The Centers for Medicare & Medicaid Services (CMS) recently added a new modifier to the list of reportable modifiers under the outpatient prospective payment system (OPPS). Modifier –CA, Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission, became effective January 1, 2003.
In order to receive payment for services billed with modifier –CA hospitals are instructed by CMS that all of the following conditions 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.
Hospitals are also instructed to submit a claim utilizing 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”, if all the conditions for payment are met.
All services submitted on a claim that have the same date of service as the HCPCS code billed with modifier –CA will be paid under APC 977. Other services provided on the same date will not be allowed separate payment.
Claims submitted with modifier –CA appended to the HCPCS code that has a status indicator "C" if billed with other services furnished on the same date of service will be suspended. The Medicare Summary Notice (MSN) that is triggered by the outpatient code editor (OCE) edit 49 would be substitued with MSN #18.20 that states "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 additional information regarding modifier –CA see, Transmittal A-02-129.