(Medicare Claims Processing Manual)

After determining a gap -fill amount, an A/B MAC (B)  may consider if a least costly alternative to a new test exists.  If an A/B MAC (B)  determines a least costly alternative test exists, the A/B MAC (B)  may adopt the payment amount of the least costly alternative test as the gap -fill amount for the new test code.  The least costly alternative amount will be considered the local fee, and CMS will use this payment amount in establishing the NLA.  However i n this case, the A/B MAC (B)  must report two payment a mounts, the gap- fill amount prior to determination of a least costly alternative and the payment amount that the A/B MAC (B)  has determined to be the least costly alternative.   A/B MACs (B)  should also communicate the gap -fill amounts to corresponding A/B MACs (A) and (HHH).  A/B MACs (B)  can seek assistance from RO staff to facilitate communication of the gap- fill amounts to A/B MACs (A) and (HHH) .  The list of codes which A/B MACs (B)  are required to gap -fill each year are communicated in the annual instructions.  A/B MACs (B) provide their RO with gap- fill fees according to the date communicated by CMS (usually May), to be used by CMS -Central for the development of subsequent or later laboratory fee schedules.  A/B MACs (B) submit the gap- fill fees in a right- justified format.  These gap -fill data should be transmitted in an ASCII file with the following file specifications to MStevenson@cms.hhs.gov with a copy to Agreenberg@cms.hhs.gov to assist with coordinated collection of the gap- fill fees.   Data Set Name: CLXXXXX.TXT* (ASCII File)   (*Denotes A/B MAC (B) 5 -  digit number)   Gap-filled Fees Record Layout   Data Element Name  Picture  Location  Comment  Year  X(4)  1 - 4 Set to Year (e.g., 2003)  HCPCS Code  X(5)  5 - 9  Modifier  X(2)  10 - 11  A/B MAC (B) Number  X(5)  12 - 16  Locality  X(2)  17 - 18 00 = Denotes Single State A/B MAC (B)  01 = North Dakota  02 = South Dakota  20 = Puerto Rico 40 = New Hampshire  50 = Vermont  Gap-fill Amount 9(5)V99  19 - 25 Prior to any determination of a least costly alternative  Least Costly Alternative Amount  9(5)V99  26-32  Least Costly Alternative Code  X(5)  33-37   40.4.1 - A/B MACs (B) Forward HCPCS Gap Fill Amounts to A/B MACs (A) and (HHH)  (Rev. 1, 10- 01-03)  CMS Memo 9 -13-02 HCPCS Gap -fillR3.doc   Any A/B MAC (B) that establishes a HCPCS gap fill payment rate for its own use, or at the request of an A/B MAC (A) or (HHH), must forward the information to the contacts at all A/B MACs (A) or (HHH) with providers in the A/B MAC (B) service area.   A/B MACs (B) that establish HCPCS gap -fill payment rates for their own needs should forward the information to A/B MACs (A) and (HHH) as soon as practicable.  A/B MACs (A) and (HHH) are to contact the appropriate A/B MAC (B) to request a gap fill payment rate with 5 working days of the suspension of claims containing HCPCS codes(s) for which payment rate is needed and has not been forwarded.  A/B MACs (B) must provide the payment rate to the requesting A/B MAC (A) or (HHH) (and all other A/B MACs (A) or (HHH) with providers in that common jurisdiction) within 10 working days of receipt of the request.   Requests for policy clarification in A/B MAC (B) establishing the HCPCS gap fill payment rates or A/B MAC (A) or (HHH) procedures for the use thereof should be directed to the respective Regional Office HCPCS business function experts (BFE).  Examples of t he need for A/B MAC (A) or (HHH) consultation with the BFE are coverage questions and receipt of unresolved significant inconsistencies in fee amounts from different A/B MACs (B) for the same HCPCS.  The A/B MAC (A) or (HHH) should consult the A/B MACs (B)  with disparate fees before contacting the BFE.   An A/B MAC (A) or (HHH) experiencing delay in replies or nonresponses from an A/B MAC (B) should alert it respective Consortium Contractor Management Staff (CCMS) Contract Manager (CM).  The CM will coordinate with his/her counterpart assigned to the A/B M AC (B) to achieve more timely action by the A/B MAC (B).   It is the A/B MAC (A)s or (HHH)s responsibility to ascertain the amount or consult with the A/B MAC (B), CCMS -CM, or BFE timely.  A/B MAC (A or (HHH) requests to apply CC 15 to claims which are paid untimely solely because of a delay in ascertaining a HCPCS gap fill amount from the A/B MAC (B) should be addressed to the respective CM.  The CM will contact the HCPCS BFE for a decision.  Requests for application of CC 15 to claims for which the A/B MAC (A) or (HHH) did not request the gap fill payment rate within 5 working days of the claim suspension and/or did not seek timely advice from the RO BFE concerning application of gap fill amount will not be honored.  