(Medicare Claims Processing Manual)

Date of  Service  Revenue  Code  HCPCS  Modifier  Charges  7/5/2001 0450 99283 25 $150 7/5/2001 0450 12011  $300 7/5/2001 0450 12035   7/5/2001 0250   $70 7/5/2001 0270   $85  The charge for both surgical procedures in this example is reflected in the $300 charge shown on the line with procedure code 12011.   180.3 - Unlisted Service or Procedure  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  An unlisted HCPCS code represents an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code.  The CPT code book lists a number of unlisted service or procedure codes, which can be found at the end of a section or  subsection.  Alternatively, a summary list of the unlisted CPT codes can be found in the Guidelines section for each chapter of the CPT code book.  The long descriptors for these codes start with the term Unlisted and the last 2 digits of the codes ofte n end in 99.   Under the OPPS, CMS generally assigns the unlisted service or procedure codes to the lowest level APC within the most appropriate clinically related series of APCs.  Payment for items reported with unlisted codes is often packaged.   For non- OPPS payment purposes, when an unlisted service or procedure code is reported, a report describing the service or procedure shall be submitted with the claim.  Pertinent information includes a definition or description of the nature, extent, and ne ed for the procedure or service, as well as the providers time, effort, and equipment necessary to provide the service.   When a Medicare contractor receives a claim with an unlisted HCPCS code for non -OPPS payment, the contractor shall verify that no existing HCPCS code adequately describes the procedure or service.  Unlisted codes should be reported only if no other specifi c HCPCS codes adequately describe the procedure or service.  If an unlisted code is submitted on a claim and the contractor has verified that the code submitted is correct, the contractor pays the claim using the unlisted code, based on the applicable non- OPPS payment methodology.  However, if it is determined that an unlisted code was  submitted in error because the procedure or service is described by a specific HCPCS code, the contractor shall advise the hospital or CAH of the appropriate code and process the claim.  If a procedure or service reported with an unlisted code is reported frequently, the contractor shall advise the provider that a request for a specific CPT code or alphanumeric HCPCS code should be made.   The latest list of Unlisted CPT codes for procedures and services can be found at http://www.cms.hhs.gov/HospitalOutpatientPPS/ .  Select Annual Policy Files from the box at the left, then select the applicable year, and scroll down to Related Links.  Select CYXXXX Unlisted CPT Codes.   Medicare contractors shall review this list once a year since it is updated annually on or about January 1 of the calendar year.   Future updates will be issued in a Recurring Update Notification.   180.4 - Proper Reporting of Condition Code G0 (Zero)  (Rev. 1, 10- 03-03)  Hospitals subject to OPPS report Condition Code G0 on FLs 24- 30 (or the corresponding electronic location) when multiple medical visits occurred on the same day in the same revenue center but the visits were distinct and constituted independent visits.  An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain.  Multiple medical visits on the same day in the same revenue center may be submitted on separate claims.  Hospitals should report condition code G0 on the second claim.  Appropriate reporting of Condition Code G0 allows for accurate payment under OPPS in this situation.  The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.   To further illustrate, the following table describes actions the OCE takes when multiple medical visits occur on the same day in the same revenue code center:   Evaluation and Management (E&M)  Revenue Center  Condition Code  OCE Action  2 or more  Two or more E&M codes have the same revenue center  No G0  Assign medical APC to each line item with E&M code and deny all line items with E&M code except the line item with the highest APC payment  2 or more  Two or more E&M codes have the same revenue center  G0 Assign medical APC to each line item with E&M code.   180.5 - Proper Reporting of Condition Codes 20 and 21  (Rev. 1, 10- 03-03)  Hospitals and CMHCs report condition codes 20 and 21 when they realize the services are excluded from coverage but:    The beneficiary has requested a formal determination (condition code 20) (claim may contain both covered and noncovered charges); or    The provider is requesting a denial notice from Medicare to bill Medicaid or other insurers (condition code 21).  The A/B MACs (A) advise hospitals and CMHCs when billing condition code 21 that a separate claim must be submitted.  Claims with condition code 21 must be submitted with all noncovered charges.   180.6 - Emergency Room (ER) Services That Span Multiple Service Dates (Rev. 2361, Issued: 11- 25-11, Effective: 01 -01-12 and 04- 01-12, Implementation; 04-02-12)  Emergency room (ER) services provided by hospital outpatient departments (OPPS & Non-OPPS) should be billed in the following manner:    Emergency room services are reported under the 045x revenue code    The line item date of service for the ER encounter is the date the patient entered the ER even if the patients encounter spans multiple service dates    For all other services related to the ER encounter (i.e., lab, radiology, etc) the line item date of service reported is the date the service was actually rendered   Note:  For patients in a Skilled Nursing Facility (SNF) see Chapter 6, Section 20.1.2.2 Emergency Services for special billing instructions using the ET modifier.  