tag:blogger.com,1999:blog-18144288779869397842024-03-19T04:41:21.133-07:00cms claimbillingமாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.comBlogger150125tag:blogger.com,1999:blog-1814428877986939784.post-35358979104548869812017-12-13T07:53:00.000-08:002017-12-13T07:53:22.110-08:00Drugs<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If the pancreas transplant occurs after the kidney transplant, immunosuppressive therapy
will begin with the date of discharge from the inpatient stay for the pancreas transplant.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Charges for Pancreas Acquisition Services</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">A separate organ acquisition cost center has been established for pancreas transplantation.
The Medicare cost report will include a separate line to account for pancreas
transplantation costs. The 42 CFR 412.2(e)(4) was changed to include pancreas in the list
of organ acquisition costs that are paid on a reasonable cost basis.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Acquisition costs for pancreas transplantation as well as kidney transplants will occur in
Revenue Center 081X. The contractor overrides any claims that suspend due to repetition
of revenue code 081X on the same claim if the patient had a simultaneous kidney/pancreas
transplant. It pays for acquisition costs for both kidney and pancreas organs if transplants
are performed simultaneously. It will not pay for more than two organ acquisitions on the
same claim. In addition, the contractor remove acquisition charges prior to sending the
claims to Pricer so such charges are not included in the outlier calculation.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Medicare Summary Notices (MSN) and Remittance Advice Messages</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If the provider submits a claim for simultaneous pancreas kidney transplantation or
pancreas transplantation following a kidney transplant, and omits one of the appropriate
diagnosis/procedure codes, the contractor shall reject the claim.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The following reflects the remittance advice messages and associated codes that will
appear when rejecting/denying claims under this policy</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Group Code: CO </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">CARC: B15 </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">RARC: N/A</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">MSN: 16.32</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"></span></div>
<a name='more'></a><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If no evidence of a prior kidney transplant is presented, then the contractor shall deny the
claim.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The following reflects the remittance advice messages and associated codes that will
appear when rejecting/denying claims under this policy.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Group Code: CO </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">CARC: 50 </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">RARC: MA126</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">MSN: 15.4 </span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-58652207310881929502017-12-07T07:49:00.000-08:002017-12-07T07:49:20.231-08:00 Diagnosis Codes and Descriptions<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">ICD-10-CM
code
Description </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney
disease or end stage renal disease </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">I13.11 Hypertensive heart and chronic kidney disease without heart failure,
with stage 5 chronic kidney disease, or end stage renal disease </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">I13.2 Hypertensive heart and chronic kidney disease with heart failure and
with stage 5 chronic kidney disease, or end stage renal disease </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">N18.1 Chronic kidney disease, stage 1
N18.2 Chronic kidney disease, stage 2 (mild) </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">N18.3 Chronic kidney disease, stage 3 (moderate) </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">N18.4 Chronic kidney disease, stage 4 (severe)</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">N18.5 Chronic kidney disease, stage 5 </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">N18.6 End stage renal disease </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">N18.9 Chronic kidney disease, unspecified</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>NOTE:</b> If a patient had a kidney transplant that was successful, the patient no longer has
chronic kidney failure, therefore it would be inappropriate for the provider to bill ICD-9-
CM codes 585.1 - 585.6, 585.9 or, if ICD-10-CM is applicable, the diagnosis codes N18.1
- N18.9 on such a patient. In these cases one of the following codes should be present on
the claim or in the beneficiary's history.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The provider uses the following ICD-9-CM status codes only when a kidney transplant
was performed before the pancreas transplant and ICD-9 is applicable:</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">ICD-9-
CM code
Description </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">V42.0 Organ or tissue replaced by transplant kidney</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">V43.89 Organ tissue replaced by other means, kidney or pancreas</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-10-CM is applicable, the following ICD-10-CM status codes will be used:</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>ICD-10-
CM code
Description</b> </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Z48.22 Encounter for aftercare following kidney transplant </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Z94.0 Kidney transplant status</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>NOTE:</b> If a kidney and pancreas transplants are performed simultaneously, the claim
should contain a diabetes diagnosis code and a renal failure code or one of the
hypertensive renal failure diagnosis codes. The claim should also contain two transplant
procedure codes. If the claim is for a pancreas transplant only, the claim should contain a
diabetes diagnosis code and a status code to indicate a previous kidney transplant. If the
status code is not on the claim for the pancreas transplant, the contractor will search the
beneficiary's claim history for a status code indicating a prior kidney transplant. </span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-35527016290926980942017-11-30T07:49:00.000-08:002017-11-30T07:49:09.177-08:00Billing for Pancreas Transplants<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-10 is applicable, the following procedure codes (ICD-10-PCS) are:</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• 0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• 0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Pancreas transplantation is reasonable and necessary for the following diagnosis codes.
However, since this is not an all-inclusive list, the contractor is permitted to determine if
any additional diagnosis codes will be covered for this procedure.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-9-CM is applicable, Diabetes Diagnosis Codes and Descriptions</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">ICD-9-
CM
Code
Description </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.00 Diabetes mellitus without mention of complication, type II (non-insulin
dependent) (NIDDM) (adult onset) or unspecified type, not stated as
uncontrolled. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.01 Diabetes mellitus without mention of complication, type I (insulin
dependent) (IDDM) (juvenile), not stated as uncontrolled.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.02 Diabetes mellitus without mention of complication, type II (non-insulin
dependent) (NIDDM) (adult onset) or unspecified type, uncontrolled. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.03 Diabetes mellitus without mention of complication, type I (insulin
dependent) (IDDM) (juvenile), uncontrolled.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> 250.1X Diabetes with ketoacidosis </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.2X Diabetes with hyperosmolarity </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.3X Diabetes with coma </span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.4X Diabetes with renal manifestations</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.5X Diabetes with ophthalmic manifestations </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.6X Diabetes with neurological manifestations</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.7X Diabetes with peripheral circulatory disorders </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.8X Diabetes with other specified manifestations </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">250.9X Diabetes with unspecified complication</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">NOTE: X=0-3</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-10-CM is applicable, the diagnosis codes are: E10.10 - E10.9</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Hypertensive Renal Diagnosis Codes and Descriptions if ICD-9-CM is applicable :</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">ICD-9-CM
Code
Description </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">403.01 Malignant hypertensive renal disease, with renal failure </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">403.11 Benign hypertensive renal disease, with renal failure </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">403.91 Unspecified hypertensive renal disease, with renal failure </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">404.02 Malignant hypertensive heart and renal disease, with renal failure </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">404.03 Malignant hypertensive heart and renal disease, with congestive heart
failure or renal failure </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">404.12 Benign hypertensive heart and renal disease, with renal failure </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">404.13 Benign hypertensive heart and renal disease, with congestive heart
failure or renal failure </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">404.92 Unspecified hypertensive heart and renal disease, with renal failure </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">404.93 Unspecified hypertensive heart and renal disease, with congestive heart
failure or renal failure</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>ICD-9-CM
Code
Description</b> </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">585.1 - 585.6,
585.9
Chronic Renal Failure Code</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-66739073933758212452017-11-25T07:43:00.000-08:002017-11-25T07:43:05.593-08:00Pancreas Transplants Kidney Transplants<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Effective July 1, 1999, Medicare covered pancreas transplantation when performed
simultaneously with or following a kidney transplant if ICD-9 is applicable, ICD-9-CM
procedure code 55.69. If ICD-10 is applicable, the following ICD-10-PCS codes will be
used:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">0TY00Z0,</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">0TY00Z1, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">0TY00Z2,</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">0TY10Z0. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">0TY10Z1, and</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">0TY10Z2</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Pancreas transplantation is performed to induce an insulin independent, euglycemic state
in diabetic patients. The procedure is generally limited to those patients with severe
secondary complications of diabetes including kidney failure. However, pancreas
transplantation is sometimes performed on patients with labile diabetes and hypoglycemic
unawareness.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Medicare has had a policy of not covering pancreas transplantation. The Office of Health
Technology Assessment performed an assessment on pancreas-kidney transplantation in
1994. They found reasonable graft survival outcomes for patients receiving either
simultaneous pancreas-kidney (SPK) transplantation or pancreas after kidney (PAK)
transplantation. For a list of facilities approved to perform SPK or PAK, refer to the
following Web site: https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing for Pancreas Transplants</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">There are no special provisions related to managed care participants. Managed care plans
are required to provide all Medicare covered services. Medicare does not restrict which
hospitals or physicians may perform pancreas transplantation.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The transplant procedure and revenue code 0360 for the operating room are paid under
these codes. Procedures must be reported using the current ICD procedure codes for
pancreas and kidney transplants. Providers must place at least one of the following
transplant procedure codes on the claim:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-9 Is Applicable</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">52.80 Transplant of pancreas </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">52.82 Homotransplant of pancreas</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The Medicare Code Editor (MCE) has been updated to include 52.80 and 52.82 as limited
coverage procedures. The contractor must determine if the facility is approved for the
transplant and certified for either pediatric or adult transplants dependent upon the age of
the patient. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Effective October 1, 2000, ICD-9-CM code 52.83 was moved in the MCE to non-covered.