Additionally, if the A/B MAC (B) replied at least five days before the expiration of the payment  floor, CC 15 requests will not be honored.   50 - Fee Schedules Used by Medicare A/B MACs (A) and (HHH) Processing Institutional Claims  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  A/B MACs (A) and (HHH) processing institutional claims retrieve multiple files from the CMS mainframe telecommunications system.  The HCPCS data files include deleted codes for the upcoming year.  A/B MACs (A) and (HHH) need to identify deleted codes using the HCPCS files because they are not identifiable solely from the fee schedules.  HCPCS files are also obtained from CMS annually.  New fee schedules are effective for dates of service on and after January 1 of each year.  Quarterly and emergency updates to the fee schedules are also sometimes released.  In that case, A/B MACs (A) and (HHH) implement them according to the instructions accompanying the release.   Two HCPCS files are furnished by CMS.  They are:    The annual HCPCS file update including procedure and modifier codes and deleted codes; and    A print file of the new year HCPCS codes.  The following fee schedules are furnished by CMS for use in processing institutional claims:   Fees for hospice claims for Part B services provided by the hospice beneficiarys attending physician;    Medicare Physician Fee Schedule;    Clinical Laboratory Fee Schedule discussed in 40.3 above;    Durable Medical Equipment, Prosthetics/Orthotics and Supplies (DMEPOS) Fee Schedule.  A/B MACs (HHH) with home health workloads retrieve data from all categories on this file.  All MACs retrieve data from categories prosthetic/orthotics and surgical dressi ngs;   Outpatient Rehabilitation (Therapy) and CORF Services Fee Schedule Payment Amounts (Therapy/CORF Abstract File);    CORF, outpatient Critical Access Hospital (CAH and Indian Health Services not part of the Outpatient Rehabilitation (therapy) file; and    Skilled Nursing Facility (SNF) extract file for radiology, other diagnostic and other SNF services.   50.1 - Institutional Claim Record Layout for Hospice, Radiology and Other Diagnostic Prices and Local HCPCS Codes  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This file contains hospice fee schedule prices extracted from the Physician Fee schedule.  This file contains pricing data for A/B MAC (B) -priced and local HCPCS codes for radiology, other diagnostic services, and hospice services paid under the physician fee schedule.  This file contains some high volume services such as portable x- rays.  The file is also used to pay claims for Critical Access Hospitals that have elected the optional method.  The CMS will provide the specific file names when the prices are released.  The file name will contain the label HHH.   Record Length  - 60 Record Format  - FB Block Size - 6000 Character Code  - EBCDIC  Sort Sequence  - A/B MAC (B), Locality, HCPCS Code, Modifier   Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Modifier  X(02)  6 - 7  3-Non-Facility Fee  9(05)V99  8 - 14  4-PCTC Indicator  X(01)  15 - 15 This field is only applicable when pricing Critical Access Hospitals (CAHs) that have elected the optional method (Method 2) of payment.   5-Facility Fee  9(05)V99  16 - 22  6-Effective Date  7- A/B MAC (B) Number  X(08)  X(05)   23 - 30 31 - 35  8-Locality  X(02)  36 - 37  9-**Label**  X(03)  38 - 40 HPH = Hospice Physician Services  ODX = Other Diagnostic Services  PRF = Portable Radiology RAD = Radiology 10-Filler  X(2)  41 - 42  11-Status Code  X(1)  43 - 43 Separate instructions will be used for the use of this field at a later date.  This field indicates whether the code is in the physician fee schedule and whether it is separately payable if the service is covered.  Data Element Name  Picture  Location  Comment  12-Multiple Surgery X(01)  44 - 44 Indicator indicates which payment adjustment rule for multiple procedures apply to the service.   13-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  14-Filler  X(01)  52 - 52  15- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   16-Filler  X(01)  60 - 60   50.2 - Institutional Claim Record Layout for the Durable Medical Equipment, Prosthetic, Orthotic and Supply Fee Schedule  (Rev. 3350, Issued: 09- 11-15, Effective: 01 -01-16, Implementation: 01- 04-16)  This file contains services subject to national Floors and Ceilings under the DMEPOS Fee Schedules including Surgical Dressings.  The CMS will provide the specific file names when the prices are released.   The file name will contain the label DMEPOS.   Record Length  - 60 Record Format  - FB Block Size  - 6000  Character Code  - EBCDIC  Sort Sequence  - Label, HCPCS Code, MOD, State