not medically reasonable or necessary, it immediately provides the beneficiary with an ABN.  If the patient signs an ABN, the claim includes occurrence   code 32 Date Beneficiary Notified of Intent to Bill (Proc edures or Treatments) along with the date the ABN was signed.   If the beneficiary insists that a claim be submitted for payment, the CORF must indicate on the bill (billed separately from bills with covered charges) that it is being submitted at the benef iciarys request.  This is done by using condition code 20.  If during the course of the patients treatment the A/B MAC (A) advises the CORF that covered care has ceased, the CORF must notify the beneficiary (or the beneficiarys representative) immediately.   NOTE:  Information regarding the form locator numbers that correspond to these data element names is found in Chapter 25.   100.7 - Payment of Drugs, Biologicals, and Supplies in a CORF (Rev. 1459; Issued:  02- 22-08; Effective:  07- 01-08; Implementatio n:  07 -07-08)  Drugs   Drugs and biologicals generally do not apply in a CORF setting.  Therefore, contractors are to advise their CORFs not to bill for them.   Supplies   The CORFs should not bill for the supplies they furnish when such supplies are part of the practice expense for that service.  Under the MPFS, nearly all of these expenses are already taken into account in the practice expense relative values.  However, CO RFs may bill separately for certain splint and cast supplies, represented by HCPCS codes Q4001 through Q4051, when furnishing a cast/strapping application service in the CPT code series 29000 through 29750.  Vaccines   The CORFs should refer to Chapter 18, Preventive and Screening Services, for billing guidance on influenza, pneumococcal pneumonia, and Hepatitis B vaccines and their administration.   100.8 -  Billing for DME, Prosthetic and Orthotic Devices, and Surgical Dressings  (Rev. 3220, Issued: 03- 16-15, Effective: ICD -10: Upon Implementation of ICD -10, ASC- X12: 01- 01-12, Implementation: 10- 01-14, ICD -10: Upon Implementation of ICD- 10 ASC X12: 09 -16-14)  The CORFs bill DME to the DME MAC with the ASC X12 professional claim format or Form CMS -1500 except f or claims for implanted DME, which are billed to the local A/B MAC (B).  If the CORF does not have a supplier billing number from the National Supplier Clearinghouse (NSC), it may contact the NSC to secure one.  If the local A/B   MAC (B) has issued the CORF  a provider number for billing physician services, the CORF may not use the same number when billing for DME.   100.10 -  Group Therapy Services (Code 97150)  (Rev. 1145, Issued: 12- 29-06, Effective: 01- 01-07, Implementation: on or before 01-29-07)  Policies for group therapy services for CORF are the same as group therapy services for other Part B outpatient services .  See Pub 100- 02, chapter 15, section 230.   100.10.1 - Therapy Students  (Rev. 1145, Issued: 12- 29-06, Effective: 01- 01-07, Implementation: on or  before 01 -29-07)  Policies for therapy students for CORF are the same as policies for therapy students for other Part B outpatient services.  See Pub. 100- 02, chapter 15, section 230.   100.11 -  Billing for Social Work and Psychological Services in a CORF  (Rev. 2736, Issued: 06- 28-13, Effective: 10- 01-12, Implementation: 10- 07-13)  The CORF providers shall only bill social work and psychological services with the following HCPCS code:   G0409  Social work and psychological services, directly relating to and /or the patient's rehabilitation goals, each 15 minutes, face- to-face; individual (services provided by a CORF -qualified social worker or psychologist in a CORF)   In addition, HCPCS code G0409 shall only be billed with revenue code 0569 or 0911.  100.12 -  Billing for Respiratory Therapy Services in a CORF  (Rev. 1459; Issued:  02- 22-08; Effective:  07- 01-08; Implementation:  07 -07-08)  The CORF providers shall only bill respiratory therapy services with revenue codes 0410, 0412 and 0419.  See Chapter 25, Completing and Processing the CMS -1450 Data Set, for revenue code descriptions.   Exhibit 1 - Physician Fee Schedule Abstract File  (Rev. 515, Issued: 04- 01-05, Effective: 01- 03-05, Implementation: 07- 05-05)  This file contains nonfacility  fee schedule payment amounts for the outpatient rehabilitation, and CORF HCPCS codes listed in 20.  These codes are identified in the abstract file by a value of R in the fee indicator field.  The file includes fee schedule payment amounts by locality and is available via the CMS Mainframe Telecommunications System (formerly referred to as the Network Data Mover).     Record Length:  Record Format:  Block size:  Character Code:  Sort Sequence:  60 FB 6000 EBCDIC  A/B MAC (B) , Locality HCPCS Code, Modifier   Data  Element Name  COBOL Location  Picture  Value  1  HCPCS  1-5 X(05)   2  Modifier  6-7 X(02)   3  Filler  8-9 X(02)   4 -- Non -Facility Fee  10-16 9(05)V99   5  Filler  17-23 X(07)   6  Filler  24-30 X(07)   7 -- A/B MAC (B)  Number  31-35 X(05)   8  Locality  36-37 X(02)  Identical to the radiology/diagnostic fees  9  Filler  38-40 X(03)   10 -- Fee Indicator  41-41 X(1)  R - Rehab/Audiology/CORF services  11 -- Outpatient Hospital  indicator  42-42 X(1)  0 - Fee applicable in hospital outpatient setting  1 - Fee not applicable in hospital outpatient setting  12  Filler  43-60 X(18)    Upon CMS notification, the contractor is responsible for retrieving this file and making payment based on 80 percent of the lower of the actual charge or fee schedule amount indicated on the file after the Part B deductible has been met.  The CMS will notify contractors of updates to the MPFS, file names and when the updated files will be available for retrieval.  Upon retrieval, contractors disseminate the fee schedules to their   providers.  The file is also available on the CMS Web site in the Public Use Files (PUF) area.   Addendum A  - Chapter 5, Section 20.4  Coding Guidance for Certain CPT Codes  All Claims  (Rev. 3220, Issued: 03- 16-15, Effective: ICD -10: Upon Implementation of ICD- 10, ASC- X12: 01- 01-12, Implementation: 10- 01-14, ICD -10: Upon Implementation of ICD- 10 ASC X12: 09 -16-14)