(Medicare Claims Processing Manual)

100.1 - A/B MAC (A) - Medicare Part B Services Paid Under Various Fee Schedules  (Rev. 2075, Issued: 10- 28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  The legislative change in MMA 630 of 2003, which was effective January 1, 2005, and indefinitely extended by 2902 of the  ACA, allows IHS providers to bill for other Medicare Part B services, not covered under 1848 of the Act. In an effort to clarify that these charges are not included in the AIR (which is the general method of payment) and to allow these facilities to acqu ire the appropriate certifications, IHS providers, including CAHs were allowed to begin billing separately for the following Medicare Part B services:    Prosthetic and orthotic devices (beginning July 1, 2005);   Surgical dressings (beginning July 1, 2005);   Influenza, pneumococcal, and hepatitis B vaccines (beginning January 1, 2006); and  Ambulance services (beginning January 1, 2005).   The enactment of BIPA allowed for separate billing of certain services by physicians and practitioners, including physical th erapy, occupational therapy, and speech -language pathology (including diagnostic audiology services).  100.2 - A/B MAC (A) - Medicare Part B Services Included in the All Inclusive Rate (AIR)  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation : 09-11-06)  Unless otherwise specified in this chapter, payment to IHS providers is made based on the AIR. To understand how payment is made for IHS services, it is recommended that Chapter 19 be reviewed in its entirety. Services provided in IHS provider s that are considered part of the AIR include:    Diagnostic tests (see 1861(s)(3)), covered drugs and biologicals furnished incident to a physician service (see 1861(s)(2)(A) and (b)) and DSMT services (see 1861(s)(2)(S)).    Services furnished by a RD or n utrition professional (meeting certain requirements) as defined in 105 of BIPA for MNT services for beneficiaries with diabetes or renal disease. (These health care professionals must reassign their benefits to the hospital or hospital -based clinic.)    The technical component of screening mammography services, and other radiological services.    If the IHS provider purchases laboratory services from another entity, that entity bills the hospital. The hospital bills Medicare and is paid based on the AIR.   NOTE :  This is not an all -inclusive list of services paid under the AIR.   100.3 - A/B MAC (A) - Inpatient Acute Care - Medicare Part A - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Medicare Part A provides payme nt to IHS providers for up to 90 days of covered inpatient hospital services in a benefit period.  These services are subject to Medicare Part A inpatient deductible and coinsurance.  Each beneficiary also has 60 lifetime reserve days (LTR) of inpatient ho spital services to draw upon after having used 90 days of inpatient hospital services in a benefit period.  Lifetime reserve days are subject to Medicare Part A LTR coinsurance.  Deductible and coinsurance amounts are applied by Medicare, but are waived by  the IHS.   See Pub. 100- 02, Medicare Benefit Policy Manual for more information on Medicare Part A deductible, coinsurance and benefit periods.   The IHS providers are paid for covered inpatient services under the IPPS based upon diagnostic related groups ( DRGs).  The IPPS Pricer recognizes that IHS providers are paid at a higher wage index than other acute care hospitals.   100.3.1 - A/B MAC (A)  - Inpatient Acute Care - Medicare Part A - Claims Processing  (Rev. 3049, Issued; 08- 25-14, Effective: ICD -10 - Upo n Implementation of ICD -10; ASC- X12-01-01-12, Implementation: ICD -10 - Upon Implementation of ICD -10; ASC- X12 -  09-23-14)  All charges are combined and reported under revenue code 0100 (all -inclusive room and board plus ancillary) on type of bill (TOB) 11X  (hospital inpatient).  Inpatient services are billed from admission through discharge.  Interim billing is not allowed.   See Chapter 1, 50.2 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on frequency of billing and the exceptions for interim billing.   In order to receive the appropriate payment under the IPPS, it is important that the applicable diagnosis and procedure codes are reported on the bill.  The MSN is suppressed.   100.3.2 - A/B MAC (A) - Physician Acknowledgement Statement  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Section 42 CFR 412.46 requires hospitals to obtain only one signed acknowledgment from physicians who are being granted admitting privileges at a particular IHS provider. The physician must complete the acknowledgment at the time that he/she is granted admitting privileges at the hospital or before, or at the time the physician admits his/her first patient to the hospital. When the hospital submits a claim, it must have on file a signed and dated acknowledgment from the attending physician that the physicia n has received the notice specified in 42 CFR 412.46(b). Existing acknowledgments signed by physicians already on staff remain in effect as long as the physician has admitting privileges at the hospital.   The IHS providers must meet the conditions specifie d in 42 CFR 412, Subpart C, to receive payment under IPPS for inpatient hospital services furnished to Medicare beneficiaries.   The IHS providers are monitored to ensure that they are appropriately obtaining the acknowledgment statements from physicians with new admitting privileges as required at 42 CFR 412.46.  