The contractor must override any deny edit on claims that came in with 52.82 prior to
October 1, 2000 and adjust, as 52.82 is the correct code. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If the discharge date is July 1, 1999, or later: the contractor processes the bill through
Grouper and Pricer. </span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-76673068438963868922017-11-19T07:40:00.000-08:002017-11-19T07:40:10.352-08:00Bill Review Procedures<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The contractor takes the following actions to process liver transplant bills.</span></div>
<div style="text-align: justify;">
<b><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Operative Report</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The contractor requires the operative report with all claims for liver transplants, or sends a
development request to the hospital for each liver transplant with a diagnosis code for a
covered condition.</span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: "times" , "times new roman" , serif; font-size: large;">MCE Interface</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">The MCE contains a limited coverage edit for liver transplant procedures using ICD-9-
CM code 50.59 if ICD-9 is applicable, and, if ICD-10 is applicable, using ICD-10-PCS
codes 0FY00Z0, 0FY00Z1, and 0FY00Z2.</span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Where a liver transplant procedure code is identified by the MCE, the contractor shall
check the provider number and effective date to determine if the provider is an approved
liver transplant facility at the time of the transplant, and the contractor shall also determine
if the facility is certified for adults and/or pediatric transplants dependent upon the
patient’s age. If yes, the claim is suspended for review of the operative report to
determine whether the beneficiary has at least one of the covered conditions when the
diagnosis code is for a covered condition. If payment is appropriate (i.e., the facility is
approved, the service is furnished on or after the approval date, and the beneficiary has a
covered condition), the contractor sends the claim to Grouper and Pricer.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">If none of the diagnoses codes are for a covered condition, or if the provider is not an
approved liver transplant facility, the contractor denies the claim.</span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><b>NOTE:</b> Some noncovered conditions are included in the covered diagnostic codes. (The
diagnostic codes are broader than the covered conditions. Do not pay for noncovered
conditions.</span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Grouper</span></b></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">If the bill shows a discharge date before March 8, 1990, the liver transplant procedure is
not covered. If the discharge date is March 8, 1990 or later, the contractor processes the
bill through Grouper and Pricer. If the discharge date is after March 7, 1990, and before
October 1, 1990, Grouper assigned CMS DRG 191 or 192. The contractor sent the bill to
Pricer with review code 08. Pricer would then overlay CMS DRG 191 or 192 with CMS
DRG 480 and the weights and thresholds for CMS DRG 480 to price the bill. If the
discharge date is after September 30, 1990, Grouper assigns CMS DRG 480 and Pricer is able to price without using review code 08. If the discharge date is after September 30,
2007, Grouper assigns MS-DRG 005 or 006 (Liver transplant with MCC or Intestinal
Transplant or Liver transplant without MCC, respectively) and Pricer is able to price
without using review code 08.</span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: "times" , "times new roman" , serif; font-size: large;">Liver Transplant Billing From Non-approved Hospitals</span></b></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: "times" , "times new roman" , serif; font-size: large;">Where a liver transplant and covered services are provided by a non-approved hospital, the
bill data processed through Grouper and Pricer must exclude transplant procedure codes
and related charges. </span></div>
<div style="text-align: justify;">
<br /></div>
<span style="font-size: large;">When CMS approves a hospital to furnish liver transplant services, it informs the hospital
of the effective date in the approval letter. The contractor will receive a copy of the letter.</span></div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-12574730085204673872017-11-13T07:38:00.000-08:002017-11-13T07:38:01.636-08:00Liver Transplants<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">For Medicare coverage purposes, liver transplants are considered medically reasonable
and necessary for specified conditions when performed in facilities that meet specific
criteria.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Effective for claims with dates of service June 21, 2012 and later, contractors may, at their
discretion cover adult liver transplantation for patients with extrahepatic unresectable
cholangiocarcinoma (CCA), (2) liver metastases due to a neuroendocrine tumor (NET) or
(3) hemangioendothelimo (HAE) when furnished in an approved Liver Transplant Center (below). All other nationally non-covered malignancies continue to remain nationally
non-covered.</span></div>
<br />
<div style="text-align: justify;">
<span style="font-family: Times, "Times New Roman", serif; font-size: large; font-weight: bold;"><br /></span></div>
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><div style="text-align: justify;">
<b>Standard Liver Acquisition Charge</b></div>
</span><br />
<br />
<div style="text-align: justify;">
<span style="font-family: Times, "Times New Roman", serif; font-size: large; font-weight: bold;"><br /></span></div>
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><div style="text-align: justify;">
Each transplant facility must develop a standard charge for acquiring a cadaver liver from
costs it expects to incur in the acquisition of livers.</div>
</span><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">This standard charge is not a charge that represents the acquisition cost of a specific liver.
Rather, it is a charge that reflects the average cost associated with a liver acquisition.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Services associated with liver acquisition are billed from the organ procurement
organization or, in some cases, the excising hospital to the transplant hospital. The
excising hospital does not submit a billing form to the A/B MAC (A). The transplant
hospital keeps an itemized statement that identifies the services furnished, the charges, the
person receiving the service (donor/recipient), and the potential transplant donor. These
charges are reflected in the transplant hospital's liver acquisition cost center and are used
in determining the hospital's standard charge for acquiring a cadaver's liver. The standard
charge is not a charge representing the acquisition cost of a specific liver. Rather, it is a
charge that reflects the average cost associated with liver acquisition. Also, it is an allinclusive
charge for all services required in acquisition of a liver, e.g., tissue typing,
transportation of organ, and surgeons' retrieval fees.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing for Liver Transplant and Acquisition Services</span></b></div>
<br />
<div style="text-align: justify;">
<span style="font-family: Times, "Times New Roman", serif; font-size: large; font-weight: bold;"><br /></span></div>
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><div style="text-align: justify;">
The inpatient claim is completed in accordance with instructions in chapter 25 for the
beneficiary who receives a covered liver transplant. Applicable standard liver acquisition
charges are identified separately by revenue code 081X. Where interim bills are
submitted, the standard acquisition charge appears on the billing form for the period
during which the transplant took place. This charge is in addition to the hospital's charge
for services furnished directly to the Medicare recipient.</div>
</span><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The contractor deducts liver acquisition charges for IPPS hospitals prior to processing
through Pricer. Costs of liver acquisition incurred by approved liver transplant facilities
are not included in the liver transplant prospective payment. They are paid on a
reasonable cost basis. This item is a "pass-through" cost for which interim payments are made. The contractor
includes liver acquisition charges under revenue code 081X in the HUIP record that it
sends to CWF and the QIO</span>.</div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-63210869486383747142017-11-07T07:35:00.000-08:002017-11-07T07:35:01.815-08:00Billing for Acquisition Services<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The hospital bills and shows acquisition charges for allogeneic stem cell transplants based
on the status of the patient (i.e., inpatient or outpatient) when the transplant is furnished.
See Pub. 100-04, chapter 4, §231.11 for instructions regarding billing for acquisition
services for allogeneic stem cell transplants that are performed in the outpatient setting.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">When the allogeneic stem cell transplant occurs in the inpatient setting, the hospital
identifies stem cell acquisition charges for allogeneic bone marrow/stem cell transplants
separately by using revenue code 0819 (Other Organ Acquisition). Revenue code 0819
charges should include all services required to acquire stem cells from a donor, as defined
above.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">On the recipient’s transplant bill, the hospital reports the acquisition charges, cost report
days, and utilization days for the donor’s hospital stay (if applicable) and/or charges for
other encounters in which the stem cells were obtained from the donor. The donor is
covered for medically necessary inpatient hospital days of care or outpatient care provided
in connection with the allogeneic stem cell transplant under Part A. Expenses incurred for
complications are paid only if they are directly and immediately attributable to the stem
cell donation procedure. The hospital reports the acquisition charges on the billing form
for the recipient, as described in the first paragraph of this section. It does not charge the
donor's days of care against the recipient's utilization record. For cost reporting purposes,
it includes the covered donor days and charges as Medicare days and charges.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The transplant hospital keeps an itemized statement that identifies the services furnished,
the charges, the person receiving the service (donor/recipient), and whether this is a
potential transplant donor or recipient. These charges will be reflected in the transplant
hospital's stem cell/bone marrow acquisition cost center. For allogeneic stem cell
acquisition services in cases that do not result in transplant, due to death of the intended
recipient or other causes, hospitals include the costs associated with the acquisition
services on the Medicare cost report. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The hospital shows charges for the transplant itself in revenue center code 0362 or another
appropriate cost center. Selection of the cost center is up to the hospital.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing for Autologous Stem Cell Transplants</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The hospital bills and shows all charges for autologous stem cell harvesting, processing,
and transplant procedures based on the status of the patient (i.e., inpatient or outpatient)
when the services are furnished. It shows charges for the actual transplant, in revenue
center code 0362 or another appropriate cost center. ICD-9-CM or ICD-10-PCS codes are
used to identify inpatient procedures.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The CPT codes describing autologous stem cell harvesting procedures may be billed and
are separately payable under the OPPS when provided in the hospital outpatient setting of
care. Autologous harvesting procedures are distinct from the acquisition services
described in Pub. 100-04, chapter 4, §231.11 and section A. above for allogeneic stem cell
transplants, which include services provided when stem cells are obtained from a donor
and not from the patient undergoing the stem cell transplant. The CPT codes describing
autologous stem cell processing procedures also may be billed and are separately payable
under the OPPS when provided to hospital outpatients.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Payment for autologous stem cell harvesting procedures performed in the hospital
inpatient setting of care, with transplant also occurring in the inpatient setting of care, is
included in the MS-DRG payment for the autologous stem cell transplant.</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-62452655994218208192017-11-01T07:30:00.001-07:002017-11-01T07:30:12.161-07:00Noncovered Conditions<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Insufficient data exist to establish definite conclusions regarding the efficacy of
autologous stem cell transplantation for the following conditions:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Acute leukemia not in remission: </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-9-CM is applicable, diagnosis codes 204.00, 205.00, 206.00, 207.00
and 208.00 are noncovered; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-10-CM is applicable, diagnosis codes C91.00, C92.00, C92.40, C92.50,
C92.60, C92.A0, C93.00, C94.00, and C95.00 are noncovered. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Chronic granulocytic leukemia: </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-9-CM is applicable, diagnosis codes 205.10 and 205.11;</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-10-CM is applicable, diagnosis codes C92.10 and C92.11. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Solid tumors (other than neuroblastoma):</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-9-CM is applicable, diagnosis codes 140.0-199.1; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-10-CM is applicable, diagnosis codes C00.0 - C80.2 and D00.0 - D09.9. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Multiple myeloma (ICD-9-CM codes 203.00 and 238.6), through September 30, 2000. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Tandem transplantation (multiple rounds of autologous stem cell transplantation) for
