Wednesday, November 9, 2016

Implantable Prosthetic Devices Billing CPT code C9899,

Implantable Prosthetic Devices

Under 42 CFR 419.2(b)(11), implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of these devices, are paid under the OPPS, and are therefore packaged with the surgical implantation procedure unless the device has pass-through payment status. This payment provision applies when such a device is billed as a Part B outpatient service, or as a Part B inpatient service when the inpatient admission is determined not reasonable and necessary and the beneficiary should have been treated as a hospital outpatient (see Pub. 100-02, Medicare Benefit Policy Manual, chapter 6, §10.1). In these circumstances, hospitals should submit the usual HCPCS code for Part B payment of the device.

In the other circumstances in which a beneficiary does not have Part A coverage of inpatient services on the date that such a device is implanted (that is, when furnished by a participating hospital to an inpatient who is not entitled to benefits under Part A, has exhausted his or her Part A benefits, or receives services not covered under Part A), hospitals paid under the OPPS should report HCPCS code, C9899, Implanted Prosthetic Device, Payable Only for Inpatients who do not Have Inpatient Coverage, that is effective for services furnished on or after January 1, 2009. This code allows an alternative Part B inpatient payment methodology for the device as discussed in this section, and may be reported only on claims with TOB 12X when the prosthetic device is implanted on a day on which the beneficiary does not have coverage under Part A because he or she is not entitled to Part A benefits, has exhausted his or her Part A benefits, or receives services not covered under Part A. The line containing this new code will be rejected if it is reported on a claim that is not a TOB 12X or if it is reported with a line item date of service on which the beneficiary has coverage of inpatient hospital services. By reporting C9899, the hospital is reporting that the item is eligible for separate OPPS payment because the primary procedure is not a payable Part B inpatient service under Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §10.2 (“Other Circumstances in Which Payment Cannot Be Made under Part A”).

If C9899 is a separately payable Part B inpatient service, the contractor shall determine the payment amount as follows. If the device has pass through status under the OPPS, the contractor shall establish the payment amount for the device at the product of the charge for the device and the hospital specific cost to charge ratio. Where the device does not have pass through status under the OPPS, the contractor shall establish the payment amount for the device at the amount for a comparable device in the DMEPOS fee schedule where there is such an amount. Payment under the DMEPOS fee schedule is made at the lesser of charges or the fee schedule amount and therefore if there is a fee for the specific item on the DMEPOS fee schedule, the payment amount for the item will be set at the lesser of the actual charges or the DMEPOS fee schedule amount. Where the item does not have pass through payment status and where there is no amount for a comparable device in the DMEPOS fee schedule, the contractor shall establish a payment amount that is specific to the particular implanted prosthetic device for the applicable calendar year. This amount (less applicable unpaid deductible and coinsurance) will be paid for that specific device for services furnished in the applicable calendar year unless the actual charge for the item is less than the established amount). Where the actual charge is less than the established amount, the contractor will pay the actual charge for the item (less applicable unpaid deductible and coinsurance).

In setting a contractor established payment rate for the specific device, the contractor takes into account the cost information available at the time the payment rate is established. This information may include, but is not limited to, the amount of device cost that would be removed from an applicable APC payment for implantation of the device if the provider received a device without cost or a full credit for the cost of the device.

If the contractor chooses to use this amount, see www.cms.hhs.gov/HospitalOutpatientPPS/ for the amount of reduction to the APC payment that would apply in these cases. From the OPPS webpage, select “Device, Radiolabeled Product, and Procedure Edits” from the list on the left side of the page. Open the file “Procedure to Device edits” to determine the HCPCS code that best describes the procedure in which the device would be used. Then identify the APC to which that procedure code maps from the most recent Addenda B on the OPPS webpage and open the file “FB/FC Modifier Procedures and Devices”. Select the applicable year’s file of APCs subject to full and partial credit reductions (for example: CY 2008 APCs Subject to Full and Partial Credit Reduction Policy”). Select the “Full offset reduction amount” that pertains to the APC that is most applicable to the device described by C9899. It would be reasonable to set this amount as payment for the device.

