(Medicare Claims Processing Manual)

For dates of service on or after October 1, 2019, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH, e xcluding ambulance providers or suppliers that are not legally authorized to furnish ambulance services to transport individuals either to or from the CAH. Additionally, if there is no provider or supplier of ambulance services located within a 35 mile dri ve of the CAH but there is an entity owned and operated by the CAH located more than a 35 mile drive from the CAH, that CAH- owned and operated entity can only be paid 101 percent of reasonable costs for its ambulance services if it is the closest provider or supplier of ambulance services to the CAH.   Section 205 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 exempts certain CAHs from the current Medicare ambulance cost per trip payment limit as well as from the ambulance fee schedule. Section 205(a) of BIPA states:   The Secretary shall pay the reasonable costs incurred in furnishing ambulance services if such services are furnished (A) by a CAH (as defined in 1861(mm)(1)) , or (B) by an entity that is owned and operated by a CAH, but only if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35 -mile drive of such CAH.  Those CAHs and CAH -owned and operated entities that meet the 35 mile rule for reasonable cost -based payment shall report condition code B2 (CAH ambulance attestation) on their bills.   When the 35 mile  rule for reasonable cost -based payment is not met, the CAH ambulance service or the ambulance service furnished by the entity that is owned and operated by the CAH, is paid based on the ambulance fee schedule.  250.6 - Clinical Diagnostic Laboratory Tests Furnished by CAHs  (Rev. 1782; Issued:  07- 30-09; Effective Date:  07 -01-09; Implementation Date:  07-06-09)  Medicare beneficiaries are not liable for any coinsurance, deductible, copayment, or other cost sharing amount for clinical diagnostic laboratory services furnished as a CAH outpatient service.   For dates of service prior to July 1, 2009, payment for clinical diagnostic laboratory tests furnished by a CAH is made at 101 percent of reasonable cost only if the patient is an outpatient of the CAH and is physically present in the CAH at the time the s pecimen is collected -  (Type of Bill (TOB), 85x).   For dates of service on or after July 1, 2009, an individual is no longer required to be physically present in a CAH at the time the specimen is collected.  However, the individual must be an outpatient of the CAH, as defined at 42 CFR 410.2 and be receiv ing services directly from the CAH.  In order for the individual to be receiving services directly from the CAH, the individual must either be receiving outpatient services in the CAH on the same day the specimen is collected, or the specimen must be colle cted by an employee of the CAH.   Tests for non- patients are billed on TOB 14x, and are paid under the lab fee schedule.   250.7 - Payment for Outpatient Services Furnished by an Indian Health Service (IHS) or Tribal CAH  (Rev. 231, Issued 07- 23-04, Effective: 01 -01-04/Implementation: 01- 03-05)  The IHS or Tribal CAHs are paid for outpatient services based on a facility specific visit rate that is established on a yearly basis from prior year cost report information.  Payment for outpatient IHS or Tribal CAH services is paid at 80% of the facility specific outpatient visit rate for both facilities electing Standard Method (I) and Optional Method (II) billing.  IHS or Tribal CAHs will follow the billing methodology for t he billing method that is chosen.  Standard Method (I) is found in 250.1 and Optional Method (II) is found in 250.2 of this chapter.  Facilities billing under the Optional Method (II) will follow the methodology for HPSA and Scarcity payments as outlined in 250.2 of this chapter.  Outpatient services provided at IHS or Tribal CAHs should be billed on an 85X type of bill.  Effective for cost reporting periods beginning on or after January 1, 2004, payment for outpatient IHS or Tribal CAH outpatient services will be made at 101% of the facility specific outpatient visit rate less applicable Part B deductible and coinsurance amounts.   250.8 - Coding for Administering Drugs in a Method II CAH  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)  This section provides billing guidance and payment instructions for hospitals when providing drugs and drug administration services in a Method II CAH.    250.8.1 - Coding for Low Osmolar Contrast Material (LOCM)  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)  Method II CAHs bill the outpatient physician involvement (professional component) for the administration of Low Osmolar Contrast Material (LOCM) with revenue code 96X, 97X or 98X on type of bill (TOB) 85X.  Bills must include an appropriate outpatient hospital visit CPT code for evaluation and management (E & M).   