1. Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
2. For services requiring a referring/ordering physician, the name and UPIN or NPI of the referring/ordering physician must be reported on the claim.
3. A claim submitted without a valid ICD-9-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
4. Advance Beneficiary Notification (ABN) Modifier Guidelines:
Services not meeting medical necessity guidelines should be billed with modifier -GA or -GZ.
The -GA modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed.
The -GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary.
If the service is statutorily non-covered, or without benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN should not be used. A waiver such as the Notice of Exclusions from Medicare Benefits (NEMB) Form CMS-20007 may be used. The NEMB Form CMS-20007 is available online at http://www.cms.hhs.gov/medicare/bni/ or http://www.cms.hhs.gov/CMSForms/CMSForms/list.asp.
5. Telemetric gastrointestinal capsule imaging for the small intestine should be coded with CPT/HCPCS code 91110.
6. For capsule endoscopy of the esophagus the record must document that the patient does not have a contraindication for nonselective beta-blocker use. The KX modifier must be reported on the claim to indicate the presence of this documentation requirement.
1. The diagnosis code(s) must best describe the patient's condition for which the service was performed.
2. Claims for endoscopy by capsule are payable under Medicare Part B in the following places of service: CPT code 91110/91111, global and 91110/91111-TC are payable in office (11), IDTF (11), and Independent Clinic (49)
3. CPT code 91110/91111-26 (interpretation) is payable in office (11), IDTF (11), inpatient hospital (21), outpatient hospital (22), Independent Clinic (49), and state or local health clinic (71).
4. The date of service should be entered as the date hook-up is performed, with a number of service (NOS) of one (1), regardless of the number of days the recorder is worn.
5. To report Patency Capsule Testing for denial purposes, use CPT code 91299, and enter "Patency Capsule Testing" in the narrative note of the claim form.
6. The ingestion of the capsule is part of the test and an evaluation & management (E&M) service may not be billed for this purpose.
7. Telemetric Gastrointestinal Capsule Imaging consists of a technical portion of the service (provision of the capsule, hookup of the recording equipment, and downloading of the digital data to the computer with processing and creation of video images) and a professional component (review of the images and interpretation with report). The place of service for the technical component of the test should be reported as the location where the download of the images to the computer is performed.
1. Guidelines for claims submitted on UB-04 to the Fiscal Intermediary
Providers should report the patient's principal admitting diagnosis in Form Locator (FL) 67 of the UB-04. Additional or secondary diagnoses may be recorded in FLs 67A - 67Q. For inpatient hospital claims subject to QIO review, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 25, Section 75 for additional instructions.)
Diagnostic tests, items and procedures are often ordered based on the patient's sign and/or symptom. When medical necessity for the service is justified by a sign or symptom that differs from the final diagnosis, the ICD-9-CM code for the sign or symptom is best reported in Form Locator 76 on the UB-04 claim form. Diagnosis codes for signs or symptoms may also be indicated in fields 68-75. (See CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 22.214.171.124 for additional instructions.)
Providers should report the patient's reason for visit (admitting diagnosis) on outpatient bills in Form Locator 76 of the UB-04. The patient's reason for visit information should be reported for all unscheduled outpatient visits when revenue codes 045X, 0516 or 0526 are present. The ICD-9-CM diagnosis code describing the patient's stated reason for seeking care (or as stated by the patient's representative) at the time of outpatient registration should be used. (See CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 126.96.36.199 for additional instructions.)
2. Bill Type Guidelines
CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100(B) states that no type of technical services, such as a technical component of a diagnostic or screening service, is ever billed on TOBs 71x or 73x. Technical services/components associated with professional services/components performed by independent RHCs or FQHCs are billed to Medicare carriers. Technical services/components associated with professional services/components performed by provider-based RHCs or FQHCs are billed by the base-provider on the TOB for the base-provider and submitted to the FI.
Per CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100(B), only four types of services are billed on TOBs 71X and 73X: Professional or primary services not subject to the Medicare outpatient mental health treatment limitation are bundled into line item(s) using revenue code 052X; services subject to the Medicare outpatient mental health treatment limitation are billed under revenue code 0900 (previously 0910); telehealth originating site facility fees under revenue code 0780 [and] FQHC supplemental payments are billed under revenue code 0519, effective for dates of service on or after 01/01/2006.
For dates of service on or after July 1, 2006, the following revenue codes should be used when billing for RHC or FQHC services, other than those services subject to the Medicare outpatient mental health treatment limitation or for the FQHC supplement payment: 0521, 0522, 0524, 0525, 0527 and 0528 (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 9, Section 100[B].)
Additional Information:For services that exceed the accepted standard of medical practice and may be deemed not medically necessary, the provider/supplier should provide the patient with an acceptable advance notice of Medicare's possible denial of payment. An advance beneficiary notice (ABN) should be signed when a provider/supplier does not want to accept financial responsibility for the service.
2/18/2008 - The description for Bill code 21 was changed
2/18/2008 - The description for Bill code 21 was changed
Coverage Topic:Diagnostic Tests and X-Rays
Bill Code:12 - Hospital-inpatient or home health visits (Part B only)
13 - Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
21 - SNF-inpatient, Part A
22 - SNF-inpatient or home health visits (Part B only)
23 - SNF-outpatient (HHA-A also)
71 - Clinic-rural health
72 - Clinic-hospital based or independent renal dialysis facility
73 - Clinic-independent provider based FQHC (eff 10/91)
85 - Special facility or ASC surgery-rural primary care hospital (eff 10/94)
Revenue Code:0409 - Other imaging services-other
0519 - Clinic-other
0520 - Free-standing clinic-general classification
0521 - Clinic visit by member to RHC/FQHC
0522 - Home visit by RHC/FQHC practitioner
0523 - Free-standing clinic-family practice
0524 - Visit by RHC/FQHC practitioner to a member in a covered Part A stay at the SNF
0525 - Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility
0526 - Free-standing clinic-urgent care (eff 10/96)
0527 - RHC/FQHC Visiting Nurse Service(s) to a member's home when in a home health shortage area
0528 - Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident)
0529 - Free-standing clinic-other
0750 - Gastro-intestinal services-general classification
0759 - Gastro-intestinal services-other
0929 - Other diagnostic services-other
0960 - Professional fees-general classification
0972 - Professional fees-radiology diagnostic
0973 - Professional fees-radiology therapeutic
0975 - Professional fees-operating room
0982 - Professional fees-outpatient services
0983 - Professional fees-clinic
0987 - Professional fees-hospital visit