patients with multiple myeloma </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-9-CM is applicable, diagnosis codes 203.00 and 238.6 and,</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-10-CM is applicable, diagnosis codes C90.00 and D47.Z9) </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Non-primary (AL) amyloidosis, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-9-CM is applicable, diagnosis code 277.3. Effective October 1, 2000;
ICD-9-CM code 277.3 was expanded to codes 277.30, 277.31, and 277.39
effective October 1, 2006. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-10-CM is applicable, diagnosis codes are E85.0 - E85.9. or </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Primary (AL) amyloidosis </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-9-CM is applicable, diagnosis codes 277.30, 277.31, and 277.39 and
for Medicare beneficiaries age 64 or older, effective October 1, 2000,
through March 14, 2005.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">o If ICD-10-CM is applicable, diagnosis codes are E85.0 - E85.9. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">NOTE: Coverage for conditions other than these specifically designated as covered or
non-covered is left to the discretion of the A/B MAC (A).</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing for Stem Cell Transplantation</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"> Billing for Allogeneic Stem Cell Transplants</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants
Acquisition charges for allogeneic stem cell transplants include, but are not limited to,
charges for the costs of the following services: </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• National Marrow Donor Program fees, if applicable, for stem cells from an
unrelated donor; </span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Tissue typing of donor and recipient;</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> • Donor evaluation; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Physician pre-admission/pre-procedure donor evaluation services; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Costs associated with harvesting procedure (e.g., general routine and special care
services, procedure/operating room and other ancillary services, apheresis services,
etc.);</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Post-operative/post-procedure evaluation of donor; and </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Preparation and processing of stem cells. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Payment for these acquisition services is included in the MS-DRG payment for the
allogeneic stem cell transplant when the transplant occurs in the inpatient setting, and in
the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs
in the outpatient setting. The Medicare contractor does not make separate payment for
these acquisition services, because hospitals may bill and receive payment only for
services provided to the Medicare beneficiary who is the recipient of the stem cell
transplant and whose illness is being treated with the stem cell transplant. Unlike the
acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid
on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in
prospective payment. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Acquisition charges for stem cell transplants apply only to allogeneic transplants, for
which stem cells are obtained from a donor (other than the recipient himself or herself).
Acquisition charges do not apply to autologous transplants (transplanted stem cells are
obtained from the recipient himself or herself), because autologous transplants involve
services provided to the beneficiary only (and not to a donor), for which the hospital may
bill and receive payment (see Pub. 100-04, chapter 4, §231.10 and paragraph B of this
section for information regarding billing for autologous stem cell transplants).</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-41979374944633042672017-10-26T00:18:00.000-07:002017-10-26T00:18:06.282-07:00Covered Conditions<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Effective for services performed on or after April 28, 1989: </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">For acute leukemia in remission for patients who have a high probability of relapse and
who have no human leucocyte antigens (HLA)-matched, the following diagnosis codes are
reported:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-9-CM is applicable, use the following Diagnosis Codes and Descriptions</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Diagnosis
Code
Description </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">204.01 Lymphoid leukemia, acute, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">205.01 Myeloid leukemia, acute, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">206.01 Monocytic leukemia, acute, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">207.01 Acute erythremia and erythroleukemia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">208.01 Leukemia of unspecified cell type, acute, in remission</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-10-CM is applicable, use the following Diagnosis Codes and Descriptions</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C91.01 Acute lymphoblastic leukemia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C92.01 Acute myeloblastic leukemia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C92.41 Acute promyelocytic leukemia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C92.51 Acute myelomonocytic leukemia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C92.61 Acute myeloid leukemia with 11q23-abnormality in remission</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C93.01 Acute monoblastic/monocytic leukemia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C94.01 Acute erythroid leukemia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C94.21 Acute megakaryoblastic leukemia, in remission </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C94.41 Acute parmyelosis with myelofibrosis, in remission</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C95.01 Acute leukemia of unspecified cell type, in remission</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">For resistant non-Hodgkin's lymphomas or those presenting with poor prognostic features
following an initial response the following diagnosis codes are reported:</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-9-CM is applicable, use the following code ranges:</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">200.00 - 200.08, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">200.10 - 00.18, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">200.20 - 200.28, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">200.80 - 200.88, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">202.00 - 202.08, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">202.80 - 202.88, and </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">202.90 - 202.98.</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-10-CM is applicable use the following code ranges:</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C82.00 - C85.29, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C85.80 - C86.6, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">C96.4, and</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> C96.Z - C96.9.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">For recurrent or refractory neuroblastoma (see ICD-9-CM Neoplasm by site, malignant for
the appropriate diagnosis code)</span></div>
<br />
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-38640569847034119542017-10-21T00:15:00.000-07:002017-10-21T00:15:02.148-07:00Billing for Autologous Stem Cell Transplants <div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The hospital bills and shows all charges for autologous stem cell harvesting, processing,
and transplant procedures based on the status of the patient (i.e., inpatient or outpatient)
when the services are furnished. It shows charges for the actual transplant, in revenue
center code 0362 or another appropriate cost center. ICD-9-CM or ICD-10-PCS codes are
used to identify inpatient procedures.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The HCPCS codes describing autologous stem cell harvesting procedures may be billed
and are separately payable under the OPPS when provided in the hospital outpatient
setting of care. Autologous harvesting procedures are distinct from the acquisition
services described in Pub. 100-04, chapter 4, §231.11 and section A. above for allogeneic
stem cell transplants, which include services provided when stem cells are obtained from a
donor and not from the patient undergoing the stem cell transplant. The HCPCS codes
describing autologous stem cell processing procedures also may be billed and are
separately payable under the OPPS when provided to hospital outpatients.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Payment for autologous stem cell harvesting procedures performed in the hospital
inpatient setting of care, with transplant also occurring in the inpatient setting of care, is
included in the MS-DRG payment for the autologous stem cell transplant.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Autologous Stem Cell Transplantation (AuSCT)</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">General</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Autologous stem cell transplantation (AuSCT) is a technique for restoring stem cells using
the patient's own previously stored cells. AuSCT must be used to effect hematopoietic
reconstitution following severely myelotoxic doses of chemotherapy (high dose
chemotherapy (HDCT)) and/or radiotherapy used to treat various malignancies.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-9-CM is applicable, use the following Procedure Codes and Descriptions</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">41.01 Autologous bone marrow transplant without purging </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">41.04 Autologous hematopoietic stem cell transplant without purging </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">41.07 Autologous hematopoietic stem cell transplant with purging </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">41.09 Autologous bone marrow transplant with purging</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">If ICD-10-PCS is applicable, use the following Procedure Codes and Descriptions -</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30230AZ Transfusion of Embryonic Stem Cells into Peripheral Vein, Open
Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30230G0 Transfusion of Autologous Bone Marrow into Peripheral Vein, Open
Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30230Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral
Vein, Open Approach
30233G0 Transfusion of Autologous Bone Marrow into Peripheral Vein,
Percutaneous Approach
30233Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral
Vein, Percutaneous Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30240G0 Transfusion of Autologous Bone Marrow into Central Vein, Open
Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30240Y0 Transfusion of Autologous Bone Marrow into Central Vein, Open
Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30243G0 Transfusion of Autologous Bone Marrow into Central Vein,
Percutaneous Approach
30243Y0 Transfusion of Autologous Hematopoietic Stem Cells into Central
Vein, Percutaneous Approach </span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30250G0 Transfusion of Autologous Bone Marrow into Peripheral Artery, Open
Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30250Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral
Artery, Open Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30253G0 Transfusion of Autologous Bone Marrow into Peripheral Artery,
Percutaneous Approach
30253Y0 Transfusion of Autologous Hematopoietic Stem Cells into Peripheral
Artery, Percutaneous Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30260G0 Transfusion of Autologous Bone Marrow into Central Artery, Open
Approach </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30260Y0 Transfusion of Autologous Hematopoietic Stem Cells into Central
Artery, Open Approach
30263G0 Transfusion of Autologous Bone Marrow into Central Artery,
Percutaneous Approach</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">30263Y0 Transfusion of Autologous Hematopoietic Stem Cells into Central
Artery, Percutaneous Approach</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-70703448324275625172017-10-16T07:04:00.000-07:002017-10-16T07:04:09.510-07:00Billing for Allogeneic Stem Cell Transplants <div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Payment for these acquisition services is included in the MS-DRG payment for the
allogeneic stem cell transplant when the transplant occurs in the inpatient setting, and in
the OPPS APC payment for the allogeneic stem cell transplant when the transplant occurs
in the outpatient setting. The Medicare contractor does not make separate payment for
these acquisition services, because hospitals may bill and receive payment only for
services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant. Unlike the
acquisition costs of solid organs for transplant (e.g., hearts and kidneys), which are paid
on a reasonable cost basis, acquisition costs for allogeneic stem cells are included in
prospective payment. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Acquisition charges for stem cell transplants apply only to allogeneic transplants, for
which stem cells are obtained from a donor (other than the recipient himself or herself).
