(Medicare Claims Processing Manual)

 Volvulus 560.2,   Volvulus gastroschisis 756.79, other [congenital] anomalies of abdominal wall,    Volvulus gastroschisis 569.89, other specified disorders of intestine,    Necrotizing enterocolitis 777.5, necrotizing enterocolitis in fetus or newborn,   Necrotizing enterocolitis 014.8, other tuberculosis of intestines, peritoneum, and mesenteric,    Necrotizing enterocolitis and splanchnic vascular thrombosis 557.0, acute vascular insufficiency of intestine,    Inflammatory bowel disease 569.9, unspecified disorder of intestine,    Radiation enteritis 777.5, necrotizing enterocolitis in fetus or newborn, and    Radiation enteritis 558.1.  If ICD -10-CM is applicable, some diagnosis codes that may be used for intestinal failure are:    Volvulus K56.2,   Enteroptosis K63.4,   Other specified diseases of intestine K63.89,   Other specified diseases of the digestive system K92.89,   Postsurgical malabsorption, not elsewhere classified K91.2,    Other congenital malformations of abdominal wall Q79.59,   Necrotizing enterocolitis in newborn, unspecified P77.9,   Stage 1 necrotizing enterocolitis in newborn P77.1,   Stage 2 necrotizing enterocolitis in newborn P77.2, and   Stage 3 necrotizing enterocolitis in newborn P77.3.  D. - Acquisition Costs   A separate organ acquisition cost center was established for acquisition costs incurred on or after October 1, 2001.  Therefore, acquisition charges billed on revenue code 081x are removed from the claims total covered charges so as to not be included in the IPPS outlier calculation.  The Medicare Cost Report will include a separate line to account for these transplantation costs.  For intestinal and multi- visceral transplants performed between April 1, 2001, and October 1, 2001, the DRG payment was payment in full for all hospital services related to this procedure.   E. - Medicare Summary Notices (MSN), Remittance Advice Messages, and Notice of Utilization Notices (NOU)   If an intestinal transplant is billed by an unapproved facility after April 1, 2001, the contractor shall deny the claim.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 171  RARC: N/A  MSN: 21.6 or 21.18 or 16.2  100 - Billing Instructions for Specific Situations  (Rev. 1, 10- 01-03)  100.1 - Billing for Abortion Services  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06 -20-16)  Effective October 1, 1998, abortions are not covered under the Medicare program except for instances where the pregnancy is a result of an act of rape or incest; or the woman suffers from a physical disorder, physical injury, or physical illness, including a life endangering physic al condition caused by the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.   A. - "G" Modifier   The "G7" modifier is defined as "the pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening."   Beginning July 1, 1999, providers should bill for abortion services using the new Modifier G7.  This modifier can be used on claims with dates of services October 1, 1998, and after.  CWF will be able to recognize the modifier beginning July 1, 1999.  B. - A/B MAC (A) Billing Instructions   1. Hospital Inpatient Billing   Hospitals use bill type 11X.  Medicare will pay only when one of the following condition codes is reported:   Condition  Code  Description  AA Abortion Performed due to Rape   Condition  Code  Description  AB Abortion Performed due to Incest  AD Abortion Performed due to life endangering physical condition   With one of the following:   If ICD -9-CM Is Applicable:   an appropriate ICD principal diagnosis code that will group to DRG 770 (Abortion W D&C, Aspiration Curettage Or Hysterotomy) or   an appropriate ICD principal diagnosis code and one of the following ICD -9-CM operating room procedure that will group to DRG 779 (Abortion W/O D&C):69.01, 69.02, 69.51, 74.91.  If ICD -10-CM is applicable, one of the following ICD -10-PCS codes are used:   ICD-10-PCS code  Description  10A07ZZ  Abortion of Products of Conception, Via Natural or Artificial Opening  10A08ZZ  Abortion of Products of Conception, Via Natural or Artificial Opening Endoscopic  10D17ZZ  Extraction of Products of Conception, Retained, Via Natural or Artificial Opening  10D18ZZ  Extraction of Products of Conception, Retained, Via Natural or Artificial Opening Endoscopic  10A07ZZ  Abortion of Products of Conception, Via Natural or Artificial Opening  10A08ZZ  Abortion of Products of Conception, Via Natural or Artificial Opening Endoscopic  10A00ZZ  Abortion of Products of Conception, Open Approach  10A03ZZ  Abortion of Products of Conception, Percutaneous Approach  10A04ZZ  Abortion of Products of Conception, Percutaneous Endoscopic Approach   Providers must use ICD -9-CM codes 69.01 and 69.02 if ICD -9-CM is applicable, or, if ICD -10-CM is applicable,  the related 1CD -10-PCS codes to describe exactly the procedure or service performed.   The A/B MAC (A) must manually review claims with the above ICD -9-CM/ICD -10-PCS procedure codes to verify that all of the above conditions are met.  2. Outpatient Billing   Hospitals will use bill type 13X and 85X.  Medicare will pay only if one of the following CPT codes is used with the "G7" modifier.   59840  59851  59856  59841  59852  59857  59850  59855  59866   C. - Common Working File (CWF) Edits   For hospital outpatient claims, CWF will bypass its edits for a managed care beneficiary who is having an abortion outside their plan and the claim is submitted with the "G7" modifier and one of the above CPT codes.   