For example, if C9899 is reporting insertion of a single chamber pacemaker (C1786 or equivalent narrative description on the claim in “remarks”) the file of procedure to device edits shows that a single chamber pacemaker is the dominant device for APC 0090 (APC 0089 is for insertion of both pacemaker and electrodes and therefore would not apply if electrodes are not also billed). The table of offset reduction amounts for CY 2008 shows that the estimated cost of a single chamber pacemaker for APC 0090 is $4881.77. It would therefore be reasonable for the contractor/MAC to set the payment rate for a single chamber pacemaker to $4881.77. In this case the coinsurance would be $936.75 (20 percent of $4881.77, which is less than the inpatient deductible).

The beneficiary coinsurance is 20 percent of the payment amount for the device (i.e. the pass through payment amount, the DMEPOS fee schedule amount, the contractor established amount, or the actual charge if less than the DMEPOS fee schedule amount or the contractor established amount for the specific device), not to exceed the Medicare inpatient deductible that is applicable to the year in which the implanted prosthetic device is furnished.

When a hospital that is not paid under the OPPS furnishes an implantable prosthetic device other than dental), which replaces all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such a device, to an inpatient who has coverage under Part B but does not have Part A coverage, and the primary procedure is not a payable Part B inpatient service under Pub. 100-02, Medicare Benefit Policy Manual, chapter 6, §10.2 (“Other Circumstances in Which Payment Cannot Be Made under Part A”), payment for the implantable prosthetic device is made under the payment mechanism that applies to other hospital outpatient services (e.g., reasonable cost, all inclusive rate, waiver).

Friday, October 28, 2016

What POS and TOS can be used for ASC facility


ASC Procedures for Completing the ASC X12 837 Professional Claim Format or the Form CMS-1500 

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.

Modifier - TC is required unless the code definition is for the technical component only.



 Medicare Summary Notices (MSN), Claim Adjustment Reason Codes, Remittance Advice Remark Codes (RAs) 


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. Use the following messages for these returned claims:

• Claim Adjustment Reason Code 16 - Claim/service lacks information which is needed for adjudication. Additional information is supplied using remittance advice remark codes whenever appropriate.

• RA Remark Code M67 - Missing/Incomplete/Invalid other procedure codes.

• RA Remark Code MA130 - Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Contractors shall deny payment for Q1003 if services are furnished in a facility other than a Medicare-approved ASC. Use the following messages when denying these claims:
• MSN 16.2 - This service cannot be paid when provided in this location/facility.

• Claims Adjustment Reason Code 58 - Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

Contractors shall deny payment for Q1003 if billed by an entity other than a Medicare-approved ASC. Use the following messages when denying these claims:
• MSN 33.1 - The ambulatory surgical center must bill for this service.

• Claim Adjustment Reason Code 170 - Payment is denied when performed/billed by this type of provider.

Contractors shall deny payment for Q1003 if submitted for payment past the discontinued date (after the 5-year period, or after February 26, 2011). Use the following messages when denying these claims:
• MSN 21.11 - This service was not covered by Medicare at the time you received it.

• Claim Adjustment Reason Code 27 - Expenses incurred after coverage terminated.

Carriers shall deny payment for Q1003 if services are furnished in a facility other than a Medicare-approved ASC. Use the following messages when denying these claims:
• MSN 16.2 - This service cannot be paid when provided in this location/facility.

• Claims Adjustment Reason Code 58 - Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

Carriers shall deny payment for Q1003 if billed by an entity other than a Medicare-approved ASC. Use the following messages when denying these claims:
• MSN 33.1 - The ambulatory surgical center must bill for this service.

• Claim Adjustment Reason Code 170 - Payment is denied when performed/billed by this type of provider.

Carriers shall deny payment for Q1003 if submitted for payment past the discontinued date (after the 5-year period, or after February 26, 2011). Use the following messages when denying these claims:
• MSN 21.11 - This service was not covered by Medicare at the time you received it.

• Claim Adjustment Reason Code 27 - Expenses incurred after coverage terminated.

Monday, October 24, 2016

How to BILL CPT CODE V2787


 Payment and Coding for Presbyopia Correcting IOLs (P-C IOLs) and Astigmatism Correcting IOLs (A-C IOLs) 

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 payment 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 (NTIOL) 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 devices 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 cataract 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 aspiration 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.

