(Medicare Claims Processing Manual)

Chapter 23 and 30 of this chapter describe the correct coding initiative (CCI) and policies to detect improper coding and duplicate procedures.  E. EKG Interpretations  For services provided between January 1, 1992, and December 31, 1993, A/B MACs (B) must not make separate payment for EKG interpretations performed or ordered as part of, or in conjunction with, visit or consultation services.  The EKG interpretation codes that are bundled in this way are 93000, 93010, 93040, and 93042.  Virtually, all EKGs are performed as part of or ordered in conjunction with a visit, including a hospital visit. If the global code is billed for, i.e., codes 93000 or 93040, A/B MACs (B) should assume that the EKG interpretation was performed or ordered as part of a visit or consultation.  Therefore, they make separate payment for the tracing only portion of the service, i.e., code 93005 for 93000 and code 93041 for 93040.  When the A/B MAC (B) makes this assumption in processing a claim, they include a message to that effect on the Medicare Summary Notice (MSN).  For services provided on or after January 1, 1994, A/B MACs (B) make separate payment for an EKG interpretation.    20.4 - Summary of Adjustments to Fee Schedule Computations  (Rev. 1931, Issued: 03- 12-10, Effective: 06-14-10, Implementation: 06-14-10)  For services prior to January 1, 1994, A/B MACs (B) computed the fee schedule amount for every service.  Through 1995, the fee schedule amount is the transition fee schedule amount.  For services after 1995, CMS computes and provides the fee schedule amount for every service discussed above.  Certain adjustments are made in order to arrive at the final fee schedule amount . Those adjustments are:    Participating versus nonparticipating differential;  Reduction for re-operations;  Site of service payment adjustment;  Multiple surgeries;  Bilateral surgery;   Anti-Markup Payment Limitation;  Provider providing less than global fee package;   Assistant at surgery;   Two surgeons/surgical team; and  Supplies.  20.4.1 - Participating Versus Nonparticipating Differential  (Rev. 1, 10- 01-03) B3-15032 For services/supplies rendered prior to January 1, 1994, the amounts allowed to nonparticipating physicians, under the fee schedule may not exceed 95 percent of the participating fee schedule amount .  Payments to other entities under the fee schedule (physiological and independent laboratories, physical and occupational therapists, portable x-ray suppliers, etc.) are not subject to this differential unless the entities are billing for a physicians professional service.  When a nonparticipating nonphysician is billing for a physicians professional service, Medicares allowance could not exceed 95 percent of the fee schedule amount.  For services/supplies rendered on or after January 1, 1994, payments to any nonparticipant may not exceed 95 percent of the fee schedule amount or other payment basis for the service/supply.  This five percent reduction applies not only to nonparticipating physicians, physician assistants, nurse midwives, and clinical nurse specialists but also to entities such as nonparticipating portable x- ray suppliers, independently practicing physical and occupational therapists, audiologists, and other diagnostic faci lities.  Furthermore, these nonparticipating entities including physicians, are subject to the five percent reduction not only when they bill for services paid for under the physician fee schedule, but also when they bill for services that are legally billable under the physician fee schedule, but which are based upon alternative payment methodologies.  As of January 1, 9994 and beyond, the services/supplies included in this latter category are drugs and biologicals provided incident to physicians services.  The payment basis for these drugs and biologicals is the lower of the average wholesale price (AWP) or the estimated acquisition cost (EAC).  Therefore, the Medicare payment allowance for incident to drugs and biologicals billed by and a nonparticipant  cannot exceed 95 percent of whichever is lower than the AWP or the EAC.   20.4.2 - Site of Service Payment Differential  (Rev. 10356, Issued: 09- 18-2020, Effective Date: 10- 19-2020, Implementation Date: 10- 19-2020)   Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians services when provided in facility and nonfacility settings.  The CMS furnishes both rates in the MPFSDB update.  The rate, facility or nonfacility, that a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face -to-face encounter with the physician, nonphysic ian practitioner (NPP) or other supplier.  In general, the POS code reflects the actual place where the beneficiary receives the face -to-face service and determines whether the facility or nonfacility payment rate is paid.  However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face -to-face encounter with the beneficiary occurred.  For the professional component (PC) of diagnostic tests, the facility and nonfacility payment rates are the same  irrespective of the POS code on the claim.  See chapter 13, section 150 of this manual for POS instructions for the PC and technical component of diagnostic tests.  