Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1262 Date: July 26, 2013

Transcription

1 anual ystem Pub One-Time Notification Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 1262 Date: July 26, 2013 hange equest 8271 UBJT: nformational Unsolicited esponse (U) or eject for dd-on odes billed without respective Primary odes. UY O NG: n dd-on code describes a service that is always performed in addition with primary service or procedure and must never be reported as a stand-alone code. These services are always done in conjunction with another procedure and are only payable when an appropriate service is also paid. This hange equest will prompt the edicare contractors to generate an U or eject for an dd- On PT ode on outpatient claims when there is no primary procedure PT code associated with the dd- On PT code or when primary procedure code associated with the dd-on PT code is not covered. TV DT: January 1, 2014 PLNTTON DT: January 6, 2014 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTUTON: (N/ if manual is not updated) =VD, N=NW, D=DLTD-Only One Per ow. /N/D N/ PT / TON / UBTON / TTL. UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers: No additional funding will be provided by ; ontractors activities are to be carried out with their operating budgets or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. V. TTNT: One-Time Notification *Unless otherwise specified, the effective date is the date of service.

2 ttachment - One-Time Notification Pub Transmittal: 1262 Date: July 26, 2013 hange equest: 8271 UBJT: nformational Unsolicited esponse (U) or eject for dd-on odes billed without respective Primary odes TV DT: January 1, 2014 PLNTTON DT: January 6, GNL NOTON. Background: The ecovery udit ontractor () program is responsible for identifying and correcting improper payments in the edicare ee-or-ervice payment process. The contractor claim data identified providers that were billing only the dd-on odes without their respective Primary odes resulting in overpayments. The enters for edicare & edicaid ervices () policy indicates: dd-on odes are always performed in addition with primary service or procedure and must never be reported as a stand-alone code. These services are always done in conjunction with another procedure and are only payable when an appropriate service is also paid. This hange equest will prompt the edicare contractors to generate an U or eject for an dd-on PT ode on outpatient claims when there is no primary procedure PT code associated with the dd-on PT code or when primary procedure code associated with the dd-on PT code is not covered. B. Policy: 1) Pub , edicare laims Processing anual, hapter 12, ection 30 ccording to Pub , edicare laims Processing anual h. 12, orrect oding Policy, ection 30, dd-on odes are only payable when billed in addition to the code for the primary procedure. Generally, these are identified with the statement list separately in addition to code for primary procedure in parentheses, and other times the supplemental code is used only with certain primary codes, which are parenthetically identified. The reason for these PT codes is to enable physicians and others to separately identify a service that is performed in certain situations as an additional service.. BUN QUNT TBL "hall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number equirement esponsibility /B The contractors shall use the list of dd-on codes with acceptable primary procedure codes in attachment as required for the following business requirements. B D hared- ystem aintainers V W Other The contractors shall create a utility to generate an U for edicare outpatient claims, in history from 04/01/13 to the implementation date of this for the billed dd-on PT code detail line when the following conditions exist:

3 Number equirement esponsibility /B D B hared- ystem aintainers V W Other 1. There is a paid edicare ospital Outpatient claim; 2. ND The Type of Bill (TOB) = 13x, 14x, or 85x; 3. ND There is a covered dd-on PT code; 4. ND There is no Primary PT code associated with the dd-on PT code on the same claim or separate claim for the same DO; 5. O There is a Primary code associated with the dd-on code that is non-covered on the same claim or separate claim for the same DO; 6. ND The reimbursement amount for the add-on PT code is greater than $ The contractors shall issue the adjustment for the edicare laim The contractors shall, upon receipt of the Wgenerated U, initiate recoupment procedures using automated processes currently in use for Us The contractors shall execute the above utility prior to the implementation of the following business requirements The W shall reject the edicare ospital Outpatient laim at the line level for the dd-on PT code when the following conditions exist: 1. There is a current ospital Outpatient claim, with a Type of Bill (TOB) = 13x, 14x or 85x; 2. ND There is a valid dd-on PT code on the claim;

4 Number equirement esponsibility /B D 3. ND There is no Primary PT code associated with the dd-on PT code on the same claim or separate claim for the same DO; B hared- ystem aintainers V W Other 4. O There is a Primary code associated with the dd-on code that is non-covered on the same claim or separate claim for the same DO The contractors shall mark the detail line item for the dd-on ode as non-covered The contractors shall have override capability for a claim upon first appeal when it is determined that the claim should have been paid The edicare claims processing contractors shall use the following group code, N message,, and codes when creating an adjustment and a reject for the outpatient claim: 1. Group ode - O; 2. N message This item or service cannot be paid as billed; 3. N122 - dd-on code cannot be billed by itself; The related or qualifying claim/service was not identified on this claim. Note: efer to the 835 ealthcare Policy dentification egment (loop 2110 ervice Payment nformation ), if present.