Acquisition charges do not apply to autologous transplants (transplanted stem cells are
obtained from the recipient himself or herself), because autologous transplants involve
services provided to the beneficiary only (and not to a donor), for which the hospital may
bill and receive payment </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing for Acquisition Services </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The hospital bills and shows acquisition charges for allogeneic stem cell transplants based
on the status of the patient (i.e., inpatient or outpatient) when the transplant is furnished.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">When the allogeneic stem cell transplant occurs in the inpatient setting, the hospital
identifies stem cell acquisition charges for allogeneic bone marrow/stem cell transplants
separately by using revenue code 0815 (Stem Cell Acquisition). Revenue code 0815
charges should include all services required to acquire stem cells from a donor, as defined
above.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">On the recipient’s transplant bill, the hospital reports the acquisition charges, cost report
days, and utilization days for the donor’s hospital stay (if applicable) and/or charges for
other encounters in which the stem cells were obtained from the donor. The donor is
covered for medically necessary inpatient hospital days of care or outpatient care provided
in connection with the allogeneic stem cell transplant under Part A. Expenses incurred for
complications are paid only if they are directly and immediately attributable to the stem
cell donation procedure. The hospital reports the acquisition charges on the billing form
for the recipient, as described in the first paragraph of this section. It does not charge the
donor's days of care against the recipient's utilization record. For cost reporting purposes,
it includes the covered donor days and charges as Medicare days and charges.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The transplant hospital keeps an itemized statement that identifies the services furnished,
the charges, the person receiving the service (donor/recipient), and whether this is a
potential transplant donor or recipient. These charges will be reflected in the transplant
hospital's stem cell/bone marrow acquisition cost center. For allogeneic stem cell
acquisition services in cases that do not result in transplant, due to death of the intended
recipient or other causes, hospitals include the costs associated with the acquisition
services on the Medicare cost report.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The hospital shows charges for the transplant itself in revenue center code 0362 or another
appropriate cost center. Selection of the cost center is up to the hospital. </span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-75068813454160377382017-10-11T06:55:00.000-07:002017-10-11T06:55:00.172-07:00Nationally Non-Covered Indications<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">I. Allogeneic Hematopoietic Stem Cell Transplantation (HSCT)</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Effective for claims with dates of service on or after May 24, 1996, through January
26, 2016, allogeneic HSCT is not covered as treatment for multiple myeloma. Refer to
Pub. 100-03, NCD Manual, chapter 1, section 110.23, for further information about
this policy, and Pub. 100-04, chapter 32, section 90, for information on coding.</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">II. Autologous Stem Cell Transplantation (AuSCT)</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Insufficient data exist to establish definite conclusions regarding the efficacy of
AuSCT for the following conditions:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">a) Acute leukemia not in remission; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">b) Chronic granulocytic leukemia; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">c) Solid tumors (other than neuroblastoma); </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">d) Up to October 1, 2000, multiple myeloma; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">e) Tandem transplantation (multiple rounds of AuSCT) for patients with multiple
myeloma;</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">f) Effective October 1, 2000, non primary AL amyloidosis; and, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">g) Effective October 1, 2000, through March 14, 2005, primary AL amyloidosis
for Medicare beneficiaries age 64 or older</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">In these cases, AuSCT is not considered reasonable and necessary within the meaning
of §l862(a)(1)(A) of the Act and is not covered under Medicare. </span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">D. Other</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">All other indications for stem cell transplantation not otherwise noted above as covered or
non-covered remain at local Medicare Administrative Contractor discretion.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing for Stem Cell Transplantation</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">A. - Billing for Allogeneic Stem Cell Transplants </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Acquisition charges for allogeneic stem cell transplants include, but are not limited to,
charges for the costs of the following services:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> National Marrow Donor Program fees, if applicable, for stem cells from an
unrelated donor; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Tissue typing of donor and recipient; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Donor evaluation;
Physician pre-admission/pre-procedure donor evaluation services; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Costs associated with harvesting procedure (e.g., general routine and special care
services, procedure/operating room and other ancillary services, apheresis services,
etc.); </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Post-operative/post-procedure evaluation of donor; and </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Preparation and processing of stem cells. </span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-6811438700876063692017-10-05T06:52:00.000-07:002017-10-05T06:52:08.965-07:00 Autologous Stem Cell Transplantation (AuSCT)<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">a. General</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Autologous stem cell transplantation (ICD-9-CM Procedure Codes 41.01,
41.04, 41.07, and 41.09; ICD-10-PCS codes 30230AZ, 30230G0, 30230Y0,
30233G0, 30233Y0, 30240G0, 30240Y0, 30243G0, 30243Y0, 30250G0,
30250Y0, 30253G0, 30253Y0, 30260G0, 30260Y0, 30263G0, and 30263Y0)
is a technique for restoring stem cells using the patient's own previously stored
cells. AuSCT must be used to effect hematopoietic reconstitution following
severely myelotoxic doses of chemotherapy (high dose chemotherapy
(HDCT)) and/or radiotherapy used to treat various malignancies</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">b. Covered Conditions</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">1. Effective for services performed on or after April 28, 1989:</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Acute leukemia in remission who have a high probability of relapse and
who have no human leucocyte antigens (HLA)-matched; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Resistant non-Hodgkin's lymphomas or those presenting with poor
prognostic features following an initial response;</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Recurrent or refractory neuroblastoma; or, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Advanced Hodgkin's disease who have failed conventional therapy and
have no HLA-matched donor. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">2. Effective for services performed on or after October 1, 2000:</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Single AuSCT is only covered for Durie-Salmon Stage II or III patients
that fit the following requirements:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Newly diagnosed or responsive multiple myeloma. This includes those
patients with previously untreated disease, those with at least a partial
response to prior chemotherapy (defined as a 50% decrease either in
measurable paraprotein [serum and/or urine] or in bone marrow
infiltration, sustained for at least 1 month), and those in responsive
relapse; and
</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Adequate cardiac, renal, pulmonary, and hepatic function</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">3. Effective for services performed on or after March 15, 2005:</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">When recognized clinical risk factors are employed to select patients for
transplantation, high dose melphalan (HDM) together with AuSCT is
reasonable and necessary for Medicare beneficiaries of any age group with
primary amyloid light chain (AL) amyloidosis who meet the following
criteria:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Amyloid deposition in 2 or fewer organs; and, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Cardiac left ventricular ejection fraction (EF) greater than 45%</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-10498246768474931202017-09-30T06:49:00.000-07:002017-09-30T06:49:07.587-07:00Nationally Covered Indications<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">I. Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">a. General </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Allogeneic stem cell transplantation (ICD-9-CM Procedure Codes 41.02,
41.03, 41.05, and 41.08,; ICD-10-PCS codes 30230G1, 30230Y1, 30233G1,
30233Y1, 30240G1, 30240Y1, 30243G1, 30243Y1, 30250G1, 30250Y1,
30253G1, 30253Y1, 30260G1, 30260Y1, 30263G1, and 30263Y1) is a
procedure in which a portion of a healthy donor's stem cells are obtained and
prepared for intravenous infusion to restore normal hematopoietic function in
recipients having an inherited or acquired hematopoietic deficiency or defect.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Expenses incurred by a donor are a covered benefit to the recipient/beneficiary
but, except for physician services, are not paid separately. Services to the
donor include physician services, hospital care in connection with screening
the stem cell, and ordinary follow-up care.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">b. Covered Conditions</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">i. Effective for services performed on or after August 1, 1978: </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">For the treatment of leukemia, leukemia in remission, or aplastic anemia
when it is reasonable and necessary; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">ii. Effective for services performed on or after June 3, 1985: </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">For the treatment of severe combined immunodeficiency disease (SCID),
and for the treatment of Wiskott-Aldrich syndrome; </span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">iii. Effective for services performed on or after August 4, 2010: </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">For the treatment of Myelodysplastic Syndromes (MDS) pursuant to
Coverage with Evidence Development (CED) in the context of a Medicareapproved,
prospective clinical study.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>iv. Effective for claims with dates of service on or after January 27, 2016:</b> </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">1. Allogeneic HSCT for multiple myeloma is covered by Medicare only
for beneficiaries with Durie-Salmon Stage II or III multiple myeloma,
or International Staging System (ISS) Stage II or Stage III multiple
myeloma, and participating in an approved prospective clinical study. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">2. Allogeneic HSCT for myelofibrosis (MF) is covered by Medicare only
for beneficiaries with Dynamic International Prognostic Scoring
System (DIPSSplus) intermediate-2 or High primary or secondary MF
and participating in an approved prospective clinical study. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">3. Allogeneic HSCT for sickle cell disease (SCD) is covered by Medicare
only for beneficiaries with severe, symptomatic SCD who participate in
an approved prospective clinical study.</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-6360183230410734612017-09-24T06:47:00.000-07:002017-09-24T06:47:05.730-07:00Bill Review Procedures<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The contractor takes the following actions to process heart transplant bills. It may
accomplish them manually or modify its MCE and Grouper interface programs to handle
the processing</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">1. MCE Interface </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The MCE creates a Limited Coverage edit for heart transplant procedure codes. Where
these procedure codes are identified by MCE, the contractor checks the provider number
to determine if the provider is an approved transplant center, and checks the effective
approval date. The contractor shall also determine if the facility is certified for adults
and/or pediatric transplants dependent upon the patient’s age. If payment is appropriate
(i.e., the center is approved and the service is on or after the approval date) it overrides the
limited coverage edit.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">2. Handling Heart Transplant Billings From Nonapproved Hospitals</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Where a heart transplant and covered services are provided by a nonapproved hospital, the
bill data processed through Grouper and Pricer must exclude transplant procedure codes
and related charges.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Stem Cell Transplantation</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">A. General </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Stem cell transplantation is a process in which stem cells are harvested from either a
patient’s (autologous) or donor’s (allogeneic) bone marrow or peripheral blood for
intravenous infusion. Autologous stem cell transplantation (AuSCT) is a technique for
restoring stem cells using the patient's own previously stored cells. AuSCT must be used
to effect hematopoietic reconstitution following severely myelotoxic doses of
chemotherapy (HDCT) and/or radiotherapy used to treat various malignancies.
