(Medicare Claims Processing Manual)

C. A/B MAC (A)  Special Billing Instructions   MNT Services can be billed to A/B MACs (A) when performed in an outpatient hospital setting.  The Hospital outpatient departments can bill for the MNT services through the A/B MAC (A) if the nutritionists or registered dietitians reassign their benefits to  the hospital.  If the hospitals do not get the reassignments the nutritionists and the registered dietitians will have to bill the Medicare A/B MAC (B) under their own provider number or the hospital will have to bill the Medicare A/B MAC (B).   NOTE:   Nutritionists and registered dietitians must obtain a Medicare provider number before they can reassign their benefits.   The only applicable bill types are 13X, 23X, 32X, and 85X.      300.5.1 - Rural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs) Special Billing Instructions  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  Detailed billing instructions for MNT services provided in Rural Health Clinics and Federally Qualified Health Centers can be found in Chapter 9, section 182 of this manual.   300.6 - Common Working File (CWF) Edits  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  The Common Working File (CWF) edit will allow 3 hours of therapy for MNT in the initial calendar year. The edit will allow more than 3 hours of therapy if there is a change in the beneficiarys medical condition, diagnosis, or treatment regimen and this change must be documented in the beneficiarys medical record. Two new G codes have been created for use when a beneficiary receives a second referral in a calendar year that allows the beneficiary to receive more than 3 hours of therapy. Another edit will a llow 2 hours of follow up MNT with another referral in subsequent years.   Advance Beneficiary Notice (ABN)   The beneficiary is liable for services denied over the limited number of hours with referrals for MNT. An Advance Beneficiary Notice (ABN) should be issued in these situations. In absence of evidence of a valid ABN, the provider will be held liable.   An ABN should not be issued for Medicare -covered services such as those provided by hospital dietitians or nutrition professionals who are qualified to render the service in their state but who have not obtained Medicare provider numbers.   Duplicate Edits   Although beneficiaries are allowed to receive training and therapy during the same time period DSMT and MNT services may not be provided on the same day to the same beneficiary. Effective April 1, 2010 CWF shall implement a new duplicate crossover edit to identify and prevent claims for DSMT/MNT services from being billed with the same dates of services for the same beneficiaries submitted from institutional providers and from a professional provider.   310 - Lung Volume Reduction Surgery  (Rev. 768, Issued:  12- 01-05; Effective:  11 -17-05; Implementation:  03 -02 06)   Lung Volume Reduction Surgery (LVRS) (also known as reduction pneumoplasty, lung shaving, or lung contouring) is an invasive surgical procedure to reduce the volume of a hyperinflated lung in order to allow the underlying compressed lung to expand, and thus, establish improved respiratory function.   Effective for 'from' dates of service on or after January 1, 2004, Medicare will cover LVRS under certain conditions as described in 240 of the Pub. 100- 03, National Coverage Determinations.   LVRS can only be performed in the facilities listed on the following website:  http://www.cms.gov/Medicare/Medicare -General -Information/MedicareApprovedFacilitie/Lung -Volume -Reduction- Surgery -LVRS.html .   LVRS is an inpatient procedure.  However pre - and post - operative services are performed on an outpatient basis and must be performed at one of the facilities certified to do so.  These procedures are paid under the Outpatient Prospective Payment System (OPPS), except for hospitals located in Maryland.   Medicare previously only covered LVRS as part of the National Emphysema Treatment Trial (NETT).  The study was limited to 18 hospitals, and patients were randomized into two arms, either medical management and LVRS or medical management.  The study was con ducted by The National Heart, Lung, and Blood Institute of the National Institutes of Health and coordinated by Johns Hopkins University (JHU).  Hospital claims for patients in the NETT were identified by the presence of Condition Code EY.  