Outpatient CAH Billing Guide - JF Part A
Outpatient CAH Billing Guide
Unique Identifying Provider Number Ranges
3rd and 4th digits = 13
Bill Type
CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1
- 851 - Admit to discharge
- 141 - Non-patient, reference laboratory services
- 852 - 1st sequential
- 853 - interim
- 854 - last sequential
- 857/147 - Adjustment
- 85Q/14Q - Reopening
- 858/148 - Cancel
- 850 - No payment
See Bill Types
Professional Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.2
Standard Option (Method 1) - Professional fees billed to Medicare Part B on a CMS-1500 Claim Form
Optional Method (Method II) - Professional fees for CAH outpatients only included on UB-04 form on revenue codes 096x, 097x or 098x.
Certified Registered Nurse Anesthetist (CRNA) Services Pass-through and Method II
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.3
CAHs qualifying for Rural Hospital Certified Registered Nurse Anesthetist (CRNA) Pass-through Exemption may elect to continue pass-through, or may include CRNA in Method II payment option. CRNA charges are reported with revenue code 0964, separate from anesthesia and supplies.
Professional Payment =
- (Time Units + Base Units) × Conversion Factor
- Subtract Deductible
- Multiply by .80
- Multiply by 1.15
Modifier QZ - Non-medically directed CRNA
Method II Professional Anesthesia Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.3
- Revenue code – 0963
- HCPCS - 00100 through 01999
- Professional Modifiers: AA, GC, QK, QY. See CAH Modifiers
- Payment =
- (Time Units + Base Units) X Conversion Factor
- Subtract deductible
- Multiply by .80
Multiply by 1.15
Method II Physician and Non-Physician Practitioner (NPP) Modifiers
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Sections 250.2
Identifies type of physician or NPP to determine appropriate percentage of MPFS payable
See CAH Modifiers
Pre-admission Bundling
CMS IOM, Publication 100-4, Medicare Claims Processing Manual, Chapter 3, Section 40.3B
Applies only when a patient receives outpatient services at a CAH that is wholly owned or operated by an IPPS hospital and is admitted as an inpatient to that IPPS hospital, either on the same day or within 3 days immediately following the day of those outpatient services.
All outpatient charges not related to the above paragraph are billed on 85x or 14x TOB separate from inpatient claim.
Emergency room, observation services, and all ancillary services rendered prior to admission cannot be included on the inpatient claim. Report each item or service on the line item on the outpatient UB-04 claim form.
Rendering and Attending Practitioner Services Reporting Requirements
CAH Method II claims must contain an attending or rendering physician's or NPP's
- National Provider Identifier (NPI)
- Last name
- First name
The practitioner information listed on the claim must match the information located on Provider Enrollment, Chain and Ownership System (PECOS). The rendering practitioners NPI must be listed at the claim line level when it is different from the rendering NPI listed at the claim level.
UB-04 Fields:
- Rendering (Form Locator (FL) 82))
- Attending (FL 76) fields
Electronic 837I Loops
- Line level rendering practitioner NPI – 2420C
CAH Ambulance Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250.5
If only ambulance within 35 miles of CAH, the CAH ambulance will receive cost based reimbursement. Ambulance claim must include condition code B2 (CAH Attestation) to show that they meet the requirement.
If another ambulance is within 35 miles, the CAH ambulance will receive payment based on the ambulance fee schedule.
Line item billing; follow Correct Coding Initiative (CCI) and Medically Unlikely Edit (MUE) guidelines
Per CMS instructions, unlisted codes (xxx99) cannot be used with professional revenue codes 96X, 97X, 98X
Bill hours of all outpatient observation; 1 unit = 1 hour. Do not include observation services on inpatient claim.
Revenue Codes:
- 0760 - General Classification Category
- 0762 - Observation Room
HCPCS Codes:
- G0378 - Hospital Observation Service, Per Hour
- G0379 - Direct Admission of Patient for Hospital Observation
Laboratory Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 2
Paid at 101% of reasonable cost when services are rendered as outpatient of the CAH or by a CAH employee. When services are not rendered by the CAH reimbursement will be made based on the Clinical Laboratory Fee Schedule.
