(Medicare Claims Processing Manual)

This field provides an indicator for services where an assistant at surgery may be paid:   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  37 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.  1 Pic (x)1  38 FIELD NAME & DESCRIPTION LENGTH & PIC Position   2 = Co -surgeons permitted; no documentation required if two specialty requirements are met.   9 = Concept does not apply. 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.   2 = Team surgeons permitted; pay by report.  9 = Concept does not apply. 1 Pic (x)1  39 Endoscopic Base Codes   This field identifies an endoscopic base code for each code with a multiple surgery indicator of 3.  5 Pic (x) 5  40-44 Performance Payment Indicator (For future use)  1 Pic x (1)  45 Diagnostic Imaging Family Indicator  88 = Subject to the reduction for diagnostic imaging (effective for services 2 Pic x (2)  46-47          Multiple procedure indicator 5 is included in this file ; however , the indicator represents the therapy multiple procedure payment reduction which never applies to professional service revenue codes on CAH  outpatient claims.  Multiple procedure indicators 6 and 7 are included in this file , however, since in these cases the reduction only applies to technical component services, they will not affect the cost -based payment on CAH claims.  On CAH claims, technical components are paid on a cost basis and so are not subject to the reductions.    There may be cases when A/B MACs (A) must manually load a HCPCS code that is contractor priced which has a multiple procedure indicator that is not on the payment indicator file.  In these cases, the MAC enters a multiple procedure indicator of 0.   50.7 - Institutional Claim Record Layout for the Mammography Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This is a physician fee schedule abstract file for mammography services payment.  The CMS will provide the specific file names when the prices are released.  The file name will contain the label MAMMO.   Record Length  - 60 Record Format  - FB Block Size  - 6000 Character Code  - EBCDIC  Sort Sequence  - A/B MAC (B), Locality HCPCS Code, Modifier   FIELD NAME & DESCRIPTION LENGTH & PIC Position  January 1, 2011, and after).  99 = Concept Does Not Apply  Effective Date  This field displays the effective date of the file in YYYYMMDD format.  8 Pic x(8)  48 - 55 Filler  30 Pic x(30)  56 -75 Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Modifier  X(02)  6 - 7  3-Non-Facility Fee  9(05)V99  8 - 14  4-PCTC Indicator  X(01)  15 - 15 This field is only applicable when pricing Critical Access Hospitals (CAHs) that have elected the optional method (Method 2) of payment. 5-Facility Fee  9(05)V99  16 - 22  6-Effective Date  7- A/B MAC (B) Number  X(08)  X(05)  23 - 30 31 - 35 Update effective date  8-Locality  X(02)  36- 37  9-Filler  X(05)  38- 42  10-Status Code  X(1)  43- 43 Separate instructions will be used for the use of this field at a later date.  This field indicates whether the code is in the physician fee schedule and whether it is separately payable if the service is covered.  11-Multiple Surgery X(01)  44 - 44 Indicator indicates which payment adjustment rule for multiple procedures apply to the service.  12-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  13-Filler  X(01)  52 - 52  14- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   15-Filler  X(01)  60 - 60   50.8 - Institutional Claim Record Layout for the Ambulance Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This is a physician fee schedule abstract file for ambulance services payment.  The CMS will provide the specific file names when the prices are released.   The file name will contain the label AMBFS.   Record Length  - 80 Record Format  - FB Block Size  - 27920 Character Code  - EBCDIC  Sort Sequence  - HCPCS, A/B MAC (B), Locality    Field Name  Format  Position  Description  1-HCPCS  X(05)  1 - 5 HCFA Common Procedure Coding System  2- A/B MAC (B) Number  X(05)  6 - 10  3-Locality Code  X(02)  11-12  4-Base RVU  9(4)v99  13 - 18 Relative Value Unit  5-Non-Facility PE GPCI  9v9(3)  19 - 22 Geographic Adjustment Factor  6-Conversion Factor  9(5)v99  23 - 29 Conversion Factor  7-Urban Mileage  9(5)v99  30 - 36 Urban payment rate or base rate mileage rate (determined by HCPCS)  8-Rural Mileage  9(5)v99  37 - 43 Rural payment rate or base rate mileage rate (determined by HCPCS)  9-Current Year  9(04)  44- 47 YYYY  10-Current Quarter  9(01)  48 Calendar Quarter -value 1 -4 11-Effective Date  9(8) 49- 56 Effective date of fee schedule file 12-Filler  X(24)  57 - 80 Future Use   60 - Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)  The CMS issues instructions for implementing and/or updating the DMEPOS fee schedule payment amounts on an annual basis (January), with quarterly updates as necessary (April, July and October).  In addition, special instructions may be issued at any time i f necessary for implementation of changes in the statute, regulations, or for other reasons.  The DMEPOS fee schedule is provided to DME MACs, the Pricing, Data Analysis and Coding Contractor (PDAC), and A/B MACs (B) via CMS mainframe telecommunication sy stem.    Upon successful receipt of the updated file(s), MACs send notification of receipt via email to price_file_receipt@cms.hhs.gov stating the name of the file received and the entities for which they were received (e.g., MAC name and A/B MAC (A) or (HHH) number).   A separate DMEPOS Fee Schedule file is released to A/B MACs (A) and (HHH), Railroad Retirement Board (RRB) and RRBs Specialty MAC, Indian Health Service, and United Mine Workers.  This fee schedule is also available on the CMS site (http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS -Fee-Schedule.html ) for other interested parties like the State Medicaid agencies and managed care organizations.  The fee schedule for parenteral and enteral nutrition (PEN) is released to the PDAC and DME MACs in a separate file.  All annual updates to fee schedules are t o be implemented on January 1 for claims with dates of service on or after January 1.   Effective February 28, 2022, national fee schedule amounts for new DMEPOS items and services that are added to the DMEPOS or PEN fee schedule files are established by CMS using the process summarized below and outlined in the regulations at 42 CFR 414.114 and 414.240. As explained in more detail in 60.3 below, MACs shall establish interim local fee schedule amounts for use in paying claims for new items and services billed using codes for miscellaneous items and services and for use in paying claims on an interim basis until the national fee schedule amounts are established.   Process for Establishing National Fee Schedule Amounts  Effective February 28, 2022  If a preliminary determination is made by CMS that a new item or service without a fee schedule pricing history falls under a DMEPOS benefit category, CMS makes a preliminary payment determination for the item or service and posts the preliminary payment determination on the website www.CMS.gov approximately 2 weeks prior to a public meeting. After consideration of public consultation provided at the public meeting on the preliminary benefit category and payment determinations for the item or service, CMS p osts final determinations on the website www.CMS.gov and implements the benefit category determinations and payment determinations for items and services through program instructions. Some determinations may be deferred to future cycles of the public consultation process if more time is needed to develop preliminary or final benefit category and payment determinations. Benefit category determinations are made using the public meeting process described above for an item or service that is the subject of a request for a HCPCS code set modification. Benefit category determinations are also made using the public meeting process in cases where a manufacturer for a new item or service is not requesting a HCPCS code set modification for the item or service, but requests CMS to determine whether the item or service falls under a DMEPOS benefit category. Benefit category determina tions are also made using the public meeting process when CMS identifies a need to address whether an item or service falls under a DMEPOS benefit category.  60.1 - Record Layout for DMEPOS Fee Schedule  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)