(Medicare Claims Processing Manual)

Modifier Reporting -  Origin and destination modifiers used for ambulance services are created by combining two alpha characters.  Each alpha character, with the exception of x, represents an origin code or a destination code.  The pair of alpha codes creates one modifier.  The first position alpha code equals origin; the second position alpha code equals destination. Origin and destination codes are listed below :  D - Diagnostic or Therapeutic Center other than P or H when these are used as origin codes   E - Residential, Domiciliary, Custodial Facility (Other than an 1819 Facility)   G - Hospital based dialysis facility (hospital or hospital related)   H - Hospital   I - Site of Transfer (e.g., airport or helicopter pad) between modes of ambulance transport   J - Nonhospital based dialysis facility   N - SNF (1819 Facility)   P - Physician's Office (Includes health maintenance organization (HMO) non -hospital facility, c linic, etc.)   R - Residence   S - Scene of Accident or Acute Event   X - (Destination code only) intermediate stop at physician's office enroute to the hospital (includes HMO non- hospital facility, clinic, etc.)   All claims processing requirements in Chapter  15 of Pub. 100- 04, Medicare Claims Processing Manual, shall apply to ambulance claims submitted by IHS independent ambulance suppliers.   The MSN is suppressed.   80.4 - A/B MAC (B) - Vaccines and Vaccine Administration -  Payment Policy (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Medicare Part B payment may be made to IHS physicians and practitioners that furnish vaccines including pneumococcal pneumonia virus (PPV), influenza virus and hepatitis B virus. Medicare Part B pay ment may be made to IHS physicians and practitioners for the administration of these vaccines.  Payment for the administration of the vaccine is based on the MPFS. Payment is made by the A/B MAC (B).  See Chapter 18 of Pub. 100- 04, Medicare Claims Processi ng Manual for more information on this benefit.  80.4.1 - A/B MAC (B) - Vaccines and Vaccine Administration - Coverage Policy (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Pneumococcal Pneumonia Vaccinations   The Medicare Part B program covers PPV and its administration when furnished in compliance with any applicable State law by any provider of services or any entity or individual with a supplier number.  This includes revaccination of patients at highest risk of pneumococc al infection.  Typically, these vaccines are administered once in a lifetime except for persons at highest risk.  See Chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual for more information on this benefit.   Hepatitis B Vaccine   The Medicare Part  B program provides coverage of hepatitis B vaccine and its administration, furnished to a Medicare beneficiary who is at high or intermediate risk of contracting hepatitis B.  See Chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual for more infor mation on this benefit.  Influenza Virus Vaccine  The Medicare Part B program covers influenza virus vaccine and its administration when furnished in compliance with any applicable State law by any provider of services or any entity or individual with a supplier number.  Typically, these vaccines are administered once a year in the fall or winter. Medicare does not require, for coverage purposes, that a doctor of medicine or osteopathy order the vaccine.  Therefore, the beneficiary may receive the vaccine upon request without a physicians order and without physician supervision.  See Chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual for more information on this benefit.   80.5 - A/B MAC (B) - Screening and Preventive Services  (Rev. 2075, Issued:  10-28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  Medicare Part B makes payment for the following screening and preventive services:    Pelvic exam;   Glaucoma screening;   Bone mass measurements;   Prostate cancer screening;   Colorectal cancer screening;   Screening pap smear;   Screening mammography;   Cardiovascular screening blood tests;   Diabetes screening tests;   DSMT;   Influenza virus vaccine and its administration, pneumococcal vaccine and its administration; hepatitis b virus and its administration;   Initial physician physical exam (IPPE) -  Welcome to Medicare;   MNT; and   Smoking and tobacco- use cessation (counseling/screening).   Payment is made for the screening and preventive services listed, excluding vaccines, based on the MPFS. Chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual contains more information on the payment of screening and preventive services, including the method of payment for vaccines.   Effective January 1, 2005, payment is made by the A/B MAC (B) for the services of IHS physicians  and practitioners furnished in hospitals and ambulatory care clinics for screening and preventive services covered under 630 MMA, indefinitely extended by 2902 of the ACA.   80.6 - A/B MAC (B) - Clinical Laboratory Services - Payment Policy (Rev. 2075, I ssued: 10 -28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  Medicare Part B payment may be made to freestanding facilities for covered clinical laboratory tests. Freestanding facilities are paid for clinical laboratory tests covered as a result of 630 MMA, indefinitely extended by 2902 of the ACA, based on the clinical laboratory fee schedule.   