(Medicare Claims Processing Manual)

 If the time period of coverage specified by the QIO/QIC does not extend to the end of the normal billing or certification period for the applicable type of bill, providers submit a discharge claim according to all applicable claims instructions plus two additional data elements.  Providers must annotate these claims with condition code C3, which is defined QIO partial approval and with occurrence span code M0, which is defined QIO approved stay dates and the dates provided by the QIO/QIC.   NOTE:   Regarding any decision that does not uphold a discharge, QIO/QIC decisions authorizing extended coverage cannot authorize delivery of services if there are not also the required physician orders needed to authorize the care.   C  Billing Beneficiaries in Cases Subject to Expedited Determinations   Providers should note a significant difference between the use of expedited determination notices and the use of ABNs.  As described in Claims Processing Manual, Chapter 1, section 60.3.1, in ABN or HHABN situations, all providers other than SNFs can bill beneficiaries for services subject to a demand bill while awaiting a Medicare determination on the coverage of the services.  The same is not true in expedited determination situations.  When a beneficiary requests an expedited determination timely, no funds may be collected until the provider receives notification of the QIO/QIC decision.  D  Reporting Provider Liability Situations   Providers may be liable as a result of two specific situations in the expedited review process:   (1) if the provider is not timely in giving information to the QIO; and   (2) if the provider does not give valid notice to the beneficiary.   Since both these events occur after the point the provider has already determined discharge is imminent, there may be no actual liability, since there may be no medical need for additional care.  However if services are required, and either of these liabil ity conditions apply, such services should be billed as noncovered line items using the GZ modifier, which indicates the provider is liable, consistent with Section 60.4.2 of this chapter.   160 - Identifying Institutional Providers  (Rev. 11794, Issued:01- 19-23, Effective: 04 -01-23, Implementation:04- 03-23)  Since May 23, 2007, Medicare institutional providers submit only the ten position numeric National Provider Identifier (NPI) as their provider identifier.    References to the six position alpha -numeric CMS Certification Number (CCN) (previously called the OSCAR number) found throughout the chapters of the Medicare Claims Processing Manual, on an ongoing basis, are supplied only for the purpose of CMS internal processing.  Therefore, these references are documented as for CMS use only.  160.1 - Reporting of Taxonomy Codes (Institutional Providers)  (Rev.11794, Issued:01- 19-23, Effective: 04 -01-23, Implementation:04- 03-23)  Institutional providers may submit a taxonomy code on claims they submit to Medicare.  Medicare does not use the taxonomy code for matching a providers NPI to the appropriate legacy identifier.  Medicare uses other claims data for this purpose.  Medicare does not use the taxonomy code for any other claims processing purpose.  Payers other than Medicare may have requirements for taxonomy codes.  Medicare will pass any taxonomy code submitted on a Medicare claim to our trading partners on crossover claims, to allow for the possibility that those payers may use it.   If an institutional provider chooses to submit taxonomy codes, the following table supplies the crosswalk from Medicares CMS Certification Number (CCN) to the appropriate taxonomy code based on the providers facility type:  Provider Type  CCN Coding  Taxonomy Code  Short -term (General and Specialty) Hospitals  0001-0879  *Positions 3-6 282N00000X Critical Access Hospitals  1300 -1399 *  282NC0060X  Long -Term Care Hospitals  2000 -2299 *  282E00000X  Hospital Based Renal Dialysis Facilities  2300-2499* 261QE0700X Independent Renal Dialysis Facilities  2500-2899* 261QE0700X Rehabilitation Hospitals  3025 -3099 *  283X00000X  Childrens Hospitals  3300 -3399 *  282NC2000X  Hospital Based Satellite Renal Dialysis Facilities  3500-3699 Type of Bill code 72X + 261QE0700X + different zip code than any renal dialysis facility that is located on that hospitals campus  Psychiatric Hospitals  4000-4499 * 283Q00000X Organ Procurement Organization (OPO)  P in third Position 335U00000X Psychiatric Unit M or S in third Position 273R00000X Rehabilitation Unit  R or T in third Position 273Y00000X Swing -Bed Unit  U, W, Y, or Z in third Position  Type of Bill Code X8X (swing bed) with one of the following taxonomy codes to define the type of facility in which the swing bed is located  275N00000X if unit in a short-term hospital (U),  282E00000X if unit in a long-term care hospital (W), 283X00000X if unit in a rehab facility (Y),  282NC0060X if unit in a critical access hospital (Z)  170 - Payment Bases for Institutional Claims  (Rev. 1526, Issued: 05- 30-08, Effective: 07 -01-08, Implementation: 07- 07-08)  There are many different payment mechanisms that apply to institutional claims.  Among these are reasonable cost, prospective payment systems, all of which require at least some bundling of services, and various fee schedules.  170.1 - Services Paid on the Medicare Physician Fee Schedule (MPFS)  (Rev. 1526, Issued: 05- 30-08, Effective: 07 -01-08, Implementation: 07- 07-08)  The following chart shows for selected Types of Bill (TOB) those revenue codes containing (some) services payable on the MPFS .  