The JHU instruc ted hospitals of the correct billing procedures for billing claims under the NETT.   320 - Outpatient Intravenous Insulin Treatment (OIVIT)  (Rev. 1930, Issued:  03- 09-10, Effective Date:  12- 23-09; Implementation Date:  04-05-10)  Effective for claims with dates of service on and after December 23, 2009, the Centers for Medicare and Medicaid Services (CMS) determines that the evidence does not support a conclusion that OIVIT improves health outcomes in Medicare beneficiaries.  Therefore, CMS has determined that OIVIT is not reasonable and necessary for any indication under section 1862(a)(1)(A) of the Social Security Act.  Services comprising an OIVIT regimen are nationally non- covered under Medicare when furnished pursuant to an OIV IT regimen.   See Pub. 100- 03, Medicare National Coverage Determinations Manual, Section 40.7, Outpatient Intravenous Insulin Treatment (Effective December 23, 2009), for general information and coverage indications.  320.1 - HCPCS Coding for OIVIT  (Rev. 1930, Issued:  03- 09-10, Effective Date:  12- 23-09; Implementation Date:  04-05-10)  HCPCS code G9147, effective with the April IOCE and MPFSDB updates, is to be used on claims with dates of service on and after December 23, 2009, billing for non- covered OIVIT and any services comprising an OIVIT regimen.  NOTE:  HCPCS codes 99199 or 94681(with or without diabetes related conditions 250.00- 250.93) are not to be used on claims billing for non- covered OIVIT and any services comprising an OIVIT regimen when furnished pursuant to an OIVIT regimen. Claims billing for H CPCS codes 99199 and 94681 for non- covered OIVIT are to be returned to provider/returned as unprocessable.   320.2 - Medicare Summary Notices (MSN), Reason Codes, and Remark Codes (Rev. 3475, Issued: 03- 04-16, Effective: 06 -06-16, Implementation: 06- 06-16)  Contractors shall return non- covered OIVIT claims billed with HCPCS 99199 to provider/return as unprocessable.   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: 16  RARC: MA66, N56 MSN: N/A  Contractors shall return non- covered OIVIT claims billed with HCPCS 94681 with or without diabetes -related conditions 250- 00-250.93 to provider/return as unprocessable.   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: 16  RARC: MA66, N56 MSN: N/A  Contractors shall deny claims for non- covered OIVIT and any services comprising an OIVIT regimen billed with HCPCS code G9147.  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: 96  RARC: N386  MSN: 16.10Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl  Date  CR#  R12421CP  12/21/2023 January 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)   01/02/2024 13488  R12423CP   12/20/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024 13222  R12369CP  11/17/2023 Implementation of Rural Emergency Hospital (REH) Provider Type   01/03/2023    12820  R12321CP  10/18/2023 Implementation of Rural Emergency Hospital (REH) Provider Type - Rescinded and replaced by Transmittal 12369  01/03/2023 12820   07/13/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92-  SENSITIVE/CONTROVERSIAL  Rescinded and replaced by Transmittal 12423 01/02/2024 13222  R11941CP  04/05/2023 Correction to Manual for Outlier Calculations 05/05/2023 13142  R11937CP  03/31/2023 April 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS)   04/03/2023 13136  R11900CP  03/13/2023 Implementation of Rural Emergency Hospital (REH) Provider Type -- Rescinded and replaced by Transmittal 12321  01/03/2023 12820  R11897CP  03/10/2023 April 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS) - Rescinded and replaced by Transmittal 11 937 04/03/2023 13136  R11801CP  01/20/203 January 2023 Update of the Hospital Outpatient Prospective  Payment System (OPPS)   01/03/2023 13031  Rev #  Issue Date  Subject  Impl  Date  CR#  R11737CP  12/08/2022 January 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS)  - Rescinded and replaced by transmittal 11801 01/03/2023 13031  R11729CP  12/06/2022 Implementation of Rural Emergency Hospital (REH) Provider Type - Rescinded and replaced by transmittal  11900 01/03/2023 12820       R11685CP  11/09/2022 Billing for Hospital Part B Inpatient Services  12/12/2022 11685   07/28/2022 Implementation of Rural Emergency Hospital (REH) Provider Type SENSITIVE/CONTROVERSIAL   Rescinded and replaced by transmittal 11729  01/03/2023 12820  R11504CP   07/21/2022 Modification of Existing Common Working File (CWF) Editing for Preventive Services   01/03/2023 12792  R11457CP  06/15/2022 July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  07/05/2022 12761  R11435CP  05/26/2022 July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  -Rescinded and Replaced by Transmittal #11457 07/05/2022 12761  R11426CP   05/20/2022 An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilit ation (ICR) Conditions of Coverage