Provider Type. Date Approved. Services (Physician/ Non- Physician Practitioner) Services (Physician/ Non-Physician Practitioner)

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1 : HealthataInsights Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North akota, Nebraska, Nevada, Oregon, South akota, Utah, Washington, Wyoming, Guam, American Samoa and Northern Marianas Issue Name Facility vs. Non- Facility Reimburse -ment (Inpatient) Issue escription Under the physician fee schedule, some procedures separate Medicare fee schedule for a physician s professional services when provided in a facility and a nonfacility. The CMS furnishes both fees in the MPFSB update. fees, when the services are provided in a facility, are applicable to procedures furnished in the facilities. Number Provider Type Non- ate Approved Affected 6/24/09 All FIs ates of Additional Information CMS Pub ; Chapter 12, Global vs TC/PC An overpayment exists when providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or professional (modifier 26) components for the same service /26/09 All CMS Pub ; Ch. 1, 120 CMS Pub ; Ch. 12, 20.2 CMS Pub ; Ch. 13, CMS Pub ; Ch. 16, Hospice Related - B related to a Hospice terminal diagnosis provided during a Hospice period are included in the Hospice payment and are not paid separately /11/09 All FIs CMS Pub , Chapter 11, 10, 40.2 and 50; CMS Pub , Chapter 9, 10 ate of eath Medicare does not pay for services rendered after the Beneficiary's date of death /15/09 All B IOM Medicare General Information, Eligibility, and Entitlement Manual Chapter ; OIG Report OEI , Medicare Payments for After ate of eath Medically Unlikely Edits Medically Unlikely Edits were implemented January 1, These edits were developed to reduce the error rate and are used to adjudicate claims at, Fiscal Intermediaries, and ME. As explained in CMS' announcement letter to providers and suppliers "An /23/09 All, Medically Unlikely Edits; and, MLN Matters MM5402

Non- Facility Reimburse -ment (Inpatient) Issue escription Under the physician fee schedule, some procedures separate Medicare fee schedule for a physician s professional services when provided in a

2 MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service". NCCI Edits National Correct Coding Initiative (NCCI) Edits identify CPT/HCPCS code combinations that should not be reported together by the same Provider for the same Beneficiary and the same date of service. Each NCCI edit has an assigned modifier indicator. A modifier indicator of 0 indicates that NCCI-associated modifiers cannot be used to bypass the edit. A modifier indicator of 1 indicates that NCCI-associated modifiers may be used to bypass an edit under appropriate circumstances. Overpayments due to NCCI edits may be identified under the same claim number or under different claim numbers /4/09 All National Correct Coding Initiative Coding Policy Manual for Medicare ; CMS Pub , Chapter Part B uplicates - Automated Review Medicare does not pay for duplicate services or equipment. An individual overpayment is an incorrect payment for provider or physician services made under title XVIII. Examples include duplicate processing of charges/claims. Provider is overpaid because the FI or carrier processed the provider s claim more than once. If an overpayment to a provider is caused by multiple processing of the same charge. IOM Pub , Chapter 3 10 and 90 s in the same group practice who are in the same specialty must bill and be paid for E&M services as though they were a single physician. If more than one E&M service is provided on the same day only one E&M service may be reported unless the services are for unrelated problems. The physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. IOM Pub Chapter Ambulance; Ambulatory Center; Non- Practitioner 4/13/10 All MAC; IOM Medicare Financial Management Manual Chapter and 90.1; Medicare Chapter 12, 30

service. Each NCCI edit has an assigned modifier indicator. A modifier indicator of 0 indicates that NCCI-associated modifiers cannot be used to bypass the edit.

3 Part B uplicates - Automated Review service is also /5/11 All MAC, emand 30; MLN Matters Number: MM6960; ; Chapter 01, 70; Medicare Chapter 16, 40.8 Add On Codes with enied Code for Profession al service is also paid /5/11 All, emand 30; Medicare Chapter 29, 240; ; Chapter 16, 40.8 Add-on Codes paid without required Code-By Lab service is also Lab 1/5/11 All emand 30; MLN Matters Number: MM6960; ; Chapter 01, 70 Provider J1 then surgery may not be /1/11 CA, HI, NV Palmetto GBA ates of Performed 09/02/08 LC # L28278 Effective with ates of Performed 09/02/2008 for Hawaii, California and Nevada. Provider J3 then surgery may not be /1/11 AZ, MN, N, S, UT, WY Noridian Administrative ates of on or after 10/01/07 LC # L24331 Effective with ates of Performed 12/01/2006 for Arizona, Montana, North akota, South akota, Utah and Wyoming