Allogeneic hematopoietic stem cell transplantation (HSCT) is a procedure in which a
portion of a healthy donor's stem cell or bone marrow is obtained and prepared for
intravenous infusion. Allogeneic HSCT may be used to restore function in recipients
having an inherited or acquired deficiency or defect. Hematopoietic stem cells are multipotent
stem cells that give rise to all the blood cell types; these stem cells form blood and
immune cells. A hematopoietic stem cell is a cell isolated from blood or bone marrow that
can renew itself, differentiate to a variety of specialized cells, can mobilize out of the bone
marrow into circulating blood, and can undergo programmed cell death, called apoptosis -
a process by which cells that are unneeded or detrimental will self-destruct.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The Centers for Medicare & Medicaid Services (CMS) is clarifying that bone marrow and
peripheral blood stem cell transplantation is a process which includes mobilization,
harvesting, and transplant of bone marrow or peripheral blood stem cells and the
administration of high dose chemotherapy or radiotherapy prior to the actual transplant.
When bone marrow or peripheral blood stem cell transplantation is covered, all necessary
steps are included in coverage. When bone marrow or peripheral blood stem cell
transplantation is non-covered, none of the steps are covered.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Allogeneic and autologous stem cell transplants are covered under Medicare for specific
diagnoses. Effective October 1, 1990, these cases were assigned to MS-DRG 009, Bone
Marrow Transplant.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The A/B MAC (A)'s Medicare Code Editor (MCE) will edit stem cell transplant procedure
codes against diagnosis codes to determine which cases meet specified coverage criteria.
Cases with a diagnosis code for a covered condition will pass (as covered) the MCE
noncovered procedure edit. When a stem cell transplant case is selected for review based
on the random selection of beneficiaries, the QIO will review the case on a post-payment
basis to assure proper coverage decisions</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Bone marrow transplant codes that are reported with an ICD-9-CM that is “not otherwise
specified” are returned to the hospital for a more specific procedure code. ICD-10-PCS
codes are more precise and clearly identify autologous and nonautologous stem cells</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The A/B MAC (A) may choose to review if data analysis deems it a priority</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-60981127536709832832017-09-19T06:45:00.000-07:002017-09-19T06:45:14.696-07:00Heart Transplants<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Cardiac transplantation is covered under Medicare when performed in a facility which is
approved by Medicare as meeting institutional coverage criteria. On April 6, 1987, CMS
Ruling 87-1, "Criteria for Medicare Coverage of Heart Transplants" was published in the
"Federal Register." For Medicare coverage purposes, heart transplants are medically
reasonable and necessary when performed in facilities that meet these criteria. If a
hospital wishes to bill Medicare for heart transplants, it must submit an application and
documentation, showing its ongoing compliance with each criterion.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If a contractor has any questions concerning the effective or approval dates of its hospitals,
it should contact its RO.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">A. - Effective Dates </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The effective date of coverage for heart transplants performed at facilities applying after
July 6, 1987, is the date the facility receives approval as a heart transplant facility.
Coverage is effective for discharges October 17, 1986 for facilities that would have
qualified and that applied by July 6, 1987. All transplant hospitals will be recertified
under the final rule, Federal Register / Vol. 72, No. 61 / Friday, March 30, 2007, / Rules
and Regulations.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The CMS informs each hospital of its effective date in an approval letter</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">B. - Drugs </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Medicare Part B covers immunosuppressive drugs following a covered transplant in an
approved facility.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">C. - Noncovered Transplants</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Medicare will not cover transplants or re-transplants in facilities that have not been
approved as meeting the facility criteria. If a beneficiary is admitted for and receives a
heart transplant from a hospital that is not approved, physicians' services, and inpatient
services associated with the transplantation procedure are not covered. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If a beneficiary received a heart transplant from a hospital while it was not an approved
facility and later requires services as a result of the noncovered transplant, the services are
covered when they are reasonable and necessary in all other respects.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>D. - Charges for Heart Acquisition Services</b> </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The excising hospital bills the OPO, who in turn bills the transplant (implant) hospital for
applicable services. It should not submit a bill to its contractor. The transplant hospital
must keep an itemized statement that identifies the services rendered, the charges, the
person receiving the service (donor/recipient), and whether this person is a potential
transplant donor or recipient. These charges are reflected in the transplant hospital's heart
acquisition cost center and are used in determining its standard charge for acquiring a
donor's heart. The standard charge is not a charge representing the acquisition cost of a
specific heart; rather, it reflects the average cost associated with each type of heart
acquisition. Also, it is an all inclusive charge for all services required in acquisition of a
heart, i.e., tissue typing, post-operative evaluation, etc. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Acquisition charges shall be billed on a 081X revenue code. Such charges are not
considered for the IPPS outlier calculation when billed for a heart transplant.</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-5029388355671809252017-09-06T00:38:00.000-07:002017-09-06T00:38:04.634-07:00Billing for Kidney Transplant and Acquisition Services<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Applicable standard kidney acquisition charges are identified separately by revenue code
0811 (Living Donor Kidney Acquisition) or 0812 (Cadaver Donor Kidney Acquisition).
Where interim bills are submitted, the standard acquisition charge appears on the billing
form for the period during which the transplant took place. This charge is in addition to
the hospital's charges for services rendered directly to the Medicare recipient. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The contractor deducts kidney acquisition charges for PPS hospitals for processing
through Pricer. These costs, incurred by approved kidney transplant hospitals, are not
included in the kidney transplant prospective payment. They are paid on a reasonable cost
basis. Interim payment is paid as a "pass through" item. (See the Provider
Reimbursement Manual, Part 1, §2802 B.8.) The contractor includes kidney acquisition
charges under the appropriate revenue code in CWF</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Bill Review Procedures </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The Medicare Code Editor (MCE) creates a Limited Coverage edit for kidney transplant
procedure codes. Where these procedure codes are identified by MCE, the contractor
checks the provider number to determine if the provider is an approved transplant center,
and checks the effective approval date. The contractor shall also determine if the facility
is certified for adults and/or pediatric transplants dependent upon the patient’s age. If
payment is appropriate (i.e., the center is approved and the service is on or after the
approval date) it overrides the limited coverage edit. </span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing for Donor Post-Kidney Transplant Complication Services </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Expenses incurred for complications that arise with respect to the donor are covered and
separately billable only if they are directly attributable to the donation surgery.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">All covered services (both institutional and professional) for complications from a
Medicare covered transplant that arise after the date of the donor’s transplant discharge
will be billed under the recipient’s health insurance claim number and are billed to the
Medicare program in the same manner as all Medicare Part B services are billed.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> All covered donor post-kidney transplant complication services must be billed to
the account of the recipient (i.e., the recipient's Medicare number) </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Modifier Q3 (Live Kidney Donor and Related Services) appears on each covered
line of the claim that contains a HCPCS code.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"></span></div>
<a name='more'></a><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Institutional claims will be required to also include:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Occurrence Code 36 (Date of Inpatient Hospital Discharge for covered transplant
patients)</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Patient Relationship Code 39 (Organ Donor)</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Contractors shall override Edit 5211 when modifier Q3 appears on claims for donor
services it receives when the recipient is deceased </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>NOTE: </b>For institutional claims which do not require modifiers, contractors may
manually override the CWF edit as necessary. </span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-35423042378569435722017-08-30T00:34:00.000-07:002017-08-30T00:34:11.050-07:00Billing for Cadaveric Donor Services<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Normally, various tests are performed to determine the type and suitability of a cadaver
kidney. Such tests may be performed by the excising hospital (which may also be a
transplant hospital) or an independent laboratory. When the excising-only hospital
performs the tests, it includes the related charges on its bill to the transplant hospital or to
the organ procurement agency.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">When the tests are performed by the transplant hospital, it uses the related costs in
establishing the standard charge for acquiring the cadaver kidney. The transplant hospital
includes the costs and charges in the appropriate departments for final cost settlement
purposes.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The cost of these services cannot be billed directly to the program, since such tests and
other procedures performed on a cadaver are not identifiable to a specific patient.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing For Physicians' Services Prior to Transplantation </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Physicians' services applicable to kidney excisions involving live donors and recipients
(during the pre-entitlement period and after entitlement, but prior to entrance into the
hospital for transplantation) as well as all physicians' services applicable to cadavers are
considered Part A hospital services (kidney acquisition costs).</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing for Physicians' Services After Transplantation</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">All physicians' services rendered to the living donor and all physicians' services rendered
to the transplant recipient are billed to the Medicare program in the same manner as all
Medicare Part B services are billed. All donor physicians' services must be billed to the
account of the recipient (i.e., the recipient's Medicare number). Modifier Q3 (Live Kidney
Donor and Related Services) appears on the claim. For services performed on or after
January 1, 2011 CWF shall allow Edit 5211 to be overridden at the contractor level. Also,
contractors shall override Edit 5211 when this modifier appears on claims for donor
services it receives when the recipient is deceased</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"></span></div>
<a name='more'></a><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>NOTE:</b> For institutional claims, contractors may manually override the CWF edit as
necessary.
