(Medicare Claims Processing Manual)

64 - HH Reimbursement  Part A -  The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount.  This Part A payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3)  of the Social Security Act.   65 - HH Reimbursement  Part B -  The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount.  This Part B payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   70 - Interest Amount -  The contractor reports the amount of interest applied to this Medicare claim.   71 - Funding of ESRD Networks -  The A/B MAC (A) reports the amount the Medicare payment was reduced to help fund ESRD networks.   72- Flat Rate Surgery Charge -  The standard charge for outpatient surgery where the provider has such a charging structure.   73- Sequestration adjustment amount.  74  Low volume hospital payment amount   75- Prior covered days for an interrupted stay.   76  Providers Interim Rate Providers percentage of billed charges interim rate during this billing period.  This applies to all outpatient hospital and skilled nursing facility (SNF) claims and home health agency (HHA) claims to which an interim rate is applicable.  The contractor reports to the left of the dollar/cents delimiter. An interim rate of 50 percent is entered as follows: 50.00.  77 - Medicare New Technology Add- On Payment -  Code indicates the amount of Medicare additional payment for new technology.  78  Off-site Zip Code - When the facility zip (Loop 2310E N403 Segment) is present for the following bill types: 12X, 13X, 14X, 22X, 23X, 34X, 72X, 74X, 75X, 81X, 82X, and 85X.  The ZIP code is associated with this value and is used to price MPFS HCPCS and Anesthesia Services for  CAH Method II.   79  Total payments for services applicable to the ESRD -  The Medicare shared system will display this payer only code on the claim.  The value represents the dollar amount for Medicare allowed payments applicable for the calculation in determining an outlier payment.   Q0  Pioneer Accountable Care Organization (ACO) non-model payment or Next Generation ACO non- model payment   Q1  Pioneer ACO model payment amount including reduction or NG ACO payment amount including reduction   Q2  Hospice claim paid from Part B Trust Fund   Q3  Prior Authorization 25% Penalty  Q4  PA Rural Model Exclusion - Physician Service Claim Reimbursement   Q5  EHR   Q6  PQRS               Q7  Islet Isolation Add -on payment amount   Q8 - Transitional Drug Add- On Payment Adjustment (TDAPA)   Q9  Medicare Performance Adjustment (MPA)   QA-QC  Not used by Medicare   QD  Device Credit   QE-QL  Not used by Medicare   QM  MIPS adjustment amount   QN  First APC pass- through device offset   QO  Second APC pass -through device offset   QP  Third APC pass -through device offset   QQ  Terminated procedure with device offset   QR  First APC pass- through drug or biological offset   QS  Second APC pass -through drug or biological offset   QT  Third APC pass -through drug or biological offset   QU Device credit with device offset   QV  Value -based purchasing adjustment amount   QW  Placeholder reserved for future use   QX-QZ  Not used by Medicare   200 - Special Services for OPPS Billing  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  200.1 - Billing for Corneal Tissue  (Rev. 3425, Issued: 12- 18-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Corneal tissue will be paid on a cost basis, not under OPPS, only when it is used in a corneal transplant procedure described by one of the following CPT codes: 65710, 65730, 65750, 65755, 65756, 65765, 65767, and any successor code or new code describing a new type of corneal transplant procedure that uses eye banked corneal tissue.  In all other procedures cornea tissue is packaged.  To receive cost based reimbursement hospitals must bill charges for corneal tissue using HCPCS code V2785.   200.2 - Hospital Dialysis Services For Patients With and Without End Stage Renal Disease (ESRD)  (Rev.  2455, Issued: 04- 26-12, Effective: 10 -01-12, Implementation; 10- 01-12)  Effective with claims with dates of service on or after August 1, 2000, hospital -based End Stage Renal Disease (ESRD) facilities must submit services covered under the ESRD benefit in 42 CFR 413.174 (maintenance dialysis and those items and services direct ly related to dialysis such as drugs, supplies) on a separate claim from services not covered under the ESRD benefit.  Items and services not covered under the ESRD benefit must be billed by the hospital using the hospital bill type and be paid under the O utpatient Prospective Payment System  (OPPS) (or to a CAH at reasonable cost).  Services covered under the ESRD benefit in 42 CFR 413.174 must be billed on the ESRD bill type and must be paid under the ESRD PPS.  