For hospital inpatient claims, CWF will bypass its edits for a managed care beneficiary who is having an abortion outside their plan and the claim is submitted with one of the above inpatient procedure codes.  D. - Medicare Summary Notices (MSN)/Explanation of Your Medicare Benefits Remittance Advice Message  If a claim is submitted with one of the above CPT procedure codes but no "G7" modifier, the claim is denied.    The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 272  RARC: N/A  MSN: 21.21  100.2 - Payment for CRNA or AA Services (Rev. 4157, Issued: 11- 02-18, Effective: 04 -01-19, Implementation: 04- 01-19)  This section discusses reasonable cost -based payment for CRNA services (42 CFR  412.113(c)).  Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass -through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.   Anesthesia services furnished on or after January 1, 1989, and before January 1, 1990, at a rural hospital or CAH by a qualified hospital employed or contracted CRNA or AA can be paid on a reasonable cost basis.  The A/B MAC (A) determines the hospital's qualification using the following criteria:    The hospital or CAH must be located in a rural area (as defined for PPS purposes) to be considered.   As of January 1, 1988, the hospital or CAH employed or contracted with a CRNA or AA.  The hospital or CAH may employ or contract with more than one CRNA or AA; however, the total number of hours of service furnished by the anesthetists may not exceed 2,080 hours per year.    The hospital or CAH must demonstrate that during the 1987 calendar year, its volume of surgical procedures (inpatient and outpatient) requiring anesthesia services did not exceed 250 procedures.    Each qualified CRNA or AA  employed or under contract with the hospital or CAH must agree in writing not to bill on a reasonable charge basis for his or her patient care to Medicare beneficiaries in that hospital or CAH.   In addition to the criteria described above, to maintain eligibility for reasonable cost -based payment for services furnished on or after January 1, 1990, a hospital or CAH must   provide data for its entire patient population to demonstrate that during ca lendar year 1987 and the year immediately preceding its election of reasonable cost payments, its volume of surgical procedures requiring anesthesia services did not exceed 500 procedures.  Effective October 1, 2002, the hospital or CAH must provide data f or its entire patient population to demonstrate that during calendar year 1987 and the year immediately preceding its election of reasonable cost payments, its volume of surgical procedures requiring anesthesia services did not exceed 800 procedures.   If a hospital or CAH did not qualify for reasonable cost -based payment for CRNA or AA services in calendar year 1989, it can qualify in subsequent years if it demonstrates to the Medicare Contractor prior to the start of the calendar year that it met these  criteria noted below:    The hospital or CAH must be located in a rural area (as defined for PPS purposes) to be considered.   As of January 1, 1988, the hospital or CAH employed or contracted with a CRNA or AA.  The hospital or CAH may employ or contract with more than one CRNA or AA; however, the total number of hours of service furnished by the anesthetists may not exceed 2,080 hours per year.    Each qualified CRNA or AA  employed or under contract with the hospital or CAH has agreed in writing not to bill on a reasonable charge basis for his or her patient care to Medicare beneficiaries in that hospital or CAH.    The hospital or CAH must provide data for its entire patient population to demonstrate that during calendar year 1987 and the year immediately preceding its election of reasonable cost payments, its volume of surgical procedures (inpatient and outpatient) requiring anesthesia services did not exceed 500 procedures.  Effective October 1, 2002, the hospital or CAH must provide data for its entire patient population to demonstrate that during calendar year 1987 and the year immediately preceding its election of reasonable cost payments, its volume of surgical procedures (inpatient and outpatient) requiring anesthesia services did not exceed 800 procedures.   Effective for calendar years beginning January 1, 1991, the A/B MAC (A) determines the number of surgical procedures for the immediately preceding year by summing the number of surgical procedures for the 9- month period ending September 30, annualized for a 12-month period.  Effective December 2, 2010, in addition to a hospital or CAH that is located in a rural area (as defined for PPS purposes), a hospital or CAH may be eligible to be paid based on reasonable cost for CRNA or AA services, if the hospital or CAH has reclassifi ed as rural under 42 Code of Federal Regulations 412.103.  To prevent duplicate payments, the A/B MAC (A) informs A/B MACs (B) of the names of CRNAs or AAs, the hospitals and/or CAHs with which they have agreements, and the effective dates of the agreements.  If the CRNA or AA bills Part B for anesthesia services furnished after the hospital's and/or CAHs election of reasonable cost payments, the A/B MAC (B) must recover the overpayment from the CRNA or AA.  Since a swing -b ed is a bed that is available for use to provide acute inpatient care or SNF -level care and the CRNA/AA pass-t hrough provision applies to hospital inpatients, CRNA and AA services provided to hospital and CAH swing-bed patients under the pass-through provision must be included on the hospital or CAH swing-bed bill.  100.3 - Resident and Interns Not Under Approved Teaching Programs  (Rev. 1, 10-01-03)  A3-3669  A. - General