</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing For Physicians' Renal Transplantation Services</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">To ensure proper payment when submitting a Part B bill for the renal surgeon's services to
the recipient, the appropriate HCPCS codes must be submitted, including HCPCS codes
for concurrent surgery, as applicable. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The bill must include all living donor physicians' services, e.g., Revenue Center code
081X. </span></div>
<div style="text-align: justify;">
<br /></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-16191969775603112272017-08-24T00:31:00.000-07:002017-08-24T00:31:00.161-07:00The Standard Kidney Acquisition Charge<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">There are two basic standard charges that must be developed by transplant hospitals from
costs expected to be incurred in the acquisition of kidneys:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> The standard charge for acquiring a live donor kidney; and</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> The standard charge for acquiring a cadaver kidney.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The standard charge is not a charge representing the acquisition cost of a specific kidney;
rather, it is a charge that reflects the average cost associated with each type of kidney
acquisition.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">When the transplant hospital bills the program for the transplant, it shows its standard
kidney acquisition charge on revenue code 081X. Kidney acquisition charges are not
considered for the IPPS outlier calculation. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Acquisition services are billed from the excising hospital to the transplant hospital. A
billing form is not submitted from the excising hospital to the FI. The transplant hospital
keeps an itemized statement that identifies the services furnished, the charges, the person
receiving the service (donor/recipient), and whether this is a potential transplant donor or
recipient. These charges are reflected in the transplant hospital's kidney acquisition cost
center and are used in determining the hospital's standard charge for acquiring a live
donor's kidney or a cadaver's kidney. The standard charge is not a charge representing the
acquisition cost of a specific kidney. Rather, it is a charge that reflects the average cost
associated with each type of kidney acquisition. Also, it is an all-inclusive charge for all
services required in acquisition of a kidney, i.e., tissue typing, post-operative evaluation.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">A. - Billing For Blood And Tissue Typing of the Transplant Recipient Whether or
Not Medicare Entitlement Is Established
</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Tissue typing and pre-transplant evaluation can be reflected only through the kidney
acquisition charge of the hospital where the transplant will take place. The transplant
hospital includes in its kidney acquisition cost center the reasonable charges it pays to the
independent laboratory or other hospital which typed the potential transplant recipient,
either before or after his entitlement. It also includes reasonable charges paid for
physician tissue typing services, applicable to live donors and recipients (during the preentitlement
period and after entitlement, but prior to hospital admission for
transplantation).</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">B. - Billing for Blood and Tissue Typing and Other Pre-Transplant Evaluation of
Live Donors </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The entitlement date of the beneficiary who will receive the transplant is not a
consideration in reimbursing for the services to donors, since no bill is submitted directly
to Medicare. All charges for services to donors prior to admission into the hospital for
excision are "billed" indirectly to Medicare through the live donor acquisition charge of
transplanting hospitals</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">C. - Billing Donor And Recipient Pre-Transplant Services (Performed by Transplant
Hospitals or Other Providers) to the Kidney Acquisition Cost Center</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The transplant hospital prepares an itemized statement of the services rendered for
submittal to its cost accounting department. Regular Medicare billing forms are not
necessary for this purpose, since no bills are submitted to the A/B MAC (A) at this point</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The itemized statement should contain information that identifies the person receiving the
service (donor/recipient), the health care insurance number, the service rendered and the
charge for the service, as well as a statement as to whether this is a potential transplant
donor or recipient. If it is a potential donor, the provider must identify the prospective
recipient.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Services performed in a hospital other than the potential transplant hospital or by an
independent laboratory are billed by that facility to the potential transplant hospital. This
holds true regardless of where in the United States the service is performed. For example,
if the donor services are performed in a Florida hospital and the transplant is to take place
in a California hospital, the Florida hospital bills the California hospital (as described in
above). The Florida hospital is paid by the California hospital, which recoups the monies
through the kidney acquisition cost center </span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-84823697272411591242017-08-20T00:25:00.000-07:002017-08-20T00:25:03.105-07:00Billing Transplant Services<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Medicare Summary Notice (MSN) for Services in Hospitals That
Do Not Charge </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Where the hospital does not charge for outpatient services, the A/B MAC (A) does not
send the individual an MSN. This avoids confusion and the appearance that the
beneficiary is liable for services received.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Billing Transplant Services</span></b></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Medicare covers the following organ transplants: kidney, heart, lung, heart/lung, liver,
pancreas, pancreas/kidney, and intestinal/multi-visceral. Medicare also covers stem cell
transplants for certain conditions.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">On March 30, 2007, the Department of Health and Human Services (DHHS) established a
regulation authorizing the survey and certification of organ transplant programs. The
Centers for Medicare & Medicaid Services (CMS) is the Federal agency responsible for
monitoring compliance with the Medicare conditions of participation. All hospital
transplant programs covered by the regulation (does not include stem cell transplants),
whether currently approved by CMS or seeking initial approval, must submit a request for
approval under the new regulations to CMS by December 26, 2007 (180 days from the
effective date of the regulation.)</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"></span></div>
<a name='more'></a><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span><br />
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Kidney Transplant - General</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">A3-3612, HO-E414</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">A major treatment for patients with ESRD is kidney transplantation. This involves
removing a kidney, usually from a living relative of the patient or from an unrelated
person who has died, and surgically placing the kidney into the patient. After the
beneficiary receives a kidney transplant, Medicare pays the transplant hospital for the
transplant and appropriate standard acquisition charges. Special provisions apply to
payment. For the list of approved Medicare certified transplant facilities, refer to the</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">following Web site:
<a href="http://www.cms.hhs.gov/CertificationandComplianc/20_Transplant.asp#TopOfPage">http://www.cms.hhs.gov/CertificationandComplianc/20_Transplant.asp#TopOfPage</a>
A transplant hospital may acquire cadaver kidneys by: </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Excising kidneys from cadavers in its own hospital; and </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Arrangements with a freestanding organ procurement organization (OPO) that
provides cadaver kidneys to any transplant hospital or by a hospital based OPO.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">A transplant hospital that is also a certified organ procurement organization may acquire
cadaver kidneys by:
Having its organ procurement team excise kidneys from cadavers in other
hospitals; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Arrangements with participating community hospitals, whether they excise
kidneys on a regular or irregular basis; and </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> Arrangements with an organ procurement organization that services the transplant
hospital as a member of a network.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">When the transplant hospital also excises the cadaver kidney, the cost of the procedure is
included in its kidney acquisition costs and is considered in arriving at its standard cadaver
kidney acquisition charge. When the transplant hospital excises a kidney to provide
another hospital, it may use its standard cadaver kidney acquisition charge or its standard
detailed departmental charges to bill that hospital. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">When the excising hospital is not a transplant hospital, it bills its customary charges for
services used in excising the cadaver kidney to the transplant hospital or organ
procurement agency. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If the transplanting hospital's organ procurement team excises the cadaver kidney at
another hospital, the cost of operating such a team is included in the transplanting
hospital's kidney acquisition costs, along with the reasonable charges billed by the other
hospital of its services.</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-49154205345078613032017-08-14T00:22:00.000-07:002017-08-14T00:22:06.248-07:00Hospitals That Do Not Charge<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">A3-3660.5 </span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Participating hospitals that do not charge individuals and also meet the exceptions to the
law that normally exclude payment for expenses paid for directly or indirectly by a
governmental entity, may be reimbursed the reasonable cost of furnishing covered
services to Medicare beneficiaries. The following special procedures apply to their bills. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Computing Medicare Billing Rate </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The Medicare billing rate per day is determined by the following equation:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Total allowable inpatient cost = cost per day per patient</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Total inpatient days</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Thus, the billing rate that appears is the average inpatient cost per day per inpatient as
calculated from entries on the latest cost settlement report approved by Medicare. Where
this is the provider's first year in the program, the A/B MAC (A) determines this rate
based on the provider's books and records the appropriate billing rate for services rendered
to Medicare beneficiaries.</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Computing Medicare Billing Rate (Inpatient) </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The Medicare billing rate is determined in the following manner:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Total available inpatient cost = Cost per day per patient</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Total inpatient days </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The A/B MAC (A) multiplies the cost per day per patient by 93 percent for short-term
hospitals and by 98 percent for long-term hospitals. Then it applies the following fixed percentages. The result is the Medicare billing rate.