80.6.1 - A/B MAC (B) - Clinical Laboratory Services - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Some cli nical laboratory procedures or tests require FDA approval before coverage is provided. Laboratory services furnished by a freestanding facility are covered under Medicare Part B if the laboratory is an approved independent clinical laboratory. However, as is the case of all diagnostic services, in order to be covered these services must be related to a patients illness or injury (or symptom or complaint) and ordered by a physician. A small number of laboratory tests can be covered as a screening and preven tive service.  Freestanding facilities bill clinical laboratory services to the designated A/B MAC (B).   See 80.1 of Chapter 15 of Pub. 100- 02, Benefit Policy Manual, for more information on this benefit.   See Chapter 16 of Pub. 100- 04, Claims Processing M anual, for detailed claims processing instructions.  See Pub. 100- 08, Medicare Program Integrity Manual, Chapter 10, for laboratory/supplier enrollment guidelines.   See Pub. 100- 07, Medicare State Operations Manual for laboratory/supplier certification requirements.   80.7 - A/B MAC (B) - Medical Nutrition Therapy (MNT) - Payment Policy (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Section 105 of BIPA permits Medicare coverage of MNT when furnished by a registered dietician  (RD) meeting certain requirements.   See Chapter 4, 300 through 300.6 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on these requirements.   Medical nutrition therapy services rendered by an RD who is an individual practitioner or member of a group practice may be provided in a beneficiarys home if the physician adequately documents the need for having the services provided in the beneficiarys home in his/her written orders.  Under these circumstances, the practitioner may render the MNT services in the beneficiarys home and bill the designated A/B MAC (B) under the practitioners or group practices A/B MAC (B) issued PIN.  Even if the practitioner has contracted with an IHS provider to provide MNT in the hospital outpatient department, the practitioner may, during hours not included in the contracted services, provide MNT in the beneficiarys home, and submit a bill to the designated A/B MAC (B), using the PIN of the practitioner or group practice.  Payment is made by the A/B MAC (B) based upon the fee schedule.   80.7.1 - A/B MAC (B) - MNT - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  If the RD providing the services is an employee of an independent or free standing clinic and the services are provided in the clinic, the services are billed to the designated A/B MAC (B).   See Chapter 4, 300 through 300.6 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on the Healthcare Common Procedure Coding System (HCPCS) codes used to bill MNT to the A/B MAC (B).   80.8 - Dual Eligibility (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  The Omnibus Budget Reconciliation Act of 1989 requires mandatory assignment of claims for physician services furnished to individuals who are eligible for Medicaid, including those individuals eligible as qualified Medicare beneficiaries. Therefore, claims for services to dual eligibles are paid as assigned claims.   80.9 - A/B MAC (B) Claims Processing and Payment Policy for ASC Claims  (Rev. 1325; Issued:  08-29-07; Effective:  01-01- 08; Implementation:  01 -07-08)  Effective for services on or after January 1, 2008, the designated IHS A/B MAC (B) shall accept and pay for claims submitted by IHS and tribal hospitals that elect to enroll as ASC facilities.  See Pub. 100-04, Medicare Claims Processing Manual, Chapter 14, for information on ASC claims processing.  See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, for information on ASC payment policy.  90 - DME General Information  (Rev. 11427; Issued: 05-20- 22; Effective: 01 -01-23; Implementation: 01-03-23)  NOTE:  CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase customer satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.  For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.  For claims with dates of service prior to January 1, 2023  processes will not change and if the CMN or DIF i s required, it will still need to be submitted with the claim, or be on file with a previous claim. This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned.   The DME MACs process claims for items of DMEPOS for us e in the beneficiarys home .  Beginning January 1, 2005, Medicare Part B makes payment for medically necessary items of DME, prosthetics, orthotics, and supplies to IHS suppliers that furnish DME for use in the beneficiarys home. See Pub. 100- 02, Medicare  Benefit Policy Manual, Chapter 15, 110 for more information on this benefit.  Note that the DME MACs make payment for DMEPOS only in cases where the beneficiary medically needs the equipment in his or her home.  Items provided during an inpatient hospita l or SNF stay are included in the payment made to the hospital or SNF, with certain exceptions.  (See Chapter 6, 20.3 of Pub. 100- 04, Medicare Claims Processing Manual for exceptions to SNF consolidated billing, and Chapter 20, 110.3 for exceptions to DM EPOS provided for fitting and training prior to an inpatient discharge.)  More information regarding when items of DMEPOS are billed to a DME MAC or to an A/B MAC (A) is outlined below.