(Manual Name)

Contractors pay ASCs a reduced amount for certain specified procedures when a specified device is furnished without cost or for which either a partial or full credit is received (e.g., device recall).  For specified pro cedure codes that include payment for a device, ASCs are required to include modifier FB on the procedure code when a specified device is furnished without cost or for which full credit is received.  If the ASC receives a partial credit of 50 percent or m ore of the cost of a specified device, the ASC is required to include modifier FC on the procedure code if the procedure is on the list of specified procedures to which the -FC reduction applies.  A single procedure code should not be submitted with both modifiers FB and - FC.  The pricing determination related to modifiers   FB and - FC is made prior to the application of multiple procedure payment reductions.  Contractors adjust beneficiary coinsurance to reflect the reduced payment amount.  Tables listing the procedures and devices to which the payment adjustments apply, and the full and partial adjustment amounts, are available on the CMS Web- site.  In order to report that the receipt of a partial credit of 50 percent or more of the cost of a device, ASCs have the option of either:  1)  Submitting the claim for the procedure to their Medicare contractor after the procedures performance but prior to manufacturer acknowledgement of credit for a specified device, and subsequently contacting the contracto r regarding a claims adjustment once the credit determination is made; or 2) holding the claim for the procedure until a determination is made by the manufacturer on the partial credit and submitting the claim with modifier FC appended to the implantation  procedure HCPCS code if the partial credit is 50 percent or more of the cost of the device.  If choosing the first billing option, to request a claims adjustment once the credit determination is made, ASCs should keep in mind that the initial Medicare payment for the procedure involving the device is conditional and subject to adjustment.  40.9 - Payment and Coding for Presbyopia Correcting IOLs (P -C IOLs) and Astigmatism Correcting IOLs (A -C IOLs)  (Rev. 11793; Issued:01 -19-23; Effective: 02 -21-23; Impleme ntation: 02- 21-23)  CMS payment policies and recognition of P -C IOLs and A- C IOLs are contained in Transmittal 636 (CR3927) and Transmittal 1228 (CR5527) respectively.   Effective for dates of service on and after January 1, 2008, when inserting an approved A-C IOL in an ASC concurrent with cataract extraction, HCPCS code V2787 (Astigmatism -correcting function of intraocular lens) should be billed to report the non -covered charges for the A -C IOL functionality of the inserted intraocular lens.  Additionally,  note that HCPCS code V2788 (Presbyopia -correcting function of intraocular lens) is no longer valid to report non -covered charges associated with the A -C IOL.  However, this code continues to be valid to report non -covered charges for a P -C IOL.  The payme nt for the conventional lens portion of the A -C IOL and P -C IOL continues to be bundled with the ASC procedure payment.   Effective for services on and after January 1, 2010, ASCs are to bill for insertion of a Category 3 new technology intraocular lens (NT IOL) that is also an approved A -C IOL or P-C IOL, concurrent with cataract extraction, using three separate codes.  ASCs shall use HCPCS code V2787 or V2788, as appropriate, to report charges associated with the non-covered functionality of the A -C IOL or P -C IOL, the appropriate HCPCS code 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devic es or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage); 66983 (Intracapsular c ataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)); or 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspirati on or phacoemulsification)), to report the covered cataract extraction and insertion procedure; and Q1003 (New technology, intraocular lens, category 3 (reduced spherical aberration) as defined in Federal Register notice, Vol. 65, dated May 3, 2000) to report the covered NTIOL aspect of the lens on claims for insertion of an A -C IOL or P -C IOL that is also designated as an NTIOL.  Listings of the CMS -approved Category 3 NTIOLs, A -C IOLs, and P -C IOLs are available on the CMS Web -site.   40.10 - Removal of D evice Portion from Certain Discounted Device-Intensive Ambulatory Surgical Center (ASC) Procedures Prior to the Administration of Anesthesia (Rev. 11793; Issued:01- 19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  Effective for claims with dates of ser vice beginning January 1, 2016, contractors will identify and process device intensive procedures and services billed with the 73 modifier, by utilizing the program payment amount appearing in the FB Mod Reduced Price field on the ASCFS record layout as th e full program payment, with the device portion removed, prior to processing the 73 modifier payment calculations.  If there is no payment amount in the FB Mod Reduced Price field of the ASCFS, then the procedure is not device intensive and this new policy would not apply.   