Services Payable on the MPFS               TOB by Revenue Code                Rev codes                                  12x IHS 12x  13x IHS 13x 22x 23x 34x 72x 74x 75x 76x 81x 82x 85x IHS 85x 030x          X                     031x          X                     032x          X X                   033x          X X                   034x          X X                   036x          X X                   0401, 0403  X   X   X X               X X 0410, 0412, 0419          X X       X           042x  X X X X X X X   X X           043x  X X X X X X X   X X           044x  X X X X X X X   X X           046x          X X                   471 X X X X X X                   048x          X X                   0550, 0559                    X           056x                    X           061x          X X                   657                       X X     070x          X X                   073x          X X                   074x          X X                   075x          X X                   771 X X X X X X X X    X       X X                                                                  Services Payable on the MPFS               TOB by Revenue Code (continued)                 12x IHS 12x  13x IHS 13x 22x 23x 34x 72x 74x 75x 76x 81x 82x 85x HIS 85x 078x  X X X X                   X X 090x          X X       X           091x          X X       X           092x          X X                   0940, 0942, 0949          X X       X           096x                            X X 097x                            X X 098x                            X X   170.1.1  Payments on the MPFS for Providers With Multiple Service Locations  (Rev. 3454, Issued: 02- 04-16, Effective: 07 -01-16, Implementation: 07- 05-16)  Services that are paid subject to the Medicare Physician Fee Schedule (MPFS) are adjusted based on the applicable payment locality.  Medicare systems determine which locality applies using ZIP codes.  In cases where the provider has only one service locati on, the payment locality used to calculate the fee amount is determined using the ZIP code of the master address contained in the Medicare contractors provider file.   Increasingly, hospitals operate off -site outpatient facilities.  Other institutional outpatient service providers, including rehabilitation agencies and Comprehensive Outpatient Rehabilitation Facilities, may operate multiple sites.  In some cases, these a dditional locations are in a different payment locality than the parent provider.  In order for MPFS payments to be accurate, the nine -digit ZIP code of the satellite facility is used to determine the locality in these cases.   Medicare outpatient service providers report the nine -digit ZIP code of the service facility location in the 2310E loop of the 837 Institutional claim transaction.  Direct Data Entry submitters also are required to report the nine -digit ZIP code of the service facility location for off-site or multiple satellite office outpatient facilities.  Paper submitters report this information in Form Locator (FL) 01 on the paper claim form.  Medicare systems us e this service facility ZIP code to determine the applicable payment locality whenever it is present.   180  Denial of Claims Due to Violations of Physician Self -Referral Prohibition  (Rev. 1578, Issued: 08- 15-08, Effective: 01 -01-09, Implementation: 01 -05-09)  180.1  Background and Policy  (Rev. 1578, Issued: 08- 15-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Under Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), a physician may not refer a Medicare patient for certain designated health services (DHS) to an entity with which the physician (or an immediate family member of the physician) ha s a financial relationship, unless an exception applies.  Section 1877 of the Act also prohibits the DHS entity from submitting claims to Medicare, the beneficiary, or any entity for DHS that are furnished as a result of a prohibited referral.  The followi ng services are DHS: clinical laboratory services; radiology and certain other imaging services (including MRIs, CT scans and ultrasound); radiation therapy services and supplies; durable medical equipment and supplies; orthotics, prosthetics, and prosthet ic devices; parenteral and enteral nutrients, equipment and supplies; physical therapy, occupational therapy, speech- language pathology services; outpatient prescription drugs; home health services and supplies; and inpatient and outpatient hospital services.  A financial relationship includes both ownership/investment interests and compensation arrangements (for example, contractual arrangements between a hospital and a physician for physician services).  The statute and regulations enumerate various exc eptions to the physician self -referral prohibition.  Violations of the statute are punishable by denial of payment for all DHS claims, refunds of amounts collected for DHS claims, and civil money penalties for knowing violations of the prohibition.  Applic able regulations are published at 42 C.F.R. Part 411, Subpart J.  180.2  Denial Code  (Rev. 1578, Issued: 08- 15-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Prior to the publication of the new CARC #213, there was no specific code to describe claims that are denied based on a violation of the physician self -referral statute at Section 1877 of the Act.  A specific code is appropriate so both the providers of DH S and the industry know that claims are being denied based on the non compliance with the physician self -referral prohibitions.  This code should be used any time a claim is denied because the physician (or an immediate family member of the physician) has a financial interest in a DHS provider and fails to meet one of the exceptions available in 42 C.F.R. 411.355- 411.357.  190  Payer Only Codes Utilized by Medicare  (Rev. 11571, Issued:08- 25-22, Effective: 09 -27-22, Implementation: 09- 27-22)  This section contains the listing of payer codes designated by the National Uniform Billing Committee to be assigned by payers only. Providers shall not submit these codes on their claims forms. The definitions indicating Medicares usage for these systema tically assigned codes are indicated next to each code value.  Condition Codes  12-14  Not currently used by Medicare.  15  Clean claim is delayed in CMS Processing System.  16  SNF Transition exception.   62  PIP Bill.  63  Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.