(Medicare Claims Processing Manual)

Advance Beneficiary Notice (ABN)   The beneficiary is liable for services denied over the limited number of hours with referrals for MNT. An Advance Beneficiary Notice (ABN ) should be issued in these situations.  In absence of evidence of a valid ABN, the provider will be held liable.   An ABN should not be issued for Medicare -covered services such as those provided by hospital dietitians or nutrition professionals who are qualified to render the service in their state but who have not obtained Medicare provider numbers.   Duplicate Edits   Although beneficiaries are allowed to receive training and therapy during the same time period DSMT  and MNT  services may not be provided on the same day to the same beneficiary.  Effective April 1, 2010 CWF shall implement a new duplicate crossover edit to identify and prevent claims for DSMT/MNT services from being billed with the same dates of services for the same beneficiaries submitted from institutional providers and from a professional provider.   310 - Lung Volume Reduction Surgery  (Rev. 768, Issued:  12- 01-05; Effective:  11- 17-05; Implementation:  03 -02 06)   Lung Volume Reduction Surgery (LVRS) (also known as reduction pneumoplasty, lung shaving, or lung contouring) is an invasive surgical procedure to reduce the volume of a hyperinflated lung in order to allow the underlying compressed lung to expand, and thus, establish improved respiratory function.   Effective for 'from' dates of service on or after January 1, 2004, Medi care 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 conducted 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 instructed 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 clai ms 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 dete rmined 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 OIVIT regimen.  See P ub. 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 HCPCS 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: 16.10 Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  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), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilitation (ICR) Conditions of Coverage  07/05/2022 12613 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 Rehabilitation (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 - 08/13/2021 12332  Rev #  Issue Date  Subject  Impl Date  CR#  Methodology for Calculation of the Cost- to-Charge Ratio [CCR] for Community Mental Health Centers [CMHCs] in the Medicare Claims Processing Manual  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 System (OPPS) - No Longer Sensitive Rescinded and Replaced by Transmittal #4513 01/06/2020 11605  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  Rev #  Issue Date  Subject  Impl Date  CR#  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  07/01/2019 10971 R4295CP  05/03/2019 Update to the Internet Only Manual (IOM) Publication (Pub.) 100-04, Chapter 4  08/27/2019 11274 R4308CP 05/16/2019 Implementation of the Medicare Performance  Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model 07/01/2019 10971  R4259CP  03/22/2019 Billing for Hospital Part B Inpatient Services  06/21/2019    11181 R4257CP 03/14/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model- Rescinded and replaced by Transmittal 4308  07/01/2019 10971 R4255CP 03/15/2019 April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)  04/01/2019 11216 R4233CP 02/08/2019 Update to Publication (Pub.) 100-04 Chapters 4 and 17 to Provide Language -Only Changes for the New Medicare Card Project  03/12/2019 11084 R4230CP 02/01/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model- Rescinded and replaced by Transmittal 4257  07/01/2019 10971 R4204CP 01/17/2019 January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/07/2019 11099  Rev #  Issue Date  Subject  Impl Date  CR#  R4186CP  12/31/2018 January 2019 Update of the Hospital Outpatient P rospective Payment System (OPPS) - Rescinded and replaced by Transmittal 4204 01/07/2019 11099 R4157CP  11/02/2018 Hospital and Critical Access Hospital (CAH) Swing -Bed Manual Revisions and Shared Systems Changes 04/01/2019 10962 R3941CP 12/22/2017 January 2018 Update of the Hospital Outpa tient Prospective Payment System (OPPS)  01/02/2018 10417 R3795CP