Thursday, October 20, 2016

CPT CODE 50590 PAYMENT GUIDE


 Payment for Extracorporeal Shock Wave Lithotripsy (ESWL) 

A ninth ASC payment group was established in a “Federal Register” notice (56 FR 67666) published December 31, 1991. The ninth payment group amount ($1,150) was assigned to only one procedure, CPT code 50590, extracorporeal shock wave lithotripsy (ESWL).

However, a court order issued March 12, 1992, has stayed the Group 9 payment rate until the Secretary publishes all information relevant to the setting of the ESWL rate, receives comments, and publishes a subsequent final notice. This has not yet been completed.

In a previous instruction (Medicare Carrier’s Manual Transmittal 1435), CMS advised carriers to make payment to ASCs for ESWL services furnished after January 29, 1992, and through the date when the ASC received notice from the carrier of the court order staying the Group 9 payment rate. This was a temporary measure to avoid penalizing ASCs that furnished ESWL services in accordance with the December 31, 1991, “Federal Register” notice and that could not have been expected to know that the March 12, 1992, court order set aside the ESWL provisions of that notice. Carriers did not make Medicare payment for ESWL as an ASC procedure when such services were furnished after the date that the carrier advised an ASC of the court order.

However carriers were instructed to retain all ASC claims for ESWL with a service date after January 29, 1992, and before the date when they were notified about the court order. It may be necessary to retrieve these clams for further action at some later date.

Beginning January 1, 2008 with the revised ASC payment system, contractors may pay for any of the ESWL services that are included on the ASC list of covered surgical procedures.

Sunday, October 16, 2016

Payment for Multiple Procedures ASC Facility


When more than one surgical procedure is performed in the same operative session, special payment rules apply, even if the procedures have the same HCPCS code.

When the ASC performs multiple surgical procedures in the same operative session that are subject to the multiple procedure discount, contractors pay 100 percent of the highest paying surgical procedure on the claim, plus 50 percent of the applicable payment rate(s) for the other ASC covered surgical procedures subject to the multiple procedure discount that are furnished in the same session. The OPPS/ASC final rule for the relevant payment year specifies whether or not a surgical procedure is subject to multiple procedure discounting for that year. Final payment is subject to the usual copayment and deductible provisions.

The multiple procedure payment reduction is the last pricing routine applied to applicable ASC procedure codes. In determining the ranking of procedures for application of the multiple procedure reduction, contractors shall use the lower of the billed charge or the ASC payment amount. The ASC surgical services billed with modifier -73 and -52 shall not be subjected to further pricing reductions. (i.e., the multiple procedure price reduction rules do not apply). Payment for an ASC surgical procedure billed with modifier -74 may be subject to the multiple procedure discount if that surgical procedure is subject to the multiple procedure discount.

A procedure performed bilaterally in one operative session is reported as two procedures, either as a single unit on two separate lines or with “2” in the units field on one line. The multiple procedure reduction of 50 percent applies to all bilateral procedures subject to multiple procedure discounting. For example, if lavage by cannulation; maxillary sinus (antrum puncture by natural ostium) (CPT code 31020) is performed bilaterally in one operative session, report 31020 on two separate lines or with “2” in the units field. Depending on whether the claim includes other services to which the multiple procedure discount applies, the contractor applies the multiple procedure reduction of 50 percent to the payment for at least one of the CPT code 31020 payment rates.

Wednesday, October 12, 2016

Payment Guide for Terminated procedure in ASC Billing


 Payment for Terminated Procedures 

The following criteria determine the appropriate ASC facility payment for a scheduled surgical procedure that is terminated due to medical complications which increase the surgical risk to the patient

A. Contractors deny payment when an ASC submits a claim for a procedure that is terminated before the patient is taken into the treatment or operating room. For example, payment is denied if scheduled surgery is canceled or postponed because the patient on intake complains of a cold or flu.

B Contractors pay 50 percent of the rate if a surgical procedure is terminated due to the onset of medical complications after the patient has been prepared for surgery and taken to the operating room but before anesthesia has been induced or the procedure initiated (use modifier 73). For example, 50 percent is paid if the patient develops an allergic reaction to a drug administered by the ASC prior to surgery or if, upon injection of a retrobulbar block, the patient experiences a retrobulbar hemorrhage which prevents continuation of the procedure. Although some supplies and resources are expended, they are not consumed to the same extent had anesthesia been fully induced and the surgery completed. Facilities use a 73 modifier to indicate that the procedure was terminated prior to induction of anesthesia or initiation of the procedure.