8 Add-on Codes paid without required Code-By Lab service is also 002282010 Lab 1/5/11 All emand 30; MLN Matters Number: MM6960; 100-04; Chapter 01, 70 Provider J1 then surgery may not be 000032011

4 Add On Codes with enied Code-By Clinical Laboratory service is also paid Lab 3/1/11 All MAC; 30; Medicare Chapter 29, 240; ; Chapter 16, 40.8 Provider J5 then surgery may not be /2/11 IA, KS, MO, NE WPS ates of On or After 07/16/10 LC # L30713 Effective with ates of Performed 07/16/2010 for the states of Iowa, Kansas, Missouri and Nebraska. Technical Componen t of iagnostic Procedures uring Inpatient Profession al When billed on the same date of service as an inpatient hospital claim, the Technical Component (TC) of diagnostics is not payable to the Part B provider. The technical component is performed by the facility while a patient is in a covered Part A Inpatient Stay /3/11 All ; emand Letter date Addendum-MPFSB File Layouts, File Layout 30 Medicare Publication ; Chapter 15, 30.1 with Provider J2 then mohs surgery may not be /22/11 AK, OR, WA Noridian ates of on or after 04/01/08 LC # L23735 Effective with ate of performed on or after 04/01/2008 for Alaska, Oregon and Washington Place of Coding for (Outpatient Hospital) To account for the increased expense that physicians incur by performing services in their offices, Medicare Part B reimburses physicians at a higher rate for certain services performed in their offices. However, when physicians perform these services in facility settings such as an Outpatient Hospital, Medicare reimburses the overhead expenses to the /10/11 All ; emand Chapter 12, Chapter 4, Office of Inspector General report: Review of Place-Of- Coding for

5 facility and the physician receives a lower reimbursement rate. An improper payment exists when physicians bill certain services with the incorrect place of service. Processed by Medicare Part B uring Calendar Years 2005 and 2006 (A ) Labs Subject to ESR Consolidat ed Billing The ESR Prospective Payment System (PPS) includes consolidated billing for limited Part B services included in the ESR facility bundled payment. Certain laboratory services and limited drugs and supplies will be subject to the Part B consolidated billing and will no longer be separately payable when provided for ESR beneficiaries by providers other than the renal dialysis facility Lab 12/2/11 All ; emand 1) ; Chapter 8, ) Change Request 7064 ated January 14, ) MLN Matters MM7064 ated January 14, 2011 Improperly Paid Modifiers TC and 26 HCPCS Codes with a PC/TC Indicator of "1" and billed with either 26 or TC in any modifier field should be paid at either the technical component or the professional component rate based on the modifier Overpayments occur when the applicable Medicare Fee Schedule amount for Modifier TC and/or 26 are not applied /13/12 All "claim paid date" which emand Addendum - MPFSB Record Layouts Excessive Units of Microslide Consultatio n Full The CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. Based on the MUE Table for Practitioner, CPT Code (Microslide Consultation) is to be reported only once per beneficiary per date of service /11/12 CA, HI, NV "claim paid date" which emand 1) CMS Medically Unlikely Edits (MUE) Overview 2) Medically Unlikely Edits (MUE) Publication Announcement Letter 3) Practitioner MUE Table Click here for a full list of the issues under review for this RAC. The issues listed above were selected as those likely to affect /Laboratory. If you have questions about information contained in this issue of ReveNews, or would like more information about McKesson s Business Performance please contact your account manager or contact us at , pathologyinfo@mckesson.com or visit Copyright 2013 McKesson Corporation and/or one of its subsidiaries. All rights reserved. All other product or company names mentioned may be trademarks, service marks or registered trademarks of their respective companies. This publication is not intended to constitute legal, accounting, financial, investment or other professional advice. Any business decisions should be made in consultation with your legal, professional and accounting advisors Sanctuary Parkway, Alpharetta, GA

limited Part B services included in the ESR facility bundled payment.

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