The list of settings where a physicians services are paid at the facility rate include:    Telehealth (POS code 02);    Outpatient Hospital-Off campus (POS code 19);   Inpatient Hospital (POS code 21);   Outpatient Hospital-On campus (POS code 22);   Emergency Room-Hospital (POS code 23);   Medicare-participating ambulatory surgical center (ASC) for a HCPCS code included on the ASC approved list of procedures (POS code 24);   Medicare-participating ASC for a procedure not on the ASC list of approved procedures with dates of service on or after January 1, 2008. (POS code 24);   Military Treatment Facility (POS code 26);   Skilled Nursing Facility (SNF) for a Part A resident (POS code 31);   Hospice  for inpatient care (POS code 34);    Ambulance  Land (POS code 41);   Ambulance  Air or Water (POS code 42);    Inpatient Psychiatric Facility (POS code 51);    Psychiatric Facility -- Partial Hospitalization (POS code 52);    Community Mental Health Center (POS code 53);   Psychiatric Residential Treatment Center (POS code 56); and    Comprehensive Inpatient Rehabilitation Facility (POS code 61).  Physicians services are paid at nonfacility rates for procedures furnished in the following settings:    Pharmacy (POS code 01);    School (POS code 03);   Homeless Shelter (POS code 04);   Prison/Correctional Facility (POS code 09);   Office (POS code 11);    Home or Private Residence of Patient (POS code 12);    Assisted Living Facility (POS code 13);   Group Home (POS code 14);   Mobile Unit (POS code 15);    Temporary Lodging (POS code 16);    Walk -in Retail Health Clinic (POS code 17);    Urgent Care Facility (POS code 20);    Birthing Center (POS code 25);    Nursing Facility and SNFs to Part B residents (POS code 32);    Custodial Care Facility (POS code 33);    Independent Clinic (POS code 49);    Federally Qualified Health Center (POS code 50);    Intermediate Health Care Facility/Individuals with Intellectual Disabilities (POS code  54);   Residential Substance Abuse Treatment Facility (POS code 55);    Non-Residential Substance Abuse Treatment Facility (POS code 57);    Non-Residential Opioid Treatment Facility (POS code 58);    Mass Immunization Center (POS code 60);    Comprehensive Outpatient Rehabilitation Facility (POS code 62);    End-Stage Renal Disease Treatment Facility (POS code 65);    State or Local Health Clinic (POS code 71);    Rural Health Clinic (POS code 72);    Independent Laboratory (POS code 81); and    Other Place of Service (POS code 99).   See chapter 26, section 10.5 of this manual for the complete listing of the Place of Service code set, including instructions and special considerations for the application of certain POS codes under Medicare.   Nonfacility rates are applicable to outpatient rehabilitative therapy procedures, including those relating to physical therapy, occupational therapy and speech -language pathology, regardless of whether they are furnished in facility or nonfacility settings .  Nonfacility rates also apply to all comprehensive outpatient rehabilitative facility (CORF) services.  In addition, payment is made at the nonfacility rate for physician services provided to CORF patients and appropriately billed using POS code 62 for C ORF.   20.4.3 - Assistant -at Surgery -Services  (Rev. 2656, Issuance: 02- 07-13, Effective: 02- 19-13, Implementation: 02- 19-13)  For assistant -at-surgery services performed by physicians, the fee schedule amount equals 16 percent of the amount otherwise applicable for the surgical payment.  A/B MACs (B) may not pay assistants- at-surgery for surgical procedures in which a physician is used as an assistant -at-surgery in fewer than five percent of the cases for that procedure nationally.  This is determined through manual reviews.  Procedures billed with the assistant- at-surgery physician modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are subject to the assistant- at-surgery policy.  Accordingly, pay claims for procedures with these modifiers only if the services of an assistant- at-surgery are authorized.  Medicares policies on billing patients in excess of the Medicare allowed amount apply to assistant -at-surgery services.  Physicians who knowingly and willfully violate this prohibition and bill a beneficiary for an assistant -at-surgery service for these p rocedures may be subject to the penalties contained under 1842(j)(2) of the Social Security Act (the Act.)  Penalties vary based on the frequency and seriousness of the violation.  Go to http://www.ssa.gov/OP_Home/ssact/title18/1800.htm and select the relevant section.   20.4.4 - Supplies  (Rev. 1, 10-01-03) B3-15900.2  A/B MACs (B) make a separate payment for supplies furnished in connection with a procedure only when one of the two following conditions exists: A. HCPCS code A4300 is billed in conjunction with the appropriate procedure in the Medicare Physician Fee Schedule Data Base (place of service is physicians office).  However, A4550, A4300, and A4263 are no longer separately payable as of 2002.  Supplies have been incorporated into the practice expense RVU for 2002.  Thus, no payment may be made for these supplies for services provided on or after January 1, 2002. B. The supply is a pharmaceutical or radiopharmaceutical diagnostic imaging agent (including codes A4641 through A4647); pharmacologic stressing agent (code J1245); or therapeutic radionuclide (CPT code 79900).  Other agents may be used which do not have an assigned HCPCS code.  The procedures performed are:  Diagnostic radiologic procedures (including diagnostic nuclear medicine) requiring pharmaceutical or radiopharmaceutical contrast media and/or pharmacologic stressing agent;  Other diagnostic tests requiring a pharmacologic stressing agent;  Clinical brachytherapy procedures (other than remote after-loading high intensity brachytherapy procedures (CPT codes 77781 through 77784) for which the expendable source is included in the TC RVUs); or  Therapeutic nuclear medicine procedures.  Drugs are not supplies, and may be paid incidental to physicians services as described in Chapter 17. 20.4.5 - Allowable Adjustments (Rev. 1, 10-01-03) B3-15055