C. Contractors make full payment of the surgical procedure if a medical complication arises which causes the procedure to be terminated after anesthesia has been induced or the procedure initiated (use modifier -74). For example, carriers make full payment if, after anesthesia has been accomplished and the surgeon has made a preliminary incision, the patient’s blood pressure increases suddenly and the surgery is terminated to avoid increasing surgical risk to the patient. In this case, the resources of the facility are consumed in essentially the same manner and to the same extent as they would have been had the surgery been completed. Facilities use a 74 modifier to indicate that the procedure was terminated after administration of anesthesia or initiation of the procedure.


An ASC claim for payment for terminated surgery must include an operative report kept on file by the ASC, and made available, if requested by the contractor. The operative report should specify the following:

• Reason for termination of surgery;

• Services actually performed;

• Supplies actually provided;

• Services not performed that would have been performed if surgery had not been terminated;

• Supplies not provided that would have been provided if the surgery had not been terminated;

• Time actually spent in each stage, e.g., pre-operative, operative, and post-operative;

• Time that would have been spent in each of these stages if the surgery had not been terminated; and

• HCPCS code for procedure had the surgery been performed.


D. Prior to January 1, 2008, carriers deduct the allowance for an unused IOL prior to calculating payment for a terminated IOL insertion procedure.

E. Beginning January 1, 2008, payment for the IOL is included in payment for the surgical procedure to implant the lens.

F. Beginning January 1, 2008, contractors apply a 50 percent payment reduction for discontinued radiology procedures and other procedures that do not require anesthesia.

Facilities use the -52 modifier to indicate the discontinuance of these applicable procedures.

G. Beginning January 1, 2008, ASC surgical services billed with the -52 or- 73 modifier are not subject to the multiple procedure discount.

Saturday, October 8, 2016

Payment for CPT 66982 - 66986


 Payment for Intraocular Lens (IOL) 

Prior to January 1, 2008, payment for facility services furnished by an ASC for IOL insertion during or subsequent to cataract surgery includes an allowance for the lens. The procedures that include insertion of an IOL are:

Payment Group 6: CPT-4 Codes 66985 and 66986 

Payment Group 8: CPT-4 Codes 66982, 66983 and 66984 

Physicians or suppliers are not paid for an IOL furnished to a beneficiary in an ASC after July 1, 1988. Separate claims for IOLs furnished to ASC patients beginning March 12, 1990 are denied. Also, effective March 12, 1990, procedures 66983 and 66984 are treated as single procedures for payment purposes.

Beginning January 1, 2008, the Medicare payment for the IOL is included in the Medicare ASC payment for the associated surgical procedure. Consequently, no separate payment for the IOL is made, except for a payment adjustment for NTIOLs established according to the process outlined in 42 CFR 416.185. ASCs should not report separate charges for conventional IOLs because their payment is included in the Medicare payment for the associated surgical procedure. The ASC payment system logic that excluded $150 for IOLs for purposes of the multiple surgery reduction in cases of cataract surgery prior to January 1, 2008 no longer applies, effective for dates of service on or after January 1, 2008.

Effective for dates of service on and after February 27, 2006, through February 26, 2011, Medicare pays an additional $50 for specified Category 3 NTIOLs that are provided in association with a covered ASC surgical procedure. The list of Category 3 NTIOLS is available at: http://www.cms.hhs.gov/ASCPayment/08_NTIOLs.asp#TopOfPage.

ASCs should use HCPCS code Q1003 to bill for a Category 3 NTIOL. HCPCS code Q1003, along with one of the approved surgical procedure codes (CPT codes 66982, 66983, 66984, 66985, 66986) are to be used on all NTIOL Category 3 claims associated with reduced spherical aberration from February 27, 2006, through February 26, 2011. The payment adjustment for the NTIOL is subject to beneficiary coinsurance but is not wage-adjusted.


Any subsequent IOL recognized by CMS as having the same characteristics as the first NTIOL recognized by CMS for a payment adjustment as a Category III NTIOL (those of reduced spherical aberration) will receive the same adjustment for the remainder of the 5-year period established by the first recognized IOL.

Popular Posts