(Medicare Claims Processing Manual)

190  Payer Only Codes Utilized by Medicare  (Rev. 11571, Issued:08- 25-22, Effective: 09 -27-22, Implementation: 09- 27-22)  This section contains the listing of payer codes designated by the National Uniform Billing Committee to be assigned by payers only. Providers shall not submit these codes on their claims forms. The definitions indicating Medicares usage for these systema tically assigned codes are indicated next to each code value.  Condition Codes  12-14  Not currently used by Medicare.  15  Clean claim is delayed in CMS Processing System.  16  SNF Transition exception.   62  PIP Bill.  63  Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.   64  Other Than Clean Claim.  65  Non -PPS Bill.  98  Data Associated With DRG 468 Has Been Validated.  EY  Lung Reduction Study Demonstration Claims.  M0  All -Inclusive Rate for Outpatient - Used by a Critical Access Hospital electing to be paid an all -inclusive rate for outpatient services.   M1  Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV). Code indicates the influenza virus vaccine or pneumonia vaccine (PPV) is being billed via the roster billing method by providers that mass immunize.  M2  Allows Home Health claims to process if provider reimbursement > $150,000.00. HHA Payment Significantly Exceeds Total Charges. Used when payment to an HHA is significantly in excess of covered billed charges.  M3  SNF 3 Day stay bypass for NG/Pioneer ACO waiver.  M4  Presence of infected wound or wound with morbid obesity  M5  Not currently used by Medicare   M6  PA Rural Health Model  M7-M9  Not currently used by Medicare.  MA  GI Bleed. (Bill Type 072x)  MA  Managed Care Enrollee (Bill Type 012x, 013x, and 076x)  MB  Pneumonia. (Bill Type 072x)  MC  Pericarditis. (Bill Type 072x)  MD  Myelodysplastic Syndrome. (Bill Type 072x)  ME  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 072x)  MF  Monoclonal Gammopathy. (Bill Type 072x)  MG  Grandfathered Tribal Federally Qualified Health Centers.  MH-MN  Not currently used by Medicare.  MO  MAC Override Appeal Timeliness.  MP  PHP claim contains initial admit week  MQ  PHP claim contains final discharge week  MR-MU  Not currently used by Medicare.  MV  20 hours for partial PHP subsequent week not met  MW  20 hours for partial PHP initial week net met MX  Wrong Surgery on Patient (Inpatient)  MY  Surgery Wrong Body Part (Inpatient)  MY  Outlier Cap Bypass (CMHC)  MZ  Surgery Wrong Patient (Inpatient)  MZ  IOCE error code bypass (Outpatient)  UU  Not currently used by Medicare.   Z0-Z9  Not currently used by Medicare.   ZA  No Positive COVID- 19 test result in M/R   ZB  Expanded Access approval   ZC  Clinical Trial of a different product   ZD-ZZ  Not currently used by Medicare.   Occurrence Codes  23  Date of Cancellation of Hospice Election period.  48  Not currently used by Medicare.  49  Original Notice of Election (NOE) receipt date.   AA-AZ  Not currently used by Medicare.  Occurrence Span Codes  79  Verified non -covered stay dates for which the provider is liable.  Z0-Z9  Not currently used by Medicare.  ZA-ZZ  Not currently used by Medicare.  Value Codes  17  Operating Outlier Amount  The A/B MAC (A) reports the amount of operating outlier payment amount made (either cost or day (day outliers have been obsolete since 1997)) in CWF with this code. It does not include any capital outlier payment in this ent ry.   18  Operating Disproportionate Share Amount  The A/B MAC (A) REPORTS THE OPERATING DISPROPORTIONATE SHARES AMOUNT APPLICIALBE. It uses the amount provided by the disproportionate share field in PRICER. It does not include any PPS capital IME adjustment e ntry.  19  Outpatient Use.  The Medicare shared system will display this payer only code on the claim for low volume providers to identify the amount of the low volume adjustment being included in the providers reimbursement. This payer only code 19 is also use d for IME on hospital claims. This instruction shall only apply to ESRD bill type 72x and must not impact any existing instructions for other bill types.  19  Inpatient Use.  Operating Indirect Medical Education Amount  The A/B MAC (A) reports operating indirect medical education amount applicable. It uses the amount provided by the indirect medical education field in PRICER. It does not include any PPS capital IME adjustment in this entry.  20  Total payment sent provider for capital under PPS, including HSP, FSP, outlier, old capital, DSH adjustment, IME adjustment, and any exception amount.  62  On Type of Bill 032x: HH Visits - Part A - The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security A ct.  62  On Type of Bills 081x 0r 082x: Number of High Routine Home Care Days -  Days that fall within the first 60 days of a routine home care hospice claim.   63  On Type of Bill 032x: HH visits  Part B - The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   63  On Type of Bills 081x 0r 082x: Number of Low Routine Home Care Days -  Days that come after the first 60 days of a routine home care hospice claim.  