(Medicare Claims Processing Manual)

80 - A/B MAC (B)  - Payment Policy and Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09 -11-06)  80.1 - A/B MAC (B)  - Medicare Part B Physician and Practitioner Services Paid Under the Medicare Physician Fee Schedule (MPFS) - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Prior to the enactment of BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and SNFs. Effective July 1, 2001, 432 BIPA extended payment to services of IHS physicians and practitioners furnished in hospitals and ambulatory care clinics.   The services that may be paid to IHS physicians and practitioners under the MPFS are as follows:    Services for which payment is made under 1848 of the Act.  Section 1848(j)(3) defines physician services paid under the MPFS. Although anesthesia services are considered to be physician services, these services are not included on the physician fee schedule database. Anesthesia services are covered and are reimbursed using a separate payment method (see 1848(d)(1)(D)). Also, included are diagnostic tests (see 1861(s)(3)), covered drugs and biologicals furnished incident to a physician service (see 1861(s)(2)(A) and (b)) and DSMT services (see 1861(s)(2)(S)).    Services furnished by a physical therapist (which includes speech -language pathology services furnished by a provider of service) or occupational therapist as described in 1861(p) of the Act for which payment under Medicare Part B is made under the MPFS.   Services furnished by a registered dietitian or nutrition professional (meeting certain requirements) as defined in 105 of BIPA for MNT services for beneficiaries with diabetes or renal disease.    Screening mammography services are paid under the MPFS based on the BIPA provision when rendered in a physicians off ice.   Drugs provided by a physician in the office setting are paid using the ASP from the Medicare Part B Drug Pricing File supplied to all A/B MACs (A) and (B) by CMS.    Audiologists can directly bill Medicare but only for diagnostic tests.   Payment for telehealth services under Medicare Part B are covered as described in Pub. 100- 04, Medicare Claims Processing Manual, Chapter12, 190.   Services furnished by a practitioner described in 1842(b)(18)(C) of the Act for which payment under Medicare Part B is made under the MPFS. The specific non -physician practitioners included and the appropriate payment percentage of the fee schedule amount are described in the following table:   Practitioner Services  Percentage of Physician Payment  Certified Registered Nurse Anesthetist (medically directed)  50 percent  Certified Registered Nurse Anesthetist (non-medically directed)  100 percent  Clinical Nurse Specialist  85 percent  Clinical Psychologist  100 percent  Clinical Social Worker  75 percent  Nurse Mid -Wife  65 percent  Nurse Practitioner  85 percent  Nutrition Professional/ Registered Dietitian  85 percent  Occupational Therapist  100 percent  Physical Therapist  100 percent  Physician Assistant  85 percent   See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 12, for information on billing by physicians and practitioners.   Subject to national coverage determinations and local coverage determinations (LCDs), pay for services included in the MPFS database that have the following status indicators:    A = active   C = A/B MAC (B) -priced code   R = restricted coverage (if no relative value units (RVUs) are shown, service is A/B MAC (B) priced)   E = excluded from physician fee schedule by regulation   For mor e information on status indicators, see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 23, 30.2.2.   80.2 - A/B MAC (B)  - Claims Processing Requirements  (Rev. 1040, Issued: 08- 25-06, Effective: 09-11-06, Implementation: 09-11-06)  1. Claims will be submitted by IHS physicians and practitioners using either the ASC X12 837 professional format or Form CMS-1500.  2. The designated A/B MAC (B) shall supply IHS physicians and practitioners with any billing software that would normally be given to physician and non- physician practitioners.   3. The designated A/B MAC (B) shall place the demonstration code 40 on all IHS physician and practitioner claims.   4. The effective date (date service was provided) for covered services to be paid is on or after July 1, 2001.  Timely claims filing requirements are not waived. Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, 70 contains more information on timely claims filing requirements.   5. The designated A/B MAC (B) shall process IHS physician and practi tioner claims using their LCD.  Refer to Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, 3.5.1.1 for more information on LCDs.  The A/B MAC (B) has three options:   Develop LCDs specifically for IHS physician and practitioner claims;   Use existing LCDs for the State in which the A/B MAC (B) resides; or   Use existing LCDs for any State for which they process claims.   The designated A/B MAC (B) shall specify which LCD they will use for processing IHS physician and practitioner claims.   6. Payment is to be made based on the Medicare locality in which the services are furnished in accordance with current jurisdictional pricing guidelines.  7. The designated  A/B MAC (B) shall use the Medicare Part B Drug -Pricing File accessed at  http://www.cms.gov/site -search/search -results.html?q=drug%20pricing%20files .  However, if a drug or biological is not currently listed in the drug- pricing file, the designated  A/B MAC (B)  shall price the drug or biological utilizing current Medicare drug payment policy. (See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 17, 20.)  8.  The designated A/B MAC (B) shall train IHS physician and practitioner staff to complete correctl y Form CMS -1500 and the electronic formats.   The designated  A/B MAC (B)  shall return as unprocessable any claim with missing or incomplete information in accordance with Chapter 1, Section 80.3.2, Handling Incomplete and Invalid Claims.   9.  