</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"></span></b></div>
<a name='more'></a><b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b><br />
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Computing Medicare Billing Rate (Outpatient) </span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The Medicare billing rate is determined by the following equation: </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Total allowable outpatient cost = average cost per visit </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Total visits (occasions of service)</span></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Thus, the billing rate is the average cost per outpatient visit as calculated from entries on
the latest cost settlement report approved by Medicare. Where this is the provider's first
year in the program, the A/B MAC (A) determines this rate based on the provider's books
and records the appropriate billing rate for services rendered to Medicare beneficiaries.</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-16853962839494552882017-08-05T22:53:00.000-07:002017-08-05T22:53:07.849-07:00Accommodations<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>Revenue Codes </b>- Codes that identify the accommodations furnished, ancillary services
provided or billing calculation are entered in this field. The code indicates whether the
rate includes charges for ancillary services or only room and board.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If the patient was furnished more than one type of accommodation, the loops or lines for
each type of accommodation are completed. This is necessary whether or not the provider
charges an all-inclusive rate according to accommodations.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Where the all-inclusive rate varies with the type of accommodation, the Remarks field is
annotated for a five-or-more bed accommodation showing the reason for the
accommodation.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>Unit of Service </b>- A quantitative measure for services furnished, by revenue category, to or
for the patient which includes items such as the number of accommodation days, pints of
blood, or renal dialysis treatments, is entered.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>Total Charges </b>- The total charges pertaining to the related revenue code for the current
billing period is entered.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>Noncovered Charges</b> - The total non-covered charges pertaining to the related revenue
code for the current billing period is entered.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Ancillary Services</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>One All-Inclusive Charge Rate </b>- Hospitals with one all-inclusive charge rate, including
ancillary services, are reflected in the revenue code. The total charge reflects the charge
for both accommodations and ancillary services.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>Separate Ancillary All-Inclusive Rate</b> - Some providers segregate charges for ancillary
services for billing purposes. Where a separate flat rate charge for ancillary services is
incurred either on a daily or total stay basis, the provider enters separate codes for the
services. These codes indicate whether the total charge includes only ancillary cost or
includes other costs (i.e., blood).</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If applicable, the following additional billing instructions are applied:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Blood</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Whenever whole blood is furnished the patient, value codes and amounts are
completed. If the all-inclusive rate does not include the charge for whole blood or
packed cells, revenue codes, rates, service dates, units, and total charges are
completed in the same way a provider not using all-inclusive rates would complete
them. When the provider discounts its customary charges for unreplaced blood to
which the deductible is applicable, it shows the charges before the discount.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> If the all-inclusive rate covers the cost of providing blood whenever a patient needs
it, the number of pints furnished, replaced, not replaced, and the estimated cost per
pint is entered in value codes and amounts. No amount can be shown in the Total
Charges column since the rate includes the cost of blood. It is not necessary to
show the cost for any replaced blood.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• All-Inclusive Charges According to Disease, Injury, or Type of Treatment</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Providers that have a charge system based on the patient's illness or injury or type
of treatment complete the applicable loops or line(s) for type of accommodation
furnished showing number of days, rate, and total charges. The rate amount and
total amounts must be the same. Blood entries are indicated as above</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Physician's Component </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">As with providers having a schedule of charges for individual services, the amount
of any physician's component included in the all-inclusive charge is removed from
the total covered charges before applying the inpatient deductible or coinsurance.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Combined Billing </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">CMS does not encourage the all-inclusive rate provider to combine bill. However,
if it does, it must develop the capability and indicate in the Remarks field, the
number and type of each service it is combined billing. To identify such cases, the
remark "Combined Billing" must be written in the Remarks field. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><b>NOTE: </b>Combined billing was eliminated with Outpatient PPS.</span></div>
<div style="text-align: justify;">
<br /></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-33740813214110495642017-07-31T22:50:00.000-07:002017-07-31T22:50:03.462-07:00Swing-Bed Services<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Swing-bed services must be billed separately from inpatient hospital services. Swing-bed
hospitals use one provider number when billing for hospital services to identify hospital
swing-bed SNF bills. The following alpha letters identify hospital swing-bed SNF bills
(for CMS use only, effective May 23, 2007, providers are required to submit only their
NPI. NOTE: The swing-bed NPI will be mapped to the 6-digit alpha-numeric legacy
(OSCAR) number.):</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">"U" = short-term/acute care hospital swing-bed;</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> "W" = long-term hospital swing-bed;</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> "Y" = rehabilitation hospital swing-bed; and</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"> ”Z”=CAH swing-bed.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">A. - Inpatient Hospital Services in a Swing-Bed</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The patient status code of 03 is inserted on the claim when the beneficiary swings from
acute to SNF level of care. (This constitutes a discharge for purposes of Medicare
payment for inpatient hospital services under PPS.) The A/B MAC (A) indicates in the
Statement Covers Through Date the last day of care at the hospital level.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If the beneficiary is discharged from a Medicare swing bed and remains in the hospital,
there is no need for a no-pay bill. However, if a beneficiary continues to receive care after
completing their stay in a SNF swing bed, in a NF swing bed, the hospital must submit
covered claims to Medicare.</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">B. - SNF Services in a Swing-Bed</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• The date of admission on the swing-bed SNF bill is the date the patient began to
receive SNF level of care services;</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• State level agreements may call for varying types of bill coding Type of Bill. The
CMS does not perform edits on type of bill coding on bills with 8 in the 2nd digit
(bill classification), in FL 18 of the CWF inpatient record if the record is identified
in FL 1 as hospital or SNF. Therefore, the A/B MAC (A) accepts, with subsequent
conversion, any bill type agreed to at the State level to identify swing-bed billing,
i.e., 18X or 21X. It must be sure the record identification of CWF FL 1 is
consistent with the provider number shown.</span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Providers Using All-Inclusive Rates for Inpatient Part A Charges</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Some providers have been approved to bill a flat fee charge for inpatient services based on
either a daily basis or total stay basis for services furnished. This is an "All-Inclusive
Rate." These charges may cover room and board, including ancillary services, or room
and board only. These instructions explain the essential data entries that must be made
using the ASC X12 837 institutional claim format or on the Form CMS-1450 by providers
that use all-inclusive rates as charges. All-inclusive rate providers are identified by one of
the following charge structures:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• One total all-inclusive charge rate for both accommodations and ancillary services,
including the cost of blood in the rate; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• One total all-inclusive charge rate for both accommodations and ancillary services,
not including the cost of blood in the rate; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• One all-inclusive charge rate for accommodations and another for ancillary
services, including the cost of blood in the all-inclusive rate; or</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• One all-inclusive charge rate for accommodations and another for ancillary
services, not including the cost of blood in the all-inclusive rate.</span></div>
<br />
<br /></div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-43567950874459727682017-07-26T22:46:00.000-07:002017-07-26T22:46:09.987-07:00Additional edits<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The A/B MAC (A) must perform the following additional edits and investigate adjustment
requests the provider submits:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• A full denial once the bill is paid, except to accomplish retraction of a duplicate
payment; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• A change in DRG based on a change in age or sex; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• A change in deductible; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• An adjustment request that changes a previously submitted QIO adjustment
request; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• An adjustment of a bill due to a change in utilization or spell data on another bill; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• A reopening to change a no-payment bill to a payment bill;</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• A reopening to pay a previously denied line item; </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• An adjustment request the provider initiates with a claim change reason code equal
to D7, with the Medicare payment amount equal to or greater that the previously
paid amount; or </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• An adjustment request with a claim change reason code equal to E0, and the claim
is for a PPS provider. The A/B MAC (A) must investigate if the change is from
patient status 02, transferred to another acute care facility.</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Late Charges</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Providers billing under Inpatient Hospital PPS, Outpatient PPS, SNF PPS, or HHA PPS
may not bill late charges, nor will the contractor accept such bills, for any type of PPS
service, inpatient or outpatient. Charges omitted from the original bill must be submitted
on an adjustment bill that contains all pertinent charges including those billed earlier.
