(Medicare Claims Processing Manual)

day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee 1 Pic (x)1  FIELD # & ITEM  LENGTH & PIC  schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report).  Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate pe rcentage.  3 = Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).  The base procedure for each code with this indicator is identified in f ield 31G. Apply the multiple endoscopy rules to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non- endoscopic procedure).  If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure.  Payment for the base procedure is included in the payment for the other endoscopy.  4 = Subject to 25% reduction of the TC diagnostic imaging (effective for services January 1, 2006 through June 30, 2010). Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1, 2010 and after). Subject to 25% reduction of the  PC of diagnostic imaging (effective for services January 1, 2012 through December 31, 2016).  Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2017 and after).  5 = Subject to 20% reduction of the practice expense component for certain therapy services furnished in office and other non-institutional settings, and 25% reduction of the practice expense component for certain therapy services furnished in institutiona l settings (effective for services January 1, 2011 and after). Subject to 50% reduction of the practice expense component for certain therapy services furnished in both institutional and non- institutional settings (effective for services April 1, 2013 and after).  6 = Subject to 25% reduction of the TC diagnostic cardiovascular services (effective for services January 1, 2013 and after).  7 = Subject to 20% reduction of the TC diagnostic ophthalmology services (effective for services January 1, 2013 and after).  9 = Concept does not apply. 22 Bilateral Surgery Indicator (Modifier 50)  This field provides an indicator for services subject to a payment adjustment.  0 = 150 percent payment adjustment for bilateral procedures does not apply.  If procedure is reported with modifier -50 or with 1 Pic (x)1  FIELD # & ITEM  LENGTH & PIC  modifiers RT and LT, base payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code.  Example: The fee schedule amount for code XXXXX is $125.  The physician report s code XXXXX- LT with an actual charge of $100 and XXXXX -RT with an actual charge of $100.  Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).  The bilateral adjustment is inappropriate for codes in this category because of (a) physiology or anatomy or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.  1 = 150 percent payment adjustment for bilateral procedures applies.  If code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150 percent of the fee schedule amount for a single code.  If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any applicable multiple procedure rules. 2 = 150 percent payment adjustment for bilateral procedure does not apply.  RVUs are already based on the procedure being performed as a bilateral procedure.  If procedure is reported with modifier - 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers with a 2 in the units field), base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code.  Example: The fee schedule amount for code YYYYY is $125.  The physician reports code YYYYY -LT with an actual charge of $100 and YYYYY- RT with an actual charge of $100.  Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The RVUs are based on a bilateral procedure because: (a) the code descriptor specifically states that the procedure is bilateral; (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally; or (c) the procedure is  usually performed as a bilateral procedure.  3 = The usual payment adjustment for bilateral procedures does not apply.  If procedure is reported with modifier - 50 or is reported for both sides on the same day by any other means (e.g., with RT and FIELD # & ITEM  LENGTH & PIC  LT modifiers or with a 2 in the units field), base payment for each side or organ or site of a paired organ on the lower of: (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side.  If procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any applicable multiple procedure rules.  Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.  9 = Concept does not apply. 23 Assistant at Surgery  This field provides an indicator for services where an assistant at surgery is never paid for per IOM.  0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.  1 = Statutory payment restriction for assistants at surgery applies to this procedure.  Assistant at surgery may not be paid. 2 = Payment restriction for assistants at surgery does not apply to this procedure.  Assistant at surgery may be paid.  9 = Concept does not apply. 1 Pic (x)1  24 Co-Surgeons (Modifier 62)  This field provides an indicator for services for which two surgeons, each in a different specialty, may be paid.  0 = Co -surgeons not permitted for this procedure.  1 = Co -surgeons could be paid; supporting documentation required to establish medical necessity of two surgeons for the procedure.  2 = Co -surgeons permitted; no documentation required if two specialty requirements are met.  9 = Concept does not apply. 1 Pic (x)1  25 Team Surgeons (Modifier 66)  This field provides an indicator for services for which team surgeons may be paid.  0 = Team surgeons not permitted for this procedure.  1 = Team surgeons could be paid; supporting documentation required to establish medical necessity of a team; pay by report.  1 Pic (x)1  FIELD # & ITEM  LENGTH & PIC  2 = Team surgeons permitted; pay by report.  9 = Concept does not apply. 26 Filler  1 Pic (x)1  27 Site of Service Differential  For 1999 and beyond, the site of service differential no longer applies.  The following definitions will apply for all years after 1998:  0 = Facility pricing does not apply. 1 = Facility pricing applies.  9 = Concept does not apply. 1 Pic (x)1  28 Non-Facility Fee Schedule Amount  This field shows the fee schedule amount for the non- facility setting.  This amount equals Field 34. Note :  Field 33 D indicates if an additional adjustment should be applied to this formula. Non-Facility Pricing Amount for the File Year  [(Work RVU * Work GPCI) +  ( Non -Facility PE RVU * PE GPCI) +  (MP RVU * MP GPCI)] * Conversion Factor  9 Pic 9(7)v99 29 Facility Fee Schedule Amount  This field shows the fee schedule amount for the facility setting.  This amount equals Field 35. Note:  Field 33D indicates if an additional adjustment should be applied to this formula. Facility Pricing Amount for the File Year  [(Work RVU * Work GPCI) +  ( Facility PE RVU * PE GPCI) +  (MP RVU * MP GPCI)] * Conversion Factor  Place of service codes to be used to identify facilities.  02  Telehealth -Medicare pays telehealth services at the facility rate.  19  Off Campus -Outpatient Hospital  21 - Inpatient Hospital  22  On Campus -Outpatient Hospital 9 Pic 9(7)v99 FIELD # & ITEM  LENGTH & PIC  23 - Emergency Room - Hospital  24 - Ambulatory Surgical Center  In a Medicare approved ASC, for an approved procedure on the ASC list, Medicare pays the lower facility fee to physicians.   Beginning with dates of service January 1, 2008, in a Medicare approved ASC, for procedures NOT on the ASC list of approved procedures, contractors will also pay the lower facility fee to physicians.  26 - Military Treatment Facility  31 - Skilled Nursing Facility  34 - Hospice  41 - Ambulance - Land  42 - Ambulance Air or Water  51 - Inpatient Psychiatric Facility  52 - Psychiatric Facility Partial Hospitalization  53 - Community Mental Health Center  56 - Psychiatric Residential Treatment Facility  61 - Comprehensive Inpatient Rehabilitation Facility  29A Anti-markup Test Indicator  This field providers an indicator for Anti -markup Test HCPCS codes:  1 = Anti -markup Test HCPCS.  9 = Concept does not apply. 1 Pic x  30 Record Effective Date  This field identifies the effective date for the MPFSDB record for each HCPCS.  The field is in YYYYMMDD format.