(Medicare Claims Processing Manual)

Effective for 'from' dates of service on or after January 1, 2004, Medicare will cover LVRS under certain conditions as described in 240 of the Pub. 100- 03, National Coverage Determinations.   LVRS can only be performed in the facilities listed on the following website:  http://www.cms.gov/Medicare/Medicare -General -Information/MedicareApprovedFacilitie/Lung -Volume -Reduction- Surgery -LVRS.html .   LVRS is an inpatient procedure.  However pre - and post - operative services are performed on an outpatient basis and must be performed at one of the facilities certified to do so.  These procedures are paid under the Outpatient Prospective Payment System (OPPS), except for hospitals located in Maryland.   Medicare previously only covered LVRS as part of the National Emphysema Treatment Trial (NETT).  The study was limited to 18 hospitals, and patients were randomized into two arms, either medical management and LVRS or medical management.  The study was con ducted by The National Heart, Lung, and Blood Institute of the National Institutes of Health and coordinated by Johns Hopkins University (JHU).  Hospital claims for patients in the NETT were identified by the presence of Condition Code EY.  The JHU instruc ted hospitals of the correct billing procedures for billing claims under the NETT.   320 - Outpatient Intravenous Insulin Treatment (OIVIT)  (Rev. 1930, Issued:  03- 09-10, Effective Date:  12- 23-09; Implementation Date:  04-05-10)  Effective for claims with dates of service on and after December 23, 2009, the Centers for Medicare and Medicaid Services (CMS) determines that the evidence does not support a conclusion that OIVIT improves health outcomes in Medicare beneficiaries.  Therefore, CMS has determined that OIVIT is not reasonable and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act.  Services comprising an OIVIT regimen are nationally non- covered under Medicare when furnished pursuant to an OIV IT regimen.   See Pub. 100- 03, Medicare National Coverage Determinations Manual, Section 40.7, Outpatient Intravenous Insulin Treatment (Effective December 23, 2009), for general information and coverage indications.  320.1 - HCPCS Coding for OIVIT  (Rev. 1930, Issued:  03- 09-10, Effective Date:  12- 23-09; Implementation Date:  04-05-10)  HCPCS code G9147, effective with the April IOCE and MPFSDB updates, is to be used on claims with dates of service on and after December 23, 2009, billing for non- covered OIVIT and any services comprising an OIVIT regimen.  NOTE:  HCPCS codes 99199 or 94681(with or without diabetes related conditions 250.00- 250.93) are not to be used on claims billing for non- covered OIVIT and any services comprising an OIVIT regimen when furnished pursuant to an OIVIT regimen. Claims billing for H CPCS codes 99199 and 94681 for non- covered OIVIT are to be returned to provider/returned as unprocessable.   320.2 - Medicare Summary Notices (MSN), Reason Codes, and Remark Codes (Rev. 3475, Issued: 03- 04-16, Effective: 06 -06-16, Implementation: 06- 06-16)  Contractors shall return non- covered OIVIT claims billed with HCPCS 99199 to provider/return as unprocessable.   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 Two.  Group Code: CO  CARC: 16  RARC: MA66, N56 MSN: N/A  Contractors shall return non- covered OIVIT claims billed with HCPCS 94681 with or without diabetes -related conditions 250- 00-250.93 to provider/return as unprocessable.   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.   Group Code: CO  CARC: 16  RARC: MA66, N56 MSN: N/A  Contractors shall deny claims for non- covered OIVIT and any services comprising an OIVIT regimen billed with HCPCS code G9147.  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.   Group Code: CO  CARC: 96  RARC: N386  MSN: 16.10Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12552CP  03/21/2024 April 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)   04/01/2024 13568  R12421CP  12/21/2023 January 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/02/2024 13488  R12423CP   12/20/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024 13222  R12369CP  11/17/2023 Implementation of Rural Emergency Hospital (REH) Provider Type   01/03/2023    12820  R12321CP  10/18/2023 Implementation of Rural Emergency Hospital (REH) Provider Type - Rescinded and replaced by Transmittal 12369  01/03/2023 12820   07/13/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92-  SENSITIVE/CONTROVERSIAL  Rescinded and replaced by Transmittal 12423 01/02/2024 13222  R11941CP  04/05/2023 Correction to Manual for Outlier Calculations 05/05/2023 13142  R11937CP  03/31/2023 April 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS)   04/03/2023 13136  R11900CP  03/13/2023 Implementation of Rural Emergency Hospital (REH) Provider Type -- Rescinded and replaced by Transmittal 12321  01/03/2023 12820  R11897CP  03/10/2023 April 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS) - Rescinded and replaced by Transmittal 11 937 04/03/2023 13136  Rev #  Issue Date  Subject  Impl Date  CR#  R11801CP  01/20/203 January 2023 Update of the Hospital Outpatient Prospective  Payment System (OPPS)   01/03/2023 13031  R11737CP  12/08/2022 January 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS)  - Rescinded and replaced by transmittal 11801 01/03/2023 13031  R11729CP  12/06/2022 Implementation of Rural Emergency Hospital (REH) Provider Type - Rescinded and replaced by transmittal  11900 01/03/2023 12820       R11685CP  11/09/2022 Billing for Hospital Part B Inpatient Services  12/12/2022 11685   07/28/2022 Implementation of Rural Emergency Hospital (REH) Provider Type SENSITIVE/CONTROVERSIAL   Rescinded and replaced by transmittal 11729 01/03/2023 12820  R11504CP   07/21/2022 Modification of Existing Common Working File (CWF) Editing for Preventive Services   01/03/2023 12792  R11457CP  06/15/2022 July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  07/05/2022 12761  R11435CP  05/26/2022 July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  -Rescinded and Replaced by Transmittal #11457 07/05/2022 12761  R11426CP   05/20/2022 An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), 07/05/2022 12613  Rev #  Issue Date  Subject  Impl Date  CR#  Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage  R11396CP  05/04/2022 Update to Chapters 3, 4, 27 and 37 of Publication (Pub.) 100- 04 Medicare Claims Processing Manual to Remove Reference to the Term "OSCAR"  10/03/2022 12715  R11272CP  02/18/2022 An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilit ation (ICR) Conditions of Coverage  -Rescinded and Replaced by Transmittal #11426  07/05/2022 12613  R11305CP  03/24/2022 April 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  04/04/2022 12666  R11150CP  12/10/2021 January 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/03/2021 12552  R10869CP  07/14/2021 Updates to Chapter 4, Section 10.11.9 -  Methodology for Calculation of the Cost-to-Charge Ratio [CCR] for Community Mental Health Centers [CMHCs] in the Medicare Claims Processing Manual  08/13/2021 12332 R10541CP  12/31/2020 January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/04/2021 12120 R4513CP  02/04/2020 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)   01/06/2020 11605 R4494CP  01/15/2020 January 2020 Update of the Hospital Outpatient Prospective Payment 01/06/2020 11605 Rev #  Issue Date  Subject  Impl Date  CR#  System (OPPS) - No Longer Sensitive Rescinded and Replaced by Transmittal #4513  12/20/2019 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) - Sensitive/Controversial  Rescinded and Replaced by Transmittal # 4494  01/06/2020 11605 R4394CP  09/13/2019 Billing for Hospital Part B Inpatient Services  10/15/2019 11413 R4390CP   09/06/2019 Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes   10/07/2019 11361 R4391CP  09/06/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model  07/01/2019 10971 R4337CP    07/18/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4391  07/01/2019 10971 R4308CP  05/16/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4337