(Medicare Claims Processing Manual)

180.1 - General Rules  (Rev. 1325; Issued:  08- 29-07; Effective:  01 -01-08; Implementation:  01 -07-08)  Hospitals subject to OPPS are required, beginning with claims with dates of service on or after August 1, 2000, to report in Form Locator 6 Statement Covers Period From Date the earliest date that services were rendered.  As a result, preoperative laboratory services will always have a line item date of service within the from and through dates on the claim.   Indian Health Service hospitals continue to bill for surgeries utilizing bill type 83X.  For other hospitals outpatient surgery subject to the ASC payment limit with dates of service prior to August 1, 2000, is reported on bill type 83X, and surgeries perf ormed August 1, 2000 and later are reported with bill type 13X.  NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims on TOB 83X for ASCs.  All IHS ASC providers must submit their claims to the designated A/B MAC (B).   180.2 - Selecting and Reporting Procedure Codes  (Rev. 1, 10- 03-03) A-01-50, A3- 3626.4.B.3   Using medical records as basic sources, hospitals report HCPCS surgical procedure codes for outpatient surgery in FL 44 adjacent to the revenue code for the operating room or other room used for the surgery.  The bill includes the hospitals charges for the surgery as well as all other services provided on the day the procedure was performed.  When multiple surgical procedures are performed at the same session, it is not necessary to bill separate charges for each procedure.  It is acceptable to bill a single charge under the revenue code that describes where the procedure was performed (e.g., operating room, treatment room, etc.) on the same line as one of the surgical procedure CPT/HCPCS codes and bill the other procedures using the appropriate CPT/HCPCS code and the same revenue code, but with 0 charges in the charge field.   In the past, some hospitals billed a single emergency room (ER) visit charge, which included charges for any surgical procedures that were performed in the ER at the time of the ER visit.  Under the OPPS, CMS requires hospitals to bill a separate charge fo r ER visits and surgical procedures effective with claims with dates of service on or after July 1, 2001.  If a surgical procedure is performed in the ER, the charge for the procedure must be billed with the emergency room revenue code.  If an ER visit occ urs on the same day, a charge should be billed for the ER visit and a separate charge should be billed for the surgical procedure(s) performed.  As described above, a single charge may be billed for all surgical procedures if more than one is performed in the ER during the same session.   EXAMPLE:  The following is an example of how a claim should be completed under these reporting requirements:   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)