For more information on the physician acknowledgement statement see Chapter 4 of Pub. 100-10, Quality Improvement Organization Manual.  100.3.3 - A/B MAC (A) - Social Admissions (Rev. 1446, Issued:   02-08-08; Effective:  07- 01-08; Implementation:  07 -07-08)  Social admissions for patient and family convenience are not covered by Medicare.  They are not billable to Medicare by IHS providers (including CAHs) on either TOB 11X (hospital inpatient) or 12X (hospital inpatient Part B).  For admissions before surgery, only the scheduled surgery and related services may be billed on TOB 83X (ambulatory surgical center) if the surgery is performed on an outpatient basis and on TOB 11X if the surgery is perfor med on an inpatient basis.  When placing a patient in a room for social reasons after discharge from an inpatient stay this portion of inpatient care may not be billed to Medicare.  Medicare disallows payment for inpatient Medicare Part B ancillary services during a social admission stay when there is another bill from a different facility for an outpatient service.  A TOB 12X from the admitting facility with a 13X (hospital outpatient) TOB from another hospital, a 72X (hospital based or freestanding renal dialysis center) TOB from a renal dialysis facility (RDF). Consequently, CWF will send an informational unsolicited response (IUR) to the designated A/B MAC (A) on receipt of the 13X or 72X bill.   Medicare also disallows payment for inpatient Part B ancillary services during a social admission stay when a TOB 12X has a line item date of service (LIDOS) that is equal to or one day following the discharge date on a TOB 11X for the same provider.  The CWF sends an IUR to the designated A/B MAC (A) in this situation.   The CWF bypasses both of these edits when the beneficiary is not entitled to Medicare Part A at the time the services on TOB 12X are rendered.   See Chapter 4, 240.2 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on social admissions.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs (TOB 83X).  All IHS ASC providers must submit their claims to the A/B MAC (B).   100.3.4 - A/B MAC (A) - Inpatient Ancillary Services - Medicare Part B - Payment Policy  (Rev. 1511; Issued:  05- 23-08; Effective:  01- 01-08; Implementation:  06 -23-08)  Certain inpatient hospital ancillary services are covered under Medicare Part B when coverage is no longer provided under  Medicare Part A due to benefits exhausted, the beneficiary is determined to be receiving a non -covered level of care, or is not eligible for Medicare Part A benefits. Chapter 4, 240 of Pub. 100- 04, Medicare Claims Processing Manual contains information on the physician services and the nonphysician medical and other health services covered under Medicare Part B when furnished by a participating IHS provider to an inpatient of the hospital, but only if payment for these services cannot be made under Medica re Part A.   The IHS providers are paid for covered inpatient Medicare Part B ancillary services based upon an all inclusive inpatient ancillary per diem rate (AIR). The AIR is established by CMS and IHS based upon a review of yearly cost reports prepared b y IHSs contractor. Upon completion of the review, IHS submits the agreed upon rate to the Office of Management and Budget (OMB) for approval. Upon approval by OMB, IHS publishes the approved rate in the Federal Register. The AIR is established for each calendar year.  The approved AIR is issued periodically in a Recurring Update Notification.   These rates are not  facility specific and should not be confused with the all inclusive facility specific inpatient ancillary per diem rate paid to CAHs based on their cost reports. For more information on the CAHs all inclusive facility specific per diem rate, see 110.3 of this chapter.   100.3.4.1 - A/B MAC (A) - Inpatient Ancillary Services - Medicare Part B - Claims Processing (Rev. 1776, Issued: 07- 24-09, Effec tive: 01 -01-09, Implementation: 01- 04-10)  All charges, except therapies, telehealth originating site facility fee , PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (all -inclusive ancillary) on TOB 12X (hospit al inpatient Part B). Medicare Part B deductible and coinsurance amounts are applied to inpatient Medicare Part B ancillary services, but are waived by the IHS.  The MSN is suppressed.   100.4 - A/B MAC (A) - Swing -bed (Rev. 1040, Issued: 08- 25-06, Effective: 09 -11-06, Implementation: 09- 11-06)  Under 1880 of the Act, Medicare Part A provides payment for hospitalization and post hospitalization extended care in SNFs, including swing -bed SNFs.   A beneficiary is entitled to 100 days of skilled nursing care in a SNF or the swing -bed unit of an acute care hospital or CAH during each benefit period. The first 20 days are covered in full, and the remaining days are subject to Medicare Part A SNF coinsurance, but is waived by the IHS.   For more information on swing -bed services see Chapter 8, in Pub. 100- 02, Medicare Benefit Policy Manual.   100.4.1 - A/B MAC (A) - Swing -bed - Medicare Part A - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Effective July 2002, IHS hospit al swing -bed services began being paid according to the SNF prospective payment system (PPS) payment methodology.  See Chapter 6, 30.6 in Pub. 100- 04, Medicare Claims Processing Manual for information on SNF PPS payment methodology.   Medicare Part A coinsurance is applied to IHS swing -bed inpatient bills, but is waived by the IHS.   100.4.1.1 - A/B MAC (A) - Swing-bed - Medicare Part A - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)