(Medicare Claims Processing Manual)

80.6 - Inflation Indexed Charge (IIC) for Nonphysician Services  (Rev. 2837, Issued: 12- 13-13, Effective: 01 -01-14 - payment reasonable charge basis/04- 01-14 - payment national fee schedule basis, Implementation: 01 -06-14 - payment reasonable charge basis/04- 07-14 - payment national fee schedule basis)   A General   Effective for services rendered on or after October 1, 1985, an additional factor -  the inflation indexed charge (IIC), is added to the factors taken into consideration in determining reasonable charges for non- physician services.  Non -physician services are defined as those Part B medical services, supplies, and equipment reimbursed on a reasonable charge basis and not subject to the application of the Medicare Economic Index (MEI).   Examples of items affected by the IIC are:    Prosthetic and orthotic devices not subject to the fee schedules [Therapeutic Shoes (2005 and prior), Intraocular Lenses (2014 and prior)];    Blood products and transfusion medicine;    Certain medical supplies used in connection with home dialysis (2011 and prior); and   Ambulance services (2001 and prior)   80.7 - Determination of Comparable Circumstances (Rev. 1, 10- 01-03) B3-5026  A/B MACs (B) do not make a reasonable charge determination that would be higher than the charge upon which they would base payment to their own policyholders for a comparable service under comparable circumstances.  The charge upon which payment is based does not mean the amount the A/B MAC (B) would be obligated to pay.  Under certain circumstances, some A/B MACs (B) pay amounts on behalf of thei r policyholders, which are below the customary and prevailing charges physicians or other persons usually make to the general public.  Payments under the medical insurance program are not limited to these lower amounts.   Comparable circumstances refers to the circumstances under which services are rendered to individuals and the nature of your health insurance programs, and the method used to determine the amounts of payment under these programs.  Generally, comparabilit y exists where:    Payment is made under the contractors own program on the customary charges of physicians or other persons, and on current prevailing charges in a locality, and   The determination does not preclude recognition of factors such as specialty status and unusual circumstances that affect the amount charged for a service.   However, even where there is comparability, coverage limitations applicable under the contractors own programs do not necessarily apply to reasonable charge determinations for Medicare purposes.   The current customary and/or prevailing charges of an A/B MAC (B)s private health plan refer to the payment screens that are presently in effect, e.g., payment levels actually being used in the A/B MAC (B)s private business for settling claims submitte d by its policy holders or subscribers.  A/B MACs (B) must, therefore, continue to apply the comparability limitation based upon their payment screens that are presently in effect, even where an update under their private insurance plans has been deferred.   If an A/B MAC (B)s private health plan allowances are later revised, it will be necessary for the A/B MAC (B) to reexamine the relationship of these new payment levels to those under the Medicare program an initiate the necessary changes through their r outine maintenance operations.   Responsibility for determining whether an A/B MAC (B)s program has comparability will fall upon the A/B MAC (B) in reporting pertinent information about its programs to CMS.  When the pertinent information has been reported, CMS will advise the A/B MAC (B ) whether any of its programs have comparability.  80.8 - Applying Criteria for Reasonable Charge Determinations  (Rev. 1, 10- 01-03) B3-5030, B3- 5030.2  The reasonable charge determination for a covered service should be based on the actual charge for the service when that charge is no higher than the applicable customary and prevailing charges.  The A/B MAC (B) should exercise judgment so that its reasona ble charge determinations are realistic and equitable.  A/B MACs (B) should take into account special factors in individual cases that might affect the reasonableness of charges.  The special factors could involve travel, medical complications, or other unusual circumstances such as prolonged time and attention required by a patients condition.   Different services and supplies for which charges are made under Part B, may not be grouped together for the purpose of making one overall reasonable charge determination.  Thus, in processing a claim for payment a separate reasonable charge determination must be made with respect to each item for which a charge is made.   80.8.1 - Waiver of Deductible and Coinsurance  (Rev. 1, 10- 01-03) B3-5220  Physicians or suppliers who routinely waive the collection of deductible or coinsurance from a beneficiary constitute a violation of the law pertaining to false claims and kickbacks.  These situations should be referred to Program Integrity area for additional investigation according to the procedures in the Medicare Program Integrity Manual.  Deductible and coinsurance amounts are taken into account (included) in determining the reasonable charge for a service or item.  In this regard, a billed amount that is not reasonably related to an expectation of payment is not considered the actual cha rge for the purpose of processing a claim or for the purpose of determining customary charges.   Where a physician/supplier makes a reasonable collection effort for the payment of coinsurance/deductibles, failure to collect payment is not considered a reduction in the physicians/suppliers charge.  To be considered a reasonable collection effort, the  effort to collect Medicare coinsurance/deductible amounts must be similar to the effort made to collect comparable amounts from non- Medicare patients.  It must also involve the issuance of a bill to the beneficiary or to the party responsible for the pati ents personal financial obligations.  