When the provider submits late charges on bills to the A/B MAC (A) as bill type XX5,
these bills contain only additional charges. Adjustment requests and not late charge bills
should be submitted for</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Services on the same day as outpatient surgery subject to the ASC limit, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• ESRD services paid under the composite rate, </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• All inpatient accommodation charges, and </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• All inpatient PPS ancillaries as adjustment requests </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The provider may submit the following charges omitted from the original paid bill to the
A/B MAC (A) as late charges:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Any outpatient services other than the exceptions stated in this paragraph. This
includes late charges for HHA services under either Part A or Part B, hospice
services, hospital outpatient services except those on the day of ambulatory
surgery subject to the ASC payment limitation, RHC services, OPT services, SNF
outpatient services, CORF services, FQHC services, CHMC services, and ESRD
services not included in the composite rate; and</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Any inpatient SNF ancillaries or inpatient hospital ancillaries other than from PPS
hospitals. The hospital may not submit late charges (XX5) for inpatient
accommodations. The hospital must submit these as adjustments (bill type XX7).</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The A/B MAC (A) has the capability to accept XX5 bill types electronically and process
them as initial bills except as described in the following paragraph. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The A/B MAC (A) also performs the following edit routines on any XX5 type bills
received:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Pass all initial bill edits, including duplicate checks. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• Must not be for any of: Inpatient PPS ancillaries, inpatient accommodations in any
facility, services on the same day as outpatient surgery subject to the ASC payment
limitation, or ESRD services included in the composite rate. These are rejected
back to the hospital with the message, “This change requires an XX7 debit-only or
XX8 cancel-only request from you. Late charges are not acceptable for inpatient
PPS ancillaries, inpatient accommodations in any facility, services on the same day
as outpatient surgery subject to the ASC payment limitation, or ESRD services
included in the composite rate.” </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• When an XX5 suspends as a duplicate, (dates of service equal or overlapping,
provider ID equal, HICNs equal, and patient surname equal), the A/B MAC (A)
must determine the status of the original paid bill. If it is denied, the A/B MAC
(A) must deny the late charge bill. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If an xx5 does not suspend as a potential duplicate, the A/B MAC (A) rejects it
back to the provider with the message, “No original bill paid. Please combine and
submit a single original bill (XX1).” </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the original bill was approved and paid, the A/B MAC (A) compares the revenue
codes on the original paid bill with the associated late charge bill:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">° For all providers (any bill type), if any are the same, and are revenue codes
041x, 042x, 043x, 044x, 063x, 076x, or 091x, the A/B MAC (A) or (HHH)
rejects the bill back to the provider with the message, “You must submit an
adjustment (7) to the original paid bill. Revenue codes subject to
utilization review are duplicated on the late charge bill.” </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">° For HHAs (bill type 32X, 33X, or 34X), the A/B MAC (HHH) must apply
the same logic for the following additional revenue codes. If any are the
same and are revenue codes 0291, 0293, 055x, 056x, 057x, 058x, 059x,
060x, 066x, the A/B MAC (HHH) rejects the bill back to the provider with
the message, "You must submit an adjustment (xx7) to the original paid
bill. Revenue codes subject to utilization review are duplicated on the late
charge bill." </span></div>
<a name='more'></a><br />
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">° For hospital outpatient services (bill type 13X only), the A/B MAC (A)
must apply the same logic for the following additional revenue codes. If
any are the same and are revenue codes 0255, 032x, 033x, 034x, 035x, 040x, 062x, 073x, 074x, 092x, or 0943, the A/B MAC (A) rejects the bill
back to the hospital with the message, "You must submit an adjustment
(xx7) to the original paid bill. Revenue codes subject to utilization review
are duplicated on the late charge bill." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">° For RDFs (bill type 72X or 73X), the A/B MAC (A) must apply the same
logic for the following additional revenue codes; if any are the same and
are revenue codes 0634, 0635, 082x, 083x, 084x, 085x, or 088x, the A/B
MAC (A) rejects the bill back to the provider with the message, “You must
submit an adjustment (XX7) to the original paid bill. Revenue codes
subject to utilization review are duplicated on the late charge bill.”</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">•If the late charges bill relates to two or more "original" paid bills, and one of these
is denied, the A/B MAC (A) must suspend and investigate the late charge bill. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• The A/B MAC (A) must compare total charges on the original paid bill with those
on the associated late charge bill, and suspend and investigate any XX5 bill type
with total charges in excess of those on the original paid bill. This edit suggests
the provider may have rebilled the already paid services. </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The A/B MAC (A) may decide to perform additional edits on late charge bills.</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0tag:blogger.com,1999:blog-1814428877986939784.post-79219992062086881212017-07-21T22:37:00.000-07:002017-07-21T22:37:21.742-07:00Claim Change Reasons<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Claim Change Reason Codes</span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The provider submits one of the following claim change reason codes to its A/B MAC (A)
with each debit-only or cancel-only adjustment request:</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<table border="1" cellpadding="0" cellspacing="0" class="MsoTableGrid" style="border-collapse: collapse; border: none; text-align: justify;">
<tbody>
<tr>
<td style="border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Bill Type<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Reason Code<o:p></o:p></span></b></div>
</td>
<td style="border-left: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-themecolor: text1; mso-border-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Explanation<o:p></o:p></span></b></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D0 (zero)<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Change
to service dates<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D1<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Change
in charges<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D2<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Change
in revenue codes/HCPCS<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D3<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Second
or subsequent interim PPS bill - inpatient only<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D4<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Change
in GROUPER input (diagnoses or procedures) - inpatient only<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX8<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D5<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Cancel-only
to correct a HICN or provider identification number<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX8<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D6<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Cancel-only
to repay a duplicate payment or OIG overpayment (includes cancellation of an
outpatient bill containing services required to be included on the inpatient
bill.)<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Change
to make Medicare the secondary payer<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D8<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Change
to make Medicare the primary payer<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">D9<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Any
other change<o:p></o:p></span></div>
</td>
</tr>
<tr>
<td style="border-top: none; border: solid black 1.0pt; mso-border-alt: solid black .5pt; mso-border-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 72.9pt;" valign="top" width="97">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">XX7<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 81.0pt;" valign="top" width="108">
<div class="MsoNormal" style="margin-bottom: 0.0001pt; text-align: center;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">E0 (zero)<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: none; border-right: solid black 1.0pt; border-top: none; mso-border-alt: solid black .5pt; mso-border-bottom-themecolor: text1; mso-border-left-alt: solid black .5pt; mso-border-left-themecolor: text1; mso-border-right-themecolor: text1; mso-border-themecolor: text1; mso-border-top-alt: solid black .5pt; mso-border-top-themecolor: text1; padding: 0in 5.4pt 0in 5.4pt; width: 324.9pt;" valign="top" width="433">
<div class="MsoNormal" style="margin-bottom: 0.0001pt;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">Change
in patient status<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><div style="text-align: justify;">
<br /></div>
</span><div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The provider may not submit more than one claim change reason code per adjustment
request. It must choose the single reason that best describes the adjustment it is
requesting. It should use claim change reason code D1 only when the charges are the only
change on the claim. Other claim change reasons frequently change charges, but the
provider may not "add" reason code D1 when this occurs.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The claim change reason code is entered as a condition code on the ASC X12 837
institutional claim format or on the hard copy Form CMS-1450 For reason codes D0-D4
and D7-D9, submit a debit-only adjustment request, bill type XX7. For reason codes D5
and D6, submit a cancel-only adjustment request, bill type XX8.</span></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></b></div>
<div style="text-align: justify;">
<b><span style="font-family: Times, Times New Roman, serif; font-size: large;">Edits on Claim Change Reason Codes</span></b></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The following edits are based on the claim change reason code. The A/B MAC (A) must
apply them to each incoming adjustment request.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the type of bill is equal to XX7 and the claim change reason code is not equal to
D0-D4, D7-D9, or E0, the A/B MAC (A) rejects the request back to the provider
with the following error message, "Claim change reason code must be present and
equal to D0-D4, D7-D9, or E0 for a debit-only adjustment request."</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the type of bill is equal to XX8 and the claim change reason code is not equal to
D5-D6, the A/B MAC (A) rejects the request back to the provider with the
following error message, "Claim change reason code must be present and equal to
D5-D6 for a cancel-only adjustment request." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the type of bill is equal to XX7 or XX8 and the ICN/DCN of the claim being
adjusted is not present, the A/B MAC (A) rejects the request back to the provider
with the following message, "ICN/DCN of the claim being adjusted is required for
an adjustment request."<a name='more'></a></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If more than one claim change reason code is present on the provider's request, the
A/B MAC (A) rejects the request back to the provider with the following message,
"only one claim change reason code may apply to a single adjustment request from a provider. Choose the single claim change reason code that best describes the
reason for the provider's request and resubmit."</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the provider submits an adjustment request as type of bill not equal to XX7 or
XX8, the A/B MAC (A) rejects the request back to the provider with the message,
"Provider submitted adjustment request must use type of bill equal to XX7 or
XX8."</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D0, the A/B MAC (A) compares the
beginning and ending dates on the provider's request to those on the claim to be
adjusted on its history. If these dates are the same, it rejects the request back to the
provider with the message, "Dates of service must change for claim change reason
code D0." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D1, the A/B MAC (A) compares the
total and line item charges on the provider's request to those on the claim to be
adjusted on its history. If these changes are the same, the A/B MAC (A) rejects
the request back to the provider with the message, "Charges must be changed for
claim change reason code D1." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D2, the A/B MAC (A) compares
revenue codes/HCPCS on the provider's request to those on the claim to be
adjusted on its history. If these codes are the same, it rejects the request back to
the provider with the message, "Revenue codes/HCPCS must change for claim
change reason code D2." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D3, the A/B MAC (A) compares the
ending date on the provider's request to that on the claim to be adjusted on its
history. If these dates are the same, it rejects the request back to the provider with
the message, "Thru dates must change for the claim change reason code D3." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D4, the A/B MAC (A) compares
diagnosis and procedure codes on the provider's request to those on the claim to be
adjusted on its history. If these codes are the same and are in the same sequence, it
rejects the request back to the provider with the message, "Diagnoses and/or
procedures must change for claim change reason code D4." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D5 or D6, type of bill must be equal to
XX8 on the provider's request. If type of bill is not equal to XX8, the A/B MAC
(A) rejects the request back to the provider with the message, "Type of bill must be
equal to XX8 for claim change reason codes D5 or D6." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D7, an MSP value code (12-16, 41-43,
or 47) must be present, if a value code, 12-16, 41-43, or 47, is not present, the A/B
MAC (A) rejects the request back to the provider with the message, "An MSP value code (12-16, 41-43, or 47) must be present for claim change reason code
D7."</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D7, and one or more of value codes 12-
16, 41-43, and/or 47 is present but each value amount is equal to 0 (zero) or
spaces, the A/B MAC (A) rejects the request back to the provider with the
message, "invalid value amount for claim change reason code D7." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to D8, and a value code 12-16, 41-43, or
47 is present, the A/B MAC (A) rejects the claim back to the provider with the
message, "Invalid value code for claim change reason D8." </span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">• If the claim change reason code is equal to E0, the A/B MAC (A) compares patient
status on the provider's request to that on the claim to be adjusted. If patient status
is the same, the A/B MAC (A) rejects the request back to the provider with the
message, "Patient status must change for claim change reason E0."</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">If an adjustment the provider initiates results in a change to a higher weighted DRG, the
A/B MAC (A) edits the adjustment request to insure it was submitted within 60 days of
the date of the remittance for the claim to be adjusted. If it is, the A/B MAC (A) processes
the claim for payment. If the remittance date is more than 60 days prior to the receipt date
of the adjustment request and results in a change to a lower weighted DRG, the A/B MAC
(A) processes the claim for payment and forwards it to CWF.</span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;"><br /></span></div>
<div style="text-align: justify;">
<span style="font-family: Times, Times New Roman, serif; font-size: large;">The A/B MAC (A) must suspend for investigation all adjustment requests with claim
change reason codes D4, D8, and D9. Providers that consistently use D9 will be
investigated and, if a pattern of abuse is evident, may be reported to the OIG.</span></div>
</div>
மாங்குளம் AVM.பாஸ்கரன் M.Techhttp://www.blogger.com/profile/14275260072192866587noreply@blogger.com0