This requirement is necessary to properly pay only unrelated ESRD services (thos e not covered under the ESRD benefit) under OPPS (or to a CAH at reasonable cost).   Medicare does not allow payment for routine or related dialysis treatments, which are covered and paid under the ESRD PPS, when furnished to ESRD patients in the outpatient department of a hospital. However, in certain medical situations in which the ESRD outpatient cannot obtain her or his regularly scheduled dialysis treatment at a certified ESRD facility, the OPPS rule for 2003 allows payment for non- routine dialysis treatments (which are not covered under the ESRD benefit) furnished to ESRD outpatients in the outpatient department of a hospital.  Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances:    Dialysis performed following or in connection with a dialysis -related procedure such as vascular access procedure or blood transfusions;    Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or    Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.   In these situations, non- ESRD certified hospital outpatient facilities are to bill Medicare using the Healthcare Common Procedure Coding System (HCPCS) code G0257 (Unscheduled or emergency dialysis treatment for an ESRD patient in a hospital outpatient department that is not certified as an ESRD facility).    HCPCS code G0257 may only be reported on type of bill 13X (hospital outpatient service) or type of bill 85X (critical access hospital) because HCPCS code G0257 only reports services for hospital outpatients with ESRD and only these bill types are used to report services to hospital outpatients.  Effective for services on and after October 1, 2012, claims containing HCPCS code G0257 will be returned to the provider for correction if G0257 is reported with a type of bill other than 13X or 85X (such as a 12x inpatient claim).   HCPCS code 90935 (Hemodialysis procedure with single physician evaluation) may be reported and paid only if one of the following two conditions is met:   1) The patient is a hospital inpatient with or without ESRD and has no coverage under Part A, but has Part B coverage.  The charge for hemodialysis is a charge for the use of a prosthetic device.  See Benefits Policy Manual 100- 02 Chapter 15 section 120.  A.  The service must be reported on a type of bill 12X or type of bill 85X.  See the Benefits Policy Manual 100- 02 Chapter 6 section 10 ( Medical and Other Health Services Furnished to Inpatients of Participating Hospitals)  for the criteria that must be met fo r services to be paid when a hospital inpatient has Part B coverage but does not have coverage under Part A; or   2) A hospital outpatient does not have ESRD and is receiving hemodialysis in the hospital outpatient department.  The service is reported on a type of bill 13X or type of bill 85X.    CPT code 90945 (Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous replacement therapies)), with single physician evaluation, may be reported by a hospital paid under the OPPS or CAH method I or method II on type of bill 12X, 13X or 85X.   200.3 - Billing Codes for Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS)  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  200.3.1 - Billing Instructions for IMRT Planning and Delivery  (Rev. 3685, Issued: 12- 22-16, Effective: 01 -01-17, Implementation: 01- 03-17)  Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT  code 77301 (IMRT planning). These codes should not be reported in addition to CPT  code 77301 when provided prior to or as part of the development of the IMRT  plan.  In addition, CPT codes 77280- 77290 (simulation- aided field settings) should not be reported for verification of the treatment field during a course of IMRT.     200.3.2 - Billing for Multi- Source Photon (Cobalt 60 -Based) Stereotactic Radiosurgery (SRS) Planning and Delivery (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  Effective for services furnished on or after January 1, 2014, hospitals must report  SRS planning and delivery services using only the CPT codes that accurately describe  the service furnished.  For the delivery services, hospitals must report CPT code  77371, 77372, or  77373.  CPT  Code  Long  Descriptor  77371 Radiation treatment delivery, stereotactic radiosurgery (srs),  complete course of treatment of cranial lesion(s) consisting of 1 session;  multi-  source cobalt 60  based  77372 Radiation treatment delivery, stereotactic radiosurgery (srs),  complete course of treatment of cranial lesion(s) consisting of 1 session;  linear accelerator  based  77373 Stereotactic body radiation therapy, treatment delivery, per fraction to  1 or more lesions, including image guidance, entire course not to exceed 5 fractions