Clinical laboratory services are not subject to deductible or coinsurance. Non-clinical laboratory services are subject to deductible and coinsurance.
Laboratory Bill Type:
- 851 - Services rendered in the CAH outpatient setting or by a CAH employee
- 141 - Laboratory tests rendered by a reference lab or outside of the CAH outpatient setting.
See Bill Types
Physical Therapy, Occupational Therapy, Speech Pathology
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.3
Effective January 1, 2014, Types of Bills 12X and 85X are subject to Part B therapy annual limitations
- Per-Beneficiary KX Modifier Thresholds
- Outpatient Rehabilitation/Therapy Modifiers
- Occurrence Codes
- Threshold Limitation
Line item billing with HCPCS and functional codes
Preventive Services
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 18
United States Preventive Services Task Force (USPSTF) grade A and B preventive services exempt from deductible and coinsurance.
Reimbursement
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 250
Method I and Method II Facility Fees - Paid at 101% of reasonable cost
Method II Professional Fees - 115% of Medicare Physician Fee Schedule (MPFS) based on the practitioner rendering the service
Payment Type
- Reasonable Cost =
- Multiply the reasonable cost by 101%
- Subtract Method II Professional Fees
- Subtract any applicable deductible and coinsurance
- Method II Professional Fees =
- Subtract Facility Fees
- Multiply the MPFS by 115%
- Subtract any applicable deductible and coinsurance
Frequency of Billing
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.2.2
All services provided on the same day should be submitted on one claim or submitted monthly for repetitive services. See IOM for CMS defined – repetitive services.
Part B Deductible
See Annual Benefits
Part B Coinsurance
See Annual Benefits
10% incentive payment for primary care or mental health services provided in Health Professional Shortage Area (HPSA). Paid on quarterly basis.
Does not apply to Dental HPSA.
Use modifier AQ for zip codes not identified as HPSA.
10% incentive Primary Care Incentive Payment (PCIP) for primary care practitioners for whom primary care services accounted for at least 60% of the allowed charges under the MPFS for the prior period.
Applies to services provided January 1, 2011 through January 1, 2016.
Primary Care Services are defined as HCPCS
- 99201-99215
- 99304-99340
- 99341-99350
Paid on quarterly basis and may receive both PCIP and HPSA if all qualifications are met.
10% HPSA Surgical Incentive Payment Program (HSIP) for major surgical procedures (10 or90 day global period) performed by general surgeons in HPSA.
Use modifier AQ for zip codes not identified as HPSA. Applies to services provided January 1, 2011, through January 1, 2016. Paid on quarterly basis and may receive both HSIP and HPSA if all qualifications are met.
Physician Quality Reporting System (PQRS)
2015 PQRS Measures Groups Specifications Supporting Documentation
CAH Method II eligible professionals (EPs) must report PQRS measurements effective January 1, 2014. EPs are doctors, physician assistants, nurse practitioners, certified nurse specialists, CRNAs, certified nurse midwives, clinical psychologists, registered dieticians, nutrition professionals, audiologists, physical therapists, occupational therapists, and qualified speech-language therapists.
Failure to report PQRS measurements will result in a negative claim adjustment starting in 2016. Providers should submit PQRS inquiries to the PQRS Registry Contractor, Quality Net, via:
- Email: Qnetsupport@hcqis.org
- Telephone: 1-866-288-8912
2014 - PQRS measurements should be reported through Electronic Health Records (EHR), Quality Net, or the Quality Clinical Data Registry (QCDR) in order to avoid the 2016 payment adjustment. Quality Data Codes (QDCs) were not allowed on the UB-04 Claim Form in 2014.
2015 - PQRS measurements should be reported through QDCs, EHR, Quality Net, or the QCDR in order to avoid the 2017 payment adjustment. Quality reporting via EHR and QDCs will have data from both sources considered in order to avoid the 2017 payment adjustment.
PQRS QDC Claim Reporting:
- Revenue code 096X, 097X or 098X
- List QDC corresponding to quality action performed by the EP
Include a $0.01 line-item charge
