(Medicare Claims Processing Manual)

See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals) and Pub 100- 04, Medicare Claims Processing Manual, Chapter 4,  10.12 (Payment Window for Outpatient Services Treated as Inpatient Services) regarding  services bundled into the original Part A claim under the 3 -day (1 -day for non- IPPS hospitals) payment window prior to the inpatient admission, that may be billed to Part B when Part A payment cannot be made.  Hospitals should use the following type of bill to report these services:    13X TOB (85X for a CAH) - Hospital outpatient services included in the payment window for outpatient services treated as inpatient services    14X TOB - Laboratory tests that are paid under the clinical laboratory fee schedule (see chapter 16, 40.3 of this manual), and included in the payment window for outpatient services treated as inpatient services   240.6 - Submitting Provider -Liable No- Pay Part A Claims and Beneficiary Liability (Rev. 2877, Issued: 02- 07-14, Effective: 10 -01-13, Implementation: 04- 07-14)  When Part A payment cannot be made for a hospital inpatient admission and the hospital, not the beneficiary, is liable under section 1879 of the Act for the cost of the Part A items and services, the hospital must submit a provider -liable no pay Part A claim (110 TOB) (see chapter 3 40.2.2,  Charges to Beneficiaries for Part A Services of this manual) .  Submission of this claim cancels any claim that may have already been submitted by the hospital for payment under Part A.  When a Medicare review contra ctor denies a Part A claim for medical necessity, the claims system converts the originally submitted 11X claim to a 110 TOB on behalf of the hospital.   When the hospital and not the beneficiary is liable for the cost of the Part A services (pursuant to the limitation on liability provision in Section 1879 of the Social Security Act), the beneficiary is not responsible for paying the deductible and coinsur ance charges related to the denied Part A claim and the beneficiarys Medicare utilization record is not charged for the services and items furnished.  The hospital must refund any payments (including coinsurance and deductible) made by the beneficiary or third party for a denied Part A claim when the provider is held financially liable for that denial (see section 1879(b) of the Act; 42 CFR  411.402; and chapter 30  30.1.2, Beneficiary Determined to Be Without Liability and 30.2.2, Provider/Practitioner/Supplier is Determined to Be Liable of this manual).   Medicare beneficiaries are liable for their usual Part B financial liability for services covered under Part B when Part A payment cannot be made, including Part B copayments for each payable Part B inpatient or Part B outpatient service.  The beneficiary is also liable for the cost of services not covered under Part B.   250 - Special Rules for Critical Access Hospital Outpatient Billing  (Rev. 1111, Issued: 11- 09-06, Effective: 04 -01-07, Implementation: 04- 02-07)  For cost reporting periods beginning before October 1, 2000, a CAH will be paid for outpatient services under the method in 250.1.  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  This provisi on was implemented with respect to cost reporting periods starting on or after October 1, 2001.   For cost reporting period beginning on or after October 1, 2001, the CAH will be paid under the method in item 1 below unless it elects to be paid under the method in 250.1 of this manual.  If a CAH elects  payment under the elective method (cost -based facility payment plus fee schedule for professional services) for a cost reporting period, that election is effective for the entire cost reporting period to which it applies.  If the CAH wishes to make a new election or change a previous election, that election should be made in writing, made on an annual basis and delivered to the appropriate A/B MAC (A), at least 30 days in advance of the beginning of the affected cost reporting period.  All outpatient CAH services, other than pneumococcal pneumonia vaccines, influenza vaccines, administration of the vaccines, screening mammograms, and clinical diagnostic laboratory tests are subject to Part B deductible and coinsurance.  Regardless of the  payment method applicable for a period, payment for outpatient CAH services is not subject to the following payment principles:    Lesser of cost or charges,    Reasonable compensation equivalent (RCE) limits,    Any type of reduction to operating or capital costs under 42 CFR 413.124 or 413.30(j)(7) , or    Blended payment rates for ASC -type, radiology, and other diagnostic services.  See 250.4 below regarding payment for screening mammography services.   250.1 - Standard Method - Cost -Based Facility Services, With Billing of A/B MAC (B) for Professional Services  (Rev. 2581, Issued: 11- 02-12, Effective: 04 -01-13, Implementation: 04- 01-13)  Effective for cost reporting periods beginning on or after January 1, 2004, payment for outpatient CAH services under this method will be made for the lesser of: 1) 80 percent of 101 percent of the reasonable cost of the CAH in furnishing those services, or 2) 101 percent of the reasonable cost of the CAH in furnishing those services, less applicable Part B deductible and coinsurance amounts.   Payment for professional medical services furnished in a CAH to CAH outpatients is made by the A/B MAC (B)  on a fee schedule, charge, or other fee basis, as would apply if the services had been furnished in a hospital outpatient department. For purposes of CAH payment, professional medical services are defined as services provided by a physician or other pract itioner, e.g., a physician assistant that could be billed directly to a A/B MAC (B)  under Part B of Medicare or a nurse practitioner that could be bil led directly to a A/B MAC (B) under Part B of Medicare.   