The IHS physicians and practitioners shall submit claims as if they were a group practice.    All IHS physicians and practitioners must apply for a group billing number via the normal processes. The designated A/B MAC (B) shall educate IHS physicians and practitione rs on these processes.    All IHS physicians and practitioners who do not currently have Medicare billing numbers with the IHS, tribe, and tribal organization with the designated A/B MAC (B) shall apply for them via the normal processes described in 40.1 Provider Enrollment with A/B MAC (B) in this chapter.  The designated A/B MAC (B) shall educate IHS physicians and practitioners on these processes.  It is the IHS, tribes, and tribal organizations responsibility to notify their physicians and other practit ioners of the need for enumeration.  The IHS physicians and other practitioners must contact the designated A/B MAC (B) to initiate the enrollment process.   10. The designated A/B MAC (B) shall identify all IHS physicians and practitioners by their PINs. P INs shall be assigned in a manner that will allow the designated A/B MAC (B) to identify which facilities are IHS, tribes, or tribal organizations. All IHS physicians and practitioners will be assigned a UPIN in accordance with current practices. See 50 Reporting Requirements for more information about PINs and UPINs.   11. The designated A/B MAC (B) shall use all current edits (including current duplicate logic and Correct Coding Initiative edits) on claims from IHS physicians and practitioners. Medical re view will be done in accordance with current procedures.   The IHS physicians and practitioners need not submit line items for non- covered services. If non- covered services are billed, then the designated A/B MAC (B) shall process the line items for non- covered services and show on the remittance advice (RA) that Medicare did not cover the services.   12. The claim will post to history, update the deductible information, and update utilization. The deductible and coinsurance will apply. IHS physicians and pra ctitioners shall not collect the deductible or coinsurance from the beneficiary.   13. The Common Working File (CWF) will subject IHS physician and practitioner claims to the working aged edit(s) using the Medicare Secondary Payer (MSP) Auxiliary (AUX) file. Where the beneficiary is shown as working aged but IHS physicians and practitioners have not submitted MSP information, the CWF will reject the claim to the designated A/B MAC (B), which will reject to IHS physicians and practitioners.   14. The IHS physi cian and practitioner claims will be processed through the CWF using existing edits.   15. A RA will be sent to IHS physicians and practitioners for each claim. See Pub. 100-04, Medicare Claims Processing Manual, Chapter 2, Remittance Notice to Providers for more information on the RA.  16. Medicare summary notices (MSNs) will be suppressed.   17.  Third party payer crossover claims will not be suppressed. See Chapter 28 of Pub-100-04, Medicare Claims Processing Manual for more information on crossover claims .  18. Interest shall be calculated on IHS physician and practitioner claims that are not paid timely, in the same manner as any other claim. See Pub. 100 -04, Medicare Claims Processing Manual, Chapter 1, 80 for more information on interest calculation.  19. Normal activities for fraud and abuse, MSP, and medical review will be required for IHS physician and practitioner claims. Aberrances that may indicate potential fraudulent behavior should be reported to the applicable regional office.   20. The contrac tor shall process claims for Medicare Railroad retiree beneficiaries.   21. The IHS physicians and practitioners are not included in the Medpar directory since these facilities treat only the AI/AN population, except in an emergency situation.   80.3 - A/B MAC (B) - Ambulance Services - Payment Policy (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Effective July 1, 2005, Medicare Part B payment may be made to IHS independent ambulance suppliers that furnish ambulance services. IHS independent ambulance suppliers bill the designated A/B MAC (B) for services.   Payment for independent ambulance supplier claims shall be based on the ambulance fee schedule and processed based on point of pickup (POP). Medicare Part B deductible and coinsurance amounts are applied, but are waived by the IHS.   For more information on the ambulance fee schedule see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 15. See Chapter 15, 10.3 for information on POP.   80.3.1 - A/B MAC (B) - Ambulance Services - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Medically necessary ambulances provided by an IHS ambulance supplier are paid based upon Chapter 15 of Pub. 100- 04, Medicare Claims Processing Manual.   Suppliers must report an origin and destination code for each ambulance service billed.   Modifier Reporting -  Origin and destination modifiers used for ambulance services are created by combining two alpha characters.  Each alpha character, with the exception of x, represents an origin code or a destination code.  The pair of alpha codes creates one modifier.  The first position alpha code equals origin; the second position alpha code equals destination. Origin and destination codes are listed below :  D - Diagnostic or Therapeutic Center other than P or H when these are used as origin codes   E - Residential, Domiciliary, Custodial Facility (Other than an 1819 Facility)   G - Hospital based dialysis facility (hospital or hospital related)   H - Hospital   I - Site of Transfer (e.g., airport or helicopter pad) between modes of ambulance transport   J - Nonhospital based dialysis facility   N - SNF (1819 Facility)   P - Physician's Office (Includes health maintenance organization (HMO) non -hospital facility, c linic, etc.)   R - Residence   S - Scene of Accident or Acute Event   X - (Destination code only) intermediate stop at physician's office enroute to the hospital (includes HMO non- hospital facility, clinic, etc.)