64  HH Reimbursement  Part A - The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount. This Part A payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) o f the Social Security Act.  65  HH Reimbursement  Part B - The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount. This Part B payment reflects the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) o f the Social Security Act.  70  Interest Amount  The contractor reports the amount of interest applied to this Medicare claim.  71  Funding of ESRD Networks - The A/B MAC (A) reports the amount the Medicare payment was reduced to help fund ESRD networks.  72  Flat Rate Surgery Charge  The standard charge for outpatient surgery where the provider has such a charging structure.  73  Sequestration adjustment amount.  74  Low volume hospital payment amount   75  Prior covered days for an interrupted stay.   76  Providers Interim Rate  Providers percentage of billed charges interim rate during this billing period. This applies to all outpatient hospital and skilled nursing facility (SNF) claims and home health agency (HHA) claims to which an interim rate i s applicable. The contractor reports to the left of the dollar/cents delimiter. An interim rate of 50 percent is entered as follows: 50.00.   77  Medicare New Technology Add -On Payment  Code indicates the amount of Medicare additional payment for new technology.   78  Off- site Zip Code  When the facility zip (Loop 2310E N403 Segment) is present for the following bill types: 012X, 013X, 014X, 022X, 023X, 034X, 072X, 074X, 075X, 081X, 082X, and 085X. The ZIP code is associated with this value and is used to price MP FS HCPCS and Anesthesia Services for CAH Method II.   79  Total payments for services applicable to the ESRD  The Medicare shared system will display this payer only code on the claim. The value represents the dollar amount for Medicare allowed payments applicable for the calculation in determining an outli er payment.   Q0  Pioneer Accountable Care Organization (ACO) non- model payment or Next Generation ACO non -model payment   Q1  Pioneer ACO model payment amount including reduction or NG ACO payment amount including reduction  Q2  Hospice claim paid from Part B Trust Fund   Q3  Prior Authorization 25% Penalty   Q4  PA Rural Model Exclusion -  Physician Service Claim Reimbursement   Q5  EHR   Q6  PQRS   Q7  Islet Isolation Add -on payment amount   Q8  Transitional Drug Add- On Payment Adjustment   Q9 - Medi care Performance Adjustment (MPA)   QA  PHP partial week input   QB  ESRD Treatment Choices (ETC) Model: Home Dialysis Payment Adjustment (HDPA) total bonus paid.  QC  OCM+ Adjustment   QD  Device Credit   QE  ET3 Model  ET3 15% bonus payment   QF  HHA -  LATE -SUB -PENALTY -AMT   QG  ESRD  Total TPNIES Amount   QH  ESRD -  TPNIES capital related assets (CRA)   QI  FQHC MDPCP DEMO  QJ  ETC Model Facility PPA   QK  Maryland Waiver Kidney Acquisition Payment   QL  Not used by Medicare   QM  MIPS adjustment amount   QN  First APC pass- through device offset   QO  Second APC pass -through device offset   QP  Third APC pass -through device offset   QQ  Terminated procedure with device offset   QR  First APC pass- through drug or biological offset  QS  Second APC pass -through drug or biological offset  QT  Third APC pass -through drug or biological offset  QU Device credit with device offset  QV  Value -based purchasing adjustment amount  QW  PHP partial week output   QX-QZ  Not used by Medicare   Z0-Z8  Not used by Medicare   Z9  COVID -19 PHE End Date   ZA-ZZ  Not used by Medicare  200 - Qualified Medicare Beneficiary (QMB) Program  (Rev. 4332, Issued: 07- 03-19, Effective: 10 -01-19, Implementation: 10- 07-19)  The Qualified Medicare Beneficiary (QMB) Program is a Medicaid program that assists low -income beneficiaries with Medicare premiums and cost -sharing. Federal law bars Medicare providers from billing an individual enrolled in QMB for Medicare Part A and Par t B cost -sharing for covered items and services. See section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997.    Providers and suppliers may bill State Medicaid agencies for Medicare cost -sharing amounts. However, as permitted by Federal law, States may limit Medicare cost -sharing payments, under certain circumstances. Regardless, persons enrolled in the QMB program  have no legal liability to pay Medicare providers for Medicare Part A or Part B cost -sharing for covered items and services.   Medicare providers who violate these billing prohibitions are violating their Medicare Provider Agreement and may be subject to sanctions. (See Sections 1902(n)(3)(C); 1905(p)(3); 1866(a)(1)(A); 1848(g)(3)(A) of the Social Security Act.)   Note: providers may seek reimbursement for unpaid Medicare deductible and coinsurance amounts as a Medicare bad debt.  Before a provider can be reimbursed for bad debts related to dual-eligible beneficiaries, Medicare policy under CMS Pub. 15- 1, Chapter 3, Section 312 of the Provider Reimbursement Manual (PRM) requires a determination and documentation of the states liability for any cost sharing amounts.   To effectuate this, Medicare requires the provider to bill the state to determine that the state is n ot liable for payment, even if the Medicare provider is not enrolled or the service is not covered under the states Medicaid plan.