In general, payment for professional medical services, under the cost -based CAH payment plus professional services billed to the A/B MAC (B)  method should be made on the same basis as would apply if the services had been furnished in the outpatient department of a hospital.   Bill type 85X is used for all outpatient services including services approved as ASC services. Non-patient laboratory specimens (those not meeting the criteria for reasonable cost payment in 250.6) will be billed on a 14X type of bill.   (See Section 250.6 -  Clinical Diagnostic Laboratory Tests Furnished by CAHs.)   250.1.1 - Special Instructions for Non -covered Time Increments in Standard Method Critical Access Hospitals (CAHs)  (Rev. 1921, Issued: 02- 19-10, Effective: 04 -01-10, Implementation: 04- 05-10)  CAHs sometimes bill outpatient therapy services using HCPCS that by definition give specific time increments like those discussed in Chapter 5, sections 20 and 40.  However, standard method CAHs are not subject to payment on a fee basis under the Medicare Physician Fee Schedule, therefore these CAHs should follow the instructions below if there is a need to bill non- covered increments.   When HCPCS codes required for reporting do not specify an increment of billing in their definition (i.e., 15 minute intervals), the unit for the line item is 1, and CAHs should follow the general instructions given for billing non- covered charges in Chapter 1, section 60, either by the line item or on no payment claims.  Several of the outpatient therapy HCPCS codes, however, are defined in specific time increments, and units reported on line items should be consistent with these definitions. In such cases, when both covered and non- covered increments are provided in the s ame visit on the same date of service, CAHs should bill as follows:    Report covered and non- covered units in separate line items, even when part of the same visit, with one line item for all covered and non- covered increments in a visit, and another for all non- covered increments in that same visit;   Use ABN- related modifiers when appropriate to explain non- coverage and payment liability of specific lines (i.e., - GY, see Chapter 1, section 60 for details on these modifiers);    Do not report non- covered line items that are part of a partially covered service on a separate no payment claim (i.e., using condition code 21).  Instead, always report them on the same claim with the separate lines for the covered portion of the service.  No payment claims received for the same date, same beneficiary, same provider and same therapy service as a for -payment claim will be rejected. A distinct reason code will make providers aware of the reason for the rejection, and they can correct their bi lling to have covered and non- covered portions of the same service on the same claim;    Do not report non- covered line items as part of the required reporting of value codes 50, 51 and 52 for covered visits (i.e., where all increments are non- covered and there are no covered charges for the line item, since these line items are either part of an already counted partially covered visit, or an entirely non- covered visit); and    Never split a single increment into a covered and non- covered portion.   250.2 - Optional Method for Outpatient Services:  Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional Services  (Rev. 3019, Issued: 08- 07-14, Effective: 01 -01-12, ICD -10: Upon Implementation of ICD-  10, Implementation: 09- 08-14, ICD -10: Upon Implementation of ICD - 10)  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  A CAH may elect to be paid for outpatient services in any cost re porting period under this method by filing a written election with the A/B MAC (A) on an annual basis at least 30 days before start of the Cost Reporting period to which the election applies.  An election of this payment method, once made for a cost report ing period, remains in effect for all of that period for the CAH.   Effective for cost reporting periods beginning on or after October 1, 2010 if a CAH elected the optional method for its most recent cost reporting period beginning before October 1, 2010 or chooses to elect the optional method on or after October 1, 2010, that election remains in place until it is terminated, an annual election is no longer required.  If a CAH elects the optional method on or after October 1, 2010, it must submit its request in writing to its A/B MAC (A) at least 30 days before the start of  the first cost reporting period for which the election is effective.  That election will not terminate unless the CAH submits a termination request to its A/B MAC (A) at least 30 days before the start of its next cost reporting period.   The Medicare Prescription Drugs, Improvement, and Modernization Act (MMA) of 2003, changed the requirement that each practitioner rendering a service at a CAH that has elected the optional method, reassign their billing rights to that CAH.  This provision allows each practitioner to choose whether to reassign billing rights to the CAH or file claims for professional services through their A/B MAC (B).  The reassignment will remain in effect for that entire cost reporting period.  The individual practitioner must certify, using the Form CMS -855R, if he/she wishes to reassign their billing rights.  The CAH must then forward a copy of Form CMS -855R to the A/B MAC (A), and the A/B MACs (B) must have the practitioner sign an attestation  that clearly states that the practitioner will not bill the A/B MAC (A) or A/B MAC (B) for any services rendered at the CAH once the reassignment has been given to the CAH.  This attestation will remain at the CAH.