To process claims correctly, when device intensive procedures and services are billed with the 73 and FB/FC modifiers, the FB/FC modifier is ignored for this line item unused device, and the line item would continue to be processed as st ated above.   For ASCs subject to the Ambulatory Surgical Center Quality Reporting (ASCQR) Program payment reduction, contractors shall utilize the procedure payment amount located in the respective Penalty FB Mod Reduced Price field on the ASCFS in place of the payment amount in the FB Mod Reduced Price field or the Penalty Price field on the ASCFS in place of the payment amount in the Price field, as appropriate.   50 - ASC Procedures for Completing the ASC X12 837 Professional Claim Format or the Form CMS- 1500 (Rev. 11793; Issued:01- 19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  The Place of Service (POS) code is 24 for procedures performed in an ASC.  Prior to January 1, 2008, Type of Service (TOS) code is F (ASC Facility Usage for Surgical Services) is appropriate when modifier SG appears on an ASC claim.  Otherwise TOS 2 (surgery) for professional services rendered in an ASC is appropriate.  Beginning January 1, 2008, ASCs no longer are required to include the SG modifier on facility claims in Medicare.  The contractors shall assign TOS code F to codes billed by specialty 49 for Place of Service 24.   60 - Medicare Summary Notices (MSN), Claim Adjustment R eason Codes, Remittance Advice Remark Codes (RAs)  (Rev. 1325; Issued: 08- 29-07; Effective:  01 -01-08; Implementation:  01 -07-08)  60.1 - Applicable Messages for NTIOLs  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02 -10-17)  Contractors shall return as unprocessable any claims for NTIOLs containing Q1003 alone or with a code other than one of the procedure codes listed in 40.3.    The contractor shall use the following remittance advice messages and associated codes when returning claim s under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 16  RARC: M67  MSN: N/A  Contractors shall deny payment for Q1003 if services are furnished in a facility other than a Medicare -approved ASC.   The contractor shall use the following remittance advice messages and associated codes when denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 58  RARC: N/A  MSN: 16.2  Contractors shall deny payment for Q1003 if billed by an entity other than a Medicare -approved ASC.    The contractor shall use the following remittance advice messages and associated codes when denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 170  RARC: N/A  MSN: 33.1  Contractors shall deny payment for Q1003 if submitted for payment past the discontinued date (after the 5 -year period, or after February 26, 2011).  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: 27  RARC: N/A  MSN: 21.11  A/B MACs (B) shall deny payment for Q1003 if services are furnished in a facility other than a Medicare -approved ASC.    The contractor shall use the following remittance advice messages and associated codes when denying claims  under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 58  RARC: N/A  MSN: 16.2  60.2 - Applicable Messages for ASC 2008 Payment Changes Effective January 1, 2008  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02 -10-17)  Contractors shall deny services not included on the ASC facility payment files (ASCFS and ASC DRUG files) when billed by ASCs (specialty 49).   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: 8  RARC: N95  MSN: 26.4  If there is no approved ASC surgical procedure on t he same date for the billing ASC in history, contractors shall return pass -through device claims/line items, brachytherapy claims/line items, drug code (including C9399) claims/line items, and any other ancillary service claims/line items such as radiology  procedure claim/line items on the ASCFS list or ASCDRUG list as unprocessable.   The contractor shall use the following remittance advice messages and associated codes when returning claims under this policy.  This CARC/RARC combination is compliant with C AQH CORE Business Scenario Three.   Group Code: CO  CARC: 16  RARC: M51  MSN: N/A  Contractors shall deny the technical component for all ancillary services on the ASCFS list billed by specialties other than 49 provided in an ASC setting (POS 24).  The contrac tor shall use the following remittance advice messages and associated codes when denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 171  RARC: N/A  MSN: 16.2  Contractors shall deny globally billed  ancillary services on the ASCFS list if billed by specialties other than 49 provided in an ASC setting (POS 24).  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: 4  RARC: N/A  MSN: 16.2  Contractors shall deny separately billed implantable devices.   The contractor shall use the followi ng remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four.  Group Code: CO  CARC: 97  RARC: M97  MSN: 16.32  If there is a related, approv ed surgical procedure for the billing ASC for the same date of service, also include the following MSN message: 16.8.  60.3  Applicable ASC Messages for Certain Payment Indicators Effective for Services Performed on or after January 1, 2009 (Rev. 11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)