Chapter 6, Section 20.1.2.2 applies to hospital ER services spanning multiple service dates that  are provided to patients in a Part A SNF stay and related CWF SNF consolidated billing edits.   For patients with end stage renal disease (ESRD) see Chapter 8, Section 50.1.6 for billing instructions requiring the use of the ET modifier.  Chapter 8, Section 50.1.6 applies to hospital ER services spanning multiple service dates including laboratory se rvices.   180.7 - Inpatient -only Services                                                            (Rev. 4513, Issued: 02- 04-2020, Effective: 01 -01- 2020, Implementation: 01 -06-2020)   Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment under the OPPS is appropriate and the Secretary has determined that the services designated to be inpatient only services are not appropriate to be furnished in a hos pital outpatient department. Inpatient only services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. An example of an inpatient only service is CPT code 33513, Coronary artery bypass, vein only; four coronary venous grafts. The designation of services to be inpatient -only is open to public comment each year as part of the annual rulemaking process. Procedures removed from the inpatient only list may be appropriately furnished in either the inpatient or outpatient settings and such procedures continue to be payable when furnished in the inpatient setting. There is no payment under the OPPS for services that CMS designates to be inpatient -only services. These services have an OPPS status indicator of C in the OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. For th e most current Addendum B and for Addendum E published with the OPPS notices and regulations, see http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/index.html.  Excluding the handful of exceptions discussed below, CMS does not pay for an inpatient -only service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the inpatient only procedure.  There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an inpatient -only service that would be paid under the OPPS if the inpatient service had not been furnished:  Exception 1: If the inpatient -only service is defined in CPT to be a separate procedure and the other services billed with the inpatient -only service contain a procedure that can be paid under the OPPS and that has an OPPS SI=T on the same date as the inpatient -only procedure or OPPS SI = J1 on the same claim as the inpatient -only procedure, then the inpatient -only service is denied but CMS makes payment for the separate procedure and any remaining payable OPPS services. The list of separate procedures is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/. Exception 2: If an inpatient -only service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the inpatient only service with modifier CA, then CMS makes a single payment for all se rvices reported on the claim, including the inpatient only procedure, through one unit of APC 5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure.  As of January 1, 2020, procedures that have been removed from the inpatient -only (IPO) list are exempt from certain medical review activities related to compliance with the 2 -midnight rule, which states that generally services are considered appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the patient to require a stay that crosses at least 2 midnights and admits the patient to the hospital based upon that expectation (78 FR 50913 through 50954).    Specifically, procedures that have been removed from the IPO list are not eligible for referral to Recovery Audit Contractors (RACs) for noncompliance with the 2- midnight rule within the 2 -calendar years following their removal from the IPO list. These procedures will not be considered by the Beneficiary and Family- Centered Care Quality Improvement Organizations (BFCC -QIOs) in determining whether a provider exhibits persistent noncompliance with the 2- midnight rule for purposes of referral to the RAC nor wi ll these procedures be reviewed by RACs for patient status within the 2 -calendar years following their removal from the IPO list.  During the 2- year exemption period, BFCC -QIOs will have the opportunity to review claims for procedures that have been recently removed from the IPO list in order to provide education for practitioners and providers regarding compliance with the 2-midnight  rule, but claims identified as noncompliant with the 2 -midnight rule will not be denied with respect to the site -of-service under Medicare Part A.  190  Payer Only Codes Utilized by Medicare  (Rev. 4391, Issued: 09- 06-19, Effective: 07 -01-19, Implementation: 07- 01-19)  This section contains the listing of payer codes designated by the National Uniform Billing Committee to be assigned by payers only.  Providers shall not submit these codes on their claims forms.  The definitions indicating Medicares usage for these syste matically assigned codes are indicated next to each code value.   Condition Codes   12-14 - Not currently used by Medicare.   15  Clean claim is delayed in CMS Processing System.   16  SNF Transition exception.  60  Operating Cost Day Outlier.   61  Operating Cost Outlier.   62  PIP Bill.   63  Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.   64  Other Than Clean Claim.   65  Non -PPS Bill.   98  Data Associated With DRG 468 Has Been Validated.