(Medicare Claims Processing Manual)

Inpatient hospital discharges for mitral valve TEERs shall be denied when billed without the ICD -10 diagnosis, procedure codes and clinical trial coding mentioned above. Claims that do not include these required codes shall be rejected with the following messages:   CARC 50: These are non -covered services because this is not deemed a medical necessity by the payer.   RARC N386: This decision was based on a National Coverage Determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at http://www.cms.hhs.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD.   Group Code: CO (Contractual Obligation) assigning financial liability to the provider   MSN 15.20: The following policies [NCD 20.33] were used when we made this decision   Spanish Version: MSN 15.20 -  Las siguientes polticas [NCD 20.33] fueron utilizadas cuando se tom esta decisin.   340.4 - Claims Processing Requirements for Mitral Valve TEER Services for Medicare Advantage (MA) Plan Participants  (Rev. 10985; Issued:09- 08-21, Effective:01 -19-21; Implementation:10 -08-21)   MA plans are responsible for payment of mitral valve TEER services for MA plan participants. Medicare coverage for mitral valve TEERs is not included under section 310.1 of the NCD Manual (Routine Costs in Clinical Trials).   350 - Emergency and Foreign Hospital Services  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  The conditions for payment for services furnished in a foreign country can be found in 42 CFR 424.120- 127, Subpart H -  Special Conditions: Emergency Services Furnished In a Foreign Country.  The payment exclusion for services furnished outside the U.S. is located at 42 CFR 411.9 and 42 CFR 411.9(a)(2) describes the applicability of the payment exclusion when services are furnished on board a ship.   350.1 - Services Rendered By Nonparticipating Providers  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  A.  Services in Nonparticipating Domestic Hospital   Payment may be made for certain Part A inpatient and Part B outpatient hospital services provided in a nonparticipating U.S. hospital where they are necessary to prevent the death or serious impairment of the health of the individual.  Because of the threat to the life or health of the individual, the use of the most accessible hospital equipped to furnish such services is necessary.  Items and services furnished in a domestic nonparticipating hospital may be reimbursed if the following apply:    The hospital meets the definition of an emergency hospital.  (See 350.3.)    The services meet the definition of emergency services.  (See 350.2.)    The hospital is substantially more accessible from the site of the emergency than is the nearest participating hospital.  (See 350.4.)   B.   Services Received by Medicare Beneficiaries outside the United States   Items and services furnished outside the United States and certain services rendered on board a ship are excluded from coverage except for the following services:    Emergency inpatient hospital services where the emergency occurred:  o While the beneficiary was physically present in the United States; or  o In Canada while the beneficiary was traveling without reasonable delay and by the most direct route between Alaska and another State.    Emergency or nonemergency inpatient hospital services furnished by a hospital located outside the United States, if the hospital was closer to, or substantially more accessible from, the beneficiarys United States residence than the nearest participating United States hospital that was adequately equipped to deal with, and available to provide treatment for the illness or injury.   Physician and ambulance services furnished in connection with a covered foreign hospitalization.  Program payment may not be made for any other Part B medical and other health services, including outpatient services furnished outside the United States.   Services rendered on board a ship in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished in United States territorial waters.  Services not furnished in a United States port, or within 6 hours of when the ship arrived at, or departed from, a United States port, are considered to have been furnished outside United States territorial waters, even if the ship is of United States registry.   The term United States means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, American Samoa and, for purposes of services rendered on a ship, includes the territorial waters adjoining the land areas of the United States.   A hospital that is not physically situated in one of the above jurisdictions is considered to be outside the United States, even if it is owned or operated by the United States Government.   C.  Ship Physicians Office is in the United States.   When the physicians office is inside of the United States, the contractor designated to process the shipboard claim is determined by the beneficiarys residence.   D.  Ship Physicians Office is Outside of the United States.   When the physicians office is outside of the United States, the contractor designated to process the shipboard claim is determined by the beneficiarys residence.   MSN message 16.240 (English)   Services provided aboard a ship are covered only when the ship is in United States waters.  In addition, the service must be provided by a doctor licensed to practice in the United States.  MSN message 16.240 (Spanish)   Servicios proporcionados abordo de un barco son cubiertos solamente cuando el barco est en aguas territoriales de los Estados Unidos. Adems, el servicio debe ser proporcionado por un mdico con licencia para practicar en los Estados Unidos.  Payment may not be made for any item provided or delivered to the beneficiary outside the United States, even though the beneficiary may have contracted to purchase the item while he or she was within the United States or purchased the item from an America n firm.   Under the Railroad Retirement Act, payment is made to qualified Railroad Retirement beneficiaries (QRRBs) by the RRB for covered hospital services furnished in Canadian hospitals as well as in the U.S.  Physician and ambulance services are not covered by t he Railroad Retirement Act; however, under an agreement between CMS and RRB, if the QRRB claims payment for Part B services in connection with Canadian hospitalization, RRB processes the Part B claim. In such cases the RRB determines:    Whether the requirements are met for the inpatient services; and    Whether the physician and/or ambulance services were furnished in connection with the services.   