The technical component for LOCM may be billed by both Method I and Method II CAHs with revenue code 636 and one of the following HCPCS codes as appropriate:   HCPCS Code  Descriptor  Q9945  Low osmolar contrast material (up to 149 mg/ml iodine concentration, per ml) Q9946  Low osmolar contrast material (150 - 199 mg/ml iodine concentration, per ml) Q9947  Low osmolar contrast material (200 - 249 mg/ml iodine concentration, per ml) Q9948  Low osmolar contrast material (250 - 299 mg/ml iodine concentration, per ml) Q9949  Low osmolar contrast material (300 - 349 mg/ml iodine concentration, per ml) Q9950  Low osmolar contrast material (350 - 399 mg/ml iodine concentration, per ml) Q9951  Low osmolar contrast material (400 or greater mg/ml iodine concentration, per ml)   250.8.2 - Coding for the Administration of Other Drugs and Biologicals  (Rev. 803, Issued: 01- 03-06, Effective: 04 -03-06, Implementation: 04- 03-06)  Outpatient physician involvement for hydration; therapeutic or diagnostic injections and intravenous (IV) infusions (other than hydration); and chemotherapy administration in a Method II CAH is included in the physicians evaluation and management (E & M) services. Bills must include an appropriate outpatient hospital visit E & M CPT code with revenue code 96X, 97X or 98X on TOB 85X.   See 250.2 for information on fee schedule payment for professional services.   250.9 - Coding Assistant at Surgery Services Rendered in a Method II CAH  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)  An assistant at surgery is a physician or non- physician practitioner who actively assists the physician in charge of the case in performing a surgical procedure.   Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).   Assistant at surgery services rendered by a physician or non- physician practitioner that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X or 98X and an appropriate assistant at surgery modifier.   Under authority of 42 CFR 414.40, CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes.  This includes the use of payment modifiers for assistant at surgery services.   Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when qualified resident surgeon not available) is used to bill for assistant at surgery services.  When billed without modifier AS (PA, NP or CNS services for assistant at surgery) the  use of these modifiers indicate that a physician served as an assistant at surgery.   Modifier AS is billed to indicate that a PA, NP or CNS served as the assistant at surgery. Modifier 80, 81 or 82 must also be billed when modifier AS is billed.  Claims submitted with modifier AS and without modifier 80, 81 or 82 are returned to the provider (RTPd).   250.9.1 - Use of Payment Policy Indicators for Determining Procedures Eligible for Payment of Assistants at Surgery  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)  Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, PA, NP or a CNS.  Section 1862 of the Act stipulates that no payment can be made for care that is not reasonable and necessary.  Specifically, Section 1862(15)(A) addresses services of an assistant at surgery and when those services are statutorily excluded.   Medicare uses the payment policy indicators on the Medicare Physician Fee Schedule Database (MPFSDB) to determine if assistant at surgery services are reasonable and necessary for a specific HCPCS/CPT code.  The MPFSDB is located at http://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/PFSlookup/ .  Since all of the information housed on the MPFSDB is not needed to process Method II CAH claims, the payment policy indicators that are needed are extracted on a quarterly basis for use in processing these claims and sent to the fiscal A/B MACs (A)  on the Physician Fee Schedule Payment Policy Indicator File.   See the Physician Fee Schedule Payment Policy Record Layout in 250.2 for a description of the assistant at surgery payment policy indicators.   250.9.2 - Payment of Assistant at Surgery Services Rendered in a Method II CAH  (Rev. 1620; Issued:  10- 24-08; Effective:  01 -01-08; Implementation:  04 -06-09)  Under Section 1834(g)(2)(B) of the Social Security Act (the Act) outpatient professional services performed in a Method II CAH are paid 115 percent of such amounts as would otherwise be paid under the Act if the services were not included in the outpatient  CAH services.   Section 1848(i)(2)(B) of the Act stipulates that in the case of a surgical service furnished by a physician, if payment is made separately under the Act for the services of a physician serving as an assistant at surgery, payment shall not exceed 16 percent  of the MPFS amount.  Payment for assistant at surgery services performed by a physician is calculated as follows:    ((facility specific MPFS amount times assistant at surgery reduction % (16%)) minus (deductible and coinsurance)) times 115%   Section 1833(a)(1)(O)(ii) of the Act states that in the case of a PA, NP or CNS the amounts paid for serving as an assistant at surgery shall be the lesser of the actual charge or 85 percent of the amount that would otherwise be recognized if performed by a physician who is serving as an assistant at surgery.  The payment methodology for these services has been codified in regulations found at 42 CFR 414.52(d) and 414.56(c).   Payment for assistant at surgery services performed by a PA, NP, or CNS is calculated as follows:   ((facility specific MPFS) amount times assistant at surgery reduction (16%) times non -physician practitioner reduction % (85%)) minus (deductible and coinsurance)) times 115%   250.9.3 - Assistant at Surgery Medicare Summary Notice (MSN) and Remittance Advice (RA) Messages  (Rev. 3475, Issued: 03- 04-16, Effective: 06 -06-16, Implementation: 06- 06-16)  Contractors shall deny  medically unnecessary assistant at surgery services for HCPCS/CPT codes with a payment policy indicator of 0 or 2 when an Advance Beneficiary Notice (ABN) was issued.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.