(Medicare Claims Processing Manual)

For more information on swing -bed services see Chapter 8, in Pub. 100- 02, Medicare Benefit Policy Manual.   100.4.1 - A/B MAC (A) - Swing -bed - Medicare Part A - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Effective July 2002, IHS hospit al swing -bed services began being paid according to the SNF prospective payment system (PPS) payment methodology.  See Chapter 6, 30.6 in Pub. 100- 04, Medicare Claims Processing Manual for information on SNF PPS payment methodology.   Medicare Part A coinsurance is applied to IHS swing -bed inpatient bills, but is waived by the IHS.   100.4.1.1 - A/B MAC (A) - Swing-bed - Medicare Part A - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Revenue code 0022 (special charges) and the Health Insurance Prospective Payment System (HIPPS) codes are reported on the bill along with the accommodation revenue codes.  Services are itemized and billed with the appropriate revenue code that describes the service on TOB 1 8X (hospital swing bed). Medicare swing -bed bill processing instructions are found in Chapter 6, 30 in Pub. 100- 04, Medicare Claims Processing Manual.   The MSN is suppressed.   100.4.2 - A/B MAC (A) - Swing -bed - Inpatient Ancillary Claims - Medicare Part B - Payment Policy  (Rev. 1511; Issued:  05- 23-08; Effective Date:  01- 01-08; Implementation Date:  06 -23-08)  The IHS providers are paid for covered inpatient Medicare Part B ancillary services based upon an all inclusive inpatient ancillary per diem rate (AIR). The AIR is established by CMS and IHS based upon a review of yearly cost reports prepared by IHSs contractor. Upon completion of the review, IHS submits the agreed upon rate to the OMB for approval. Upon approval by OMB, IHS publishes the approved rate in the Federal Register. The AIR is established for each calendar year.  The approved AIR is issued periodically in a Recurring Update Notification.   Medicare Part B coinsurance is applied to IHS hospital Medicare Part B inpatient ancillary bills, but waived by the IHS.   See 100.3.4 of this chapter for more information on the all -inclusive inpatient ancillary per diem rate.   100.4.2.1 - A/B MAC (A) - Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS hospital swing- bed Medicare Part B inpatient ancillary bills revert to inpatient Medicare Part B ancillary bills and are submitted under the regular hospital (or CAH) provider number (not the swi ng-bed provider number) with revenue code 0240 (all inclusive ancillary) on TOB 12X (inpatient Part B). The MSN is suppressed.  100.5 - A/B MAC (A) - Outpatient - Medicare Part B - Payment Policy  (Rev. 1511; Issued:  05- 23-08; Effective:  01- 01-08; Implementation:  06 -23-08)  The IHS providers are paid for covered outpatient services based upon an all inclusive  outpatient per visit rate (AIR). The AIR is established by CMS and IHS based upon a review of yearly cost reports prepared by IHSs contractor. Upon completion of the review, IHS submits the agreed upon rate to OMB for approval. Upon approval by OMB, IHS publishes the approved rate in the Federal Register. The AIR is established for each calendar year.  The approved AIR is issued periodically in a Recurring Update Notification.   Medicare Part B deductible and coinsurance amounts are applied to outpatient s ervices, but are waived by the IHS.   These rates are not  all inclusive inpatient ancillary per diem rates and should not be confused with the all -inclusive inpatient ancillary per diem rates paid to IHS providers for services covered under Medicare Part B when coverage is no longer provided under Medicare Part A. For more information on the all -inclusive inpatient ancillary per diem rates, see 100.3.4 of this chapter.   100.5.1 - A/B MAC (A) - Outpatient - Medicare Part B - Claims Processing  (Rev. 2075, Iss ued: 10 -28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  All charges, except for therapies, telehealth originating site facility fee , PPV, influenza virus vaccine, hepatitis B vaccine and hospital -based ambulance services are combined and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).  Regardless of the number of times a patient is seen in a given day at a particular IHS provider, the outpatient services should be billed only once (i.e., all -inclusive). An exception is when a patient is seen for a clinic visit, then returns to the emergency room later on the same day, at the same provider, for an unrelated condition (or vice versa).  Two clinic visits may be billed in this instance. The remarks section of the bill sha ll include a narrative describing the situation and why two clinic visits are being billed. When a medical visit and an emergency visit occur on the same day, condition code G0 (distinct medical visit) shall be reported on the claim.   While at least one face -to-face encounter with a physician or non -physician practitioner is required for an initial visit to count as a billable encounter, the same is not always true of return visits to obtain follow -up care ordered by the physician or non- physician practitio ner during the initial visit.  