In addition, it may include other actions, such as subsequent billings, collection letters and telephone calls or personal contacts which constitute a genuine, rather than token, collection effort.  90 - Inherent Reasonableness Used for Payment of Nonphysician Services  (Rev. 1, 10- 01-03) B3-5246, AB -98-9 (Obsolete instructions)   Placeholder for instruction when current regulation is finalized.   100 - Competitive Bidding Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Single Payment Amounts  (Rev. 2682, Issued: 04- 05-13, Effective: 07 -01-13, Implementation: 07- 01-13)  Section 1847 (b)(5) of the Social Security Act mandates that a single payment amount be established for each item in each competitive bid area based on the bids submitted and accepted for that item.  Section 1847(a)(6) of the Act requires that this payment  basis be substituted for the fee schedule payment basis otherwise applied under section 1834(a) of the Act for DME, section 1834(h) of the Act for off -the-shelf orthotics, or section 1842(s) of the Act for enteral nutrients, equipment and supplies, as appropriate.   For the Round One Rebid, the DME MACs will make payment based on the new competitive bidding single payment amounts effective for claims with dates of service on or after January 1, 2011.  The CMS issues instructions for implementing the single payment amo unts and/or updating the payment amounts quarterly for competitive bidding items.  The following files will be provided to the DME MACs and the Pricing, Data Analysis and Coding (PDAC) Contractor via CMS mainframe telecommunication system in order to impl ement a competitive bidding round:  a Healthcare Common Procedure Coding System (HCPCS) category file, a bid pricing file, a ZIP Code file, and a contract supplier  file.  All four files will contain data only for the current competitive bidding round.  The DME MACs will make manual updates to the competitive bidding files, as instructed through Recurring Update Notifications.  The following files will be provided on a quarterly basis to the DME MACs and the Pricing, Data Analysis and Coding (PDAC) Contra ctor via CMS mainframe telecommunication system:  HCPCS category file, bid pricing file, and ZIP Code file.  These files will only contain the changes for that quarter.   Upon successful receipt of the mainframe files, DME MACs will send notification of receipt via e- mail to price_file_receipt@cms.hhs.gov, stating the name of the files received and the entities for which they were received (e.g., DME MAC name).   Following program implementation and on an as needed basis, updates to the contract supplier file will be accomplished via an Excel file emailed directly from the Competitive Bidding Implementation Contractor (CBIC) to the DME MACs.  Upon successful receipt of the files, the DME MACs will send notification of receipt via email stating the name of the file received and the entities for which they were received (e.g., DME MAC name) to the CBIC.  E -mails should be sent to cbic.dmemac@palmettoGBA.com  at the CBIC.  The DME MACs shall manually update the contract supplier file with the changes by adding and/or end dating each supplier record.   Public use files containing the competitive bidding HCPCS categories, single payment amounts and ZIP Codes are available on the CBIC Website at http://www.dmecompetitivebid.com/palmetto/cbic.nsf .  100.1 - Record Layout for Competitive Bidding HCPCS Category File  (Rev. 2088, Issued: 11- 05-10, Effective: 01 -01-11, Implementation: 01- 03-11)   Field Name  Pic Position  Comment  CBA Bid Category Effective Date  X(8)  1 - 8  Bid Product Category Effective Date - CC 9(2) 1 - 2  Bid Product Category Effective Date -Year  9(2) 3 - 4  Bid Product Category Effective Date - Month 9(2) 5 - 6  Bid Product Category Effective -Day 9(2) 7 - 8  Bid Category Expiration Date  X(8)  9 - 16  Bid Product Category Expiration Date - CC 9(2) 9 - 10  Bid Product Category Expiration Date -  Year  9(2) 11 - 12  Field Name  Pic Position  Comment  Bid Product Category Expiration Date - Month 9(2) 13 - 14  Bid Product Category Expiration Date -  Day  9(2) 15 - 16  HCPCS Procedure Codes  X(13)_  17 - 29  HCPCS Procedure Code  X(5)  17 - 21 All Competitive Bidding Active Codes.  Modifier 1  X(2)  22 - 23  Modifier 2  X(2)  24 - 25  Modifier 3  X(2)  26 - 27  Modifier 4  X(2)  28 - 29  Field Name  Pic Position  Comment  CBA Area  X(5)  30 - 34 16740 = Charlotte NC -SC 16741 = Charlotte NC -SC Mail Order  17140 = Cincinnati OH  17141 = Cincinnati OH Mail Order  17460 = Cleveland OH  17461 = Cleveland OH Mail Order  19100 = Dallas TX  19101 = Dallas TX Mail Order  28140 = Kansas MO -KS 28141 = Kansas MO - KS Mail Order  33100 = Miami FL  33101 = Miami FL Mail Order  36740 = Orlando FL  36741 = Orlando FL Mail Order  38300 = Pittsburgh PA  38301 = Pittsburgh PA Mail Order  40140 = Riverside CA  40141 = Riverside CA Mail Order  Bid Product Category Number  X(3)  35 - 37 001 = Oxygen Supplies & Equipment  002 = Standard Power Wheelchairs  003 = Complex Rehab Power Wheelchairs  004 = Mail Order Diabetic Supplies  005 = Enteral Nutrients, Equipment  006 = CPAPs, RADs and Related Supplies  007 = Hospital Beds & Related Supplies  009 = Walkers & Related Supplies  010 = Support Surfaces  Field Name  Pic Position  Comment  Bid Business Rule 1  X(1)  38 - 38 When field contains S, permits non-contract physicians to bill selected CB items or H, permits Hospitals to bill selected CB items   Bid Business Rule 2  X(1)  39 - 39 When field contains S, permits non-contract physicians to bill selected CB items or H, permits Hospitals to bill selected CB items.  Bid Business Rule 3   X(1)   40 - 40  For  future use   Bid Business Rule 4   X(1)   41- 41  For future use   Bid Business Rule 5   X(1)   42 - 42  For future use  Filler  X(8)  43 - 50   100.2 - Record Layout for Competitive Bidding Pricing File  (Rev. 2088, Issued: 11- 05-10, Effective: 01 -01-11, Implementation: 01- 03-11)