The Centers for Medicare & Medicaid Services (CMS) created HCPCS modifier -CA January 2003, for situations where a procedure on the outpatient prospective payment system (OPPS) inpatient only list is performed to resuscitate or stabilize an outpatient with an emergent, life-threatening condition, and the patient dies before being admitted as an inpatient.
On November 2003, CMS created APC 0375, Ancillary outpatient services when patient expires, to ensure the appropriate payment for services rendered on the same date as procedure(s) with a status indicator (SI) of “C” billed with modifier -CA. Additionally, hospitals were instructed to use modifier -CA for procedures on the inpatient list that have a payment SI of “C” when submitting a claim on bill type 13X.
In the July 25, 2005, proposed rule, the Centers for Medicare & Medicaid Services (CMS) expressed concern regarding the large increase in the volume of hospital claims billed with modifier -CA from calendar year (CY) 2003 to 2004. According to CMS, the claims increased within that one-year time period from 18 to 300. Hospitals may have been experiencing a learning curve regarding the appropriate use of modifier -CA.
CMS is concerned that some of the procedures reported by hospitals with modifier -CA in calendar year 2004 may not have been provided to patients with emergent, life-threatening conditions where the inpatient procedure was performed on an emergency basis to resuscitate or stabilize the patient. It is felt that some of those procedures may have been provided to hospital outpatients as scheduled inpatient procedures that were not emergency interventions for patients in critical or unstable condition.
Hospitals are reminded to review the payment and billing rules for modifier -CA. According to section VI of Transmittal A-025-129, the application of modifier -CA, should only be used under the circumstances described below, as follows:
IV. A. Billing and Payment Rules For Using New Modifier: -CA, Procedure payable only in the inpatient setting when performed emergently on an outpatient who dies prior to admission
1. Instruct hospitals that in order to receive payment for a service billed with modifier -CA, all of the following condition must be met:
a. The status of the patient is outpatient
b. The patient has an emergent, life-threatening condition
c. A procedure on the inpatient list (designated by payment status indicator C) is performed on an emergency basis to resuscitate or stabilize the patient
d. The patient dies without being admitted as an inpatient.
2. If all of the conditions for payment are met, instruct hospitals to submit a claim using a 13X bill type for all services that were furnished, including the inpatient procedure (e.g., a procedure designated by OPPS payment status indicator C). Hospitals should include modifier -CA on the line with the HCPCS code for the inpatient procedure.
3. Payment for all services on a claim that have the same date of service as the HCPCS code billed with modifier -CA is made under **APC 977. Separate payment is not allowed for other services furnished on the same date.
**Since November 2003, payment is made under APC 0375.
4. Suspend claims submitted with modifier -CA appended to a HCPCS code that has a status indicator “C” if billed with other services furnished on the same date of service. Substitute Medicare Summary Notice (MSN) #18.20 (“Medicare does not pay for this service separately since payment for it is included in our allowance for other services you received on the same day”) for the MSN that is triggered by OCE edit 49.
In the November 10, 2005, Outpatient Prospective Payment System (OPPS) final rule CMS states that no changes to modifier -CA will be made at this time. However, the use of modifier -CA will continue to be monitored closely by CMS. CMS will continue to:
- Follow changes in the claims volume;
- Note inpatient procedures to which the -CA modifier is appended;
- Examine other services billed on the same date as the inpatiet procedure; and
- Analyze specific hospital patterns of billing for services with modifier -CA appended.