If a physician or non -physician practitioner orders a specific procedure or test which cannot be furnished until a later date after the date of the initial visit with the physician or non -physician practitioner, and the proce dures or tests are medically necessary, then it is appropriate for the return encounter to be billed on the date the procedure or test is furnished and for the provider to receive an additional AIR payment even if the beneficiary did not interact with a ph ysician or non- physician practitioner during the return visit.   Examples of medically necessary reasons for return visits would include a requirement that the beneficiary fast for 12 hours prior to an ordered test, or that a chest X -ray be provided two wee ks following the initiation of antibiotic treatment for pneumonia.  In addition, if a beneficiary must return on another day for a medically necessary test ordered during an initial visit because the test cannot be performed on the day it is ordered due to provider or patient constraints that cannot be overcome, the return visit would be considered medically necessary.   See Chapter18, 10 of Pub. 100- 04, Medicare Claims Processing Manual, for detailed billing instructions for vaccines. Chapter 12 of Pub. 100- 04 contains detailed billing instructions for outpatient therapy services provided by an occupational or physical therapist. See Chapter15 of Pub. 100- 04 for detailed billing instructions for ambulance services.   The MSN is suppressed.   100.6 - A/B MAC ( A) - Ambulatory Surgical Center (ASC) - Medicare Part B - Payment Policy (Rev. 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  Qualified IHS providers are reimbursed at the ASC rates published in the Federal Register.  Medicare Part B deductible and coinsurance amounts apply to ASC services, but are waived by the IHS.   See 40.2.1 of this chapter for information on enrolling with the designated A/B MAC (A) to receive payment for ASC services based on the ASC rates.   NOTE:  Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs. All IHS ASC providers must submit their claims to the A/B MAC (B).   100.6.1 - A/B MAC (A) - ASC - Medicare Part B - Claims Processing  (Rev . 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  Charges are reported under revenue code 0360 (operating room services) or 0490 (ambulatory surgical care) on TOB 83X (ambulatory surgical center).  ASC surgeries are identified with CPT codes 10000- 69979 only.  One bill is required for all services provided on the day a surgical procedure is performed.  *Exception:  Revenue code 0276 (intraocular lenses) and charges may be reported separately to report the intraocular lens for cataract surgeries.   The attending/operating UPINs are required in Form Locators 82 and 83 (A -B) on all 83X TOBs.   If all surgeries performed are not on the ASC list published in the Federal Register they should not be reported as surgeries, but rather as clinic visits with TOB 13X and revenue code 0510 (clinic).   If an admission occurs within 1 day of the ASC services, those charges must be included on the inpatient claim, if the principal diagnosis for admission and those outpatient services are the same.   The MSN is suppressed.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs. All IHS ASC providers must submit their claims to the A/B MAC (B).   100.7 - A/B MAC (A) - Critical Access Hosp ital (CAH) Inpatient - Medicare Part A - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS CAHs are paid 101 percent of the all inclusive facility specific per diem rate established on a yearly basis from the most recently filed cost report information for covered inpatient services (on and after January 1, 2004). An average of 96 hours of acute inpatient care in a CAH shall be paid by Medicare Part A.   See Chapter 3, 30.1.1.1 of Pub. 100- 04, Medicare Clai ms Processing Manual, for more information on the payment of inpatient CAH claims.  100.7.1 - A/B MAC (A) - CAH Inpatient - Medicare Part A - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  All charges are combined and reported under revenue code 0100 (all -inclusive room and board plus ancillary) on TOB 11X (hospital inpatient).  Inpatient services are billed from admission through discharge.   The MSN is suppressed.   100.7.2 - A/B MAC (A) - CAH Ancillary Ser vices -Medicare Part B - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Certain inpatient CAH ancillary services are covered under Medicare Part B when coverage is no longer provided under Medicare Part A due t o benefits exhausted, the beneficiary is determined to be receiving a non -covered level of care, or is not eligible for Medicare Part A benefits. Chapter 4, 240 of Pub. 100- 04, Medicare Claims Processing Manual contains information on the physician servic es and the nonphysician medical and other health services covered under Medicare Part B when furnished by a participating IHS provider to an inpatient of the CAH, but only if payment for these services cannot be made under Medicare Part A.   The IHS CAHs ar e paid for covered inpatient Medicare Part B ancillary services based upon 101 percent of an all inclusive facility specific per diem rate that is established on a yearly basis from prior year cost report information. Medicare Part B deductible and coinsur ance amounts are applied to inpatient Medicare Part B ancillary services, but are waived by the IHS.   100.7.2.1 - A/B MAC (A) - CAH Ancillary Services - Medicare Part B - Claims Processing (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  All charges, except therapies, telehealth originating site facility fee ,