Services for an individual who has elected religious nonmedical health care status may be covered if the above requirements are met but this revokes the religious nonmedical health care institution election.   350.2 - Establishing an Emergency  (Rev. 3287, Issued: 06- 30-15, Effective: 04 -21-15, Implementation: 04- 21-15)  Claims for emergency services must be accompanied by a physician's statement describing the nature of the emergency and stating that the services were necessary to prevent the death, or the serious impairment of, the beneficiary.  A statement that an emergency existed is not sufficient.  In addition, when inpatient services are involved, the statement must include the date when, in the physicians' judgment, the emergency ceased.  The finding of whether the patient's condition required emergency diagnosis or treatment is ordinarily based upon the physician's evaluation of the patient's condition immediately upon the beneficiary's arrival at the hospital.  However, the emergency nature of the situation may have been assessed by a physician who attended the patient where the incident resulting in hospitalization occurred (for example, a heart attack or an automobile accident).  In these cases, the attending physician who ordered the hospitalization may substantiate the claim that emergency hospitalization was necessary.   Most emergencies are of relatively short duration so that only one bill is submitted.  Generally, only one physician's statement is necessary.  However, in the rare situation where an emergency continued over an extended period, subsequent requests for payment must be accompanied by a physician's statement containing sufficient information to indicate clearly that the emergency situation still existed.  A statement that the emergency continued to exist is not acceptable.   Additional information to support a finding that the services were emergency services from the physician, the hospital, and others (e.g., the police department at the scene of an accident) may be requested.  Medical necessity can be documented by the physician on a CMS-l77l, Attending Physician's Statement and Documentation of Medicare Emergency or by the beneficiary's medical records.  The CMS-1771 can be obtained from:  Centers for Medicare & Medicaid Services  Forms Management Section  7500 Security Blvd. Baltimore, MD  21244-1850  Or, the form can be downloaded from http://cms.hhs.gov/Medicare/CMS- Forms/CMS -Forms/CMS -Forms -List.html  350.3 - Qualifications of an Emergency Services Hospital  (Rev. 3287, Issued: 06- 30-15, Effective: 04-21-15, Implementation: 04-21-15)  An emergency services hospital is a nonparticipating hospital that meets the requirements of the law's definition of a "hospital" relating to full -time nursing services and licensure under State or applicable local law.  (A federal hospital need not be licensed under state or local licensing laws to meet this definition.)  In addition, the hospital must be primarily engaged in providing, under the supervision of doctors of medicine or osteopathy, services of the type described in defining the term hospital.  The hospital must not be primarily engaged in providing skilled nursing care and related services for patients who require medical or nursing care.  Psychiatric hospitals can qualify as emergency hospitals.  350.4 - Coverage Requirements for Emergency Hospital Services Furnished Outside of the United States  (Rev. 3287, Issued: 06- 30-15, Effective: 04-21-15, Implementation: 04-21-15)  The following requirements must be met for payment to be made for emergency services received by Medicare beneficiaries in foreign hospitals:   The hospital must meet the definition of an emergency hospital and be licensed or approved by the appropriate agency of the country in which it is located.   The services meet the criteria of emergency services.   The foreign hospital must be closer to or substantially more accessible from the site of the emergency than the nearest U.S. hospital that was adequately equipped and available to treat the illness or injury.  1.  Emergency Occurred in the U.S.  (See 350.1.B for definition of the U.S.)   If the individual was physically present in the U.S. at the time the emergency occurred, the individual's reason for departure from the U.S. must have been specifically to obtain treatment at the foreign hospital.  Services are not covered where the person 's departure from the U.S. is part of a trip abroad and the foreign hospital is more accessible simply because the individual was in the process of travel.  For example, the airplane on which the individual was traveling could not readily return to permit the person's removal.  2.  Emergency Occurred in Canada   If the emergency occurred in Canada, the beneficiary must have been traveling, without unreasonable delay, by the most direct route between Alaska and another state.  Benefits are not payable if the emergency occurred while a beneficiary was vacationing.  The requirement of travel without unreasonable delay by the most direct route will be considered met if the emergency occurred while the beneficiary was enroute between Alaska and another state by the shortest practicable route, or while making a necessary  stopover in connection with such travel.   NOTE:   An emergency occurring within the Canadian inland waterway between the States of Washington and Alaska is considered to have occurred in Canada.   Ordinarily, the "shortest practicable route" is the one that results in the least amount of travel in Canada, consistent with  the mode of travel used between the point of entry into Canada and the intended point of departure.  The amount of travel in the U .S., prior to entering Canada is not pertinent.  A route involving greater travel within Canada may be considered the "shortest practicable route" if the additional travel resulted in a saving of time or was necessary because of such factors as:    Road or weather conditions;    The age of the traveler;    Health, or physical condition of the traveler;    The need to make suitable travel arrangements; or    The need to obtain acceptable accommodations.  However, the individual would be considered to have deviated from the "shortest practicable route" if the detour was unrelated to the purpose of reaching their destination (e.g., for the principal purpose of sightseeing or vacationing).   The term "necessary stopover" means a routine stopover for rest, food, or servicing of the vehicle, and a non- routine stopover (even though of significant duration) caused by such factors as unsuitable road or weather conditions, the age, health, or physical condition of the traveler, the need to make suitable travel arrangement s, or to obtain acceptable accommodations.