5 . POVD DUTON TBL Number equirement esponsibility LN rticle : provider education article related to this instruction will be available at ducation/edicare-learning-network- LN/LNattersrticles/ shortly after the is released. You will receive notification of the article release via the established "LN atters" listserv. ontractors shall post this article, or a direct link to this article, on their Web sites and include information about it in a listserv message within one week of the availability of the provider education article. n addition, the provider education article shall be included in the contractor s next regularly scheduled bulletin. ontractors are free to supplement LN atters articles with localized information that would benefit their provider community in billing and administering the edicare program correctly. /B B D Other V. UPPOTNG NOTON ection : ecommendations and supporting information associated with listed requirements: "hould" denotes a recommendation. -ef equirement Number ttachment ecommendations or other supporting information: List of dd-on PT odes with associated Primary Procedure PT odes used for business requirements ection B: ll other recommendations and supporting information: N/ V. ONTT Pre-mplementation ontact(s): arla David, or carla.david@cms.hhs.gov Post-mplementation ontact(s): ontact your ontracting Officer's epresentative (O) or ontractor anager, as applicable. V. UNDNG ection : or iscal ntermediaries (s), egional ome ealth ntermediaries (s), and/or arriers:

6 No additional funding will be provided by ; ontractors activities are to be carried out with their operating budgets ection B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. do not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. TTNT: 1

7 TTNT TYP - PT NUL DN LL PTBL PY OD (BD ON 2013 PT NUL, NTNT-ONLY NUL, D L PONG NUL ) DD-ON OD PY OD() , , 19102, , , 22532, 22533, , , 22630, 22633, 22634, , 22532, 22533, , , 22630, 22633, 22634, , 22532, 22533, , , 22630, 22633, 22634, , 22532, 22533, , , 22630, 22633, 22634, , 22532, 22533, , , 22630, 22633, 22634, , 22101, , 22112, 22114

8 TYP - PT NUL DN LL PTBL PY OD (BD ON 2013 PT NUL, NTNT-ONLY NUL, D L PONG NUL ) DD-ON OD PY OD() , , 22212, , 22222, , , , , 22556, , 22610, 22612, or when performed at a different level , or when performed at a different level , , 22630, 22633, 22634, , , , , , 63064, 63075, 63077, 63081, , , 22630, 22633, 22634, , , , , , 63064, 63075, 63077, 63081, , , 22630, 22633, , , , , , 63064, 63075, 63077, 63081, , , 22630, 22633, , , , , , 63064, 63075, 63077, 63081, , , 22630, 22633, , , , , , 63064, 63075, 63077, 63081, , , 22630, 22633, , , , , , 63064, 63075, 63077, 63081, , , 22630, 22633, , , , , , 63064, 63075, 63077, 63081, , , 22630, 22633, , , , , , 63064, 63075, 63077, 63081,

9 TYP - PT NUL DN LL PTBL PY OD (BD ON 2013 PT NUL, NTNT-ONLY NUL, D L PONG NUL ) DD-ON OD PY OD() , , 22630, 22633, 22634, , , , , , 63064, 63075, 63077, 63081, , , , 22630, 22633, , , , , , 63064, 63075, 63077, 63081, , 27356, , , 29827, , , , 31635, 31636, , 32482, , 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32503, , 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32503, 32504, 32663, 32669, 32670, , 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32503, 32504, 32505, 32663, 32666, , 32669, 32670, , , , 33207, 33208, 33212, 33213, 33214, 33216, 33217, 33221, 33222, 33223, 33228, 33229, , 33231, 33233, 33234, 33235, 33240, 33249, 33263, , , 33261, , , , , , , , , , , , , , 33935, 33945, , 33250, 33300, 33310, 33320, 33321, 33330, 33332, 33401, , 33420, , , , , 33690, 33735, 33737, , , 33915, , 33251, 33261, 33305, 33315, 33322, 33335, 33400, , , , 33496, 33500, , , , , , 33730, 33732, 33736, , , , 33814, 33853, , 33910, , 33926, , 33945, , 0318T , 0318T , 0318T , , 33863

10 TYP - PT NUL DN LL PTBL PY OD (BD ON 2013 PT NUL, NTNT-ONLY NUL, D L PONG NUL ) DD-ON OD PY OD() , , 33617, 33622, , , , , , , 33786, , 33881, 33886, , 34825, , 34805, 34813,34825, , 35556, 35566, 35570, 35571, , , , 34502, 34520, 35001, 35002, , 35102, 35103, , , , , 35566, 35570, 35571, , 35566, 35570, 35571, , 35666, , 35566, 35570, 35571, , 35623, 35656, 35666, , 35566, 35570, 35571, 35583, 35585, 35587, 35656, 35666, , , 36223, , , , , , 37230, , 32442, 32445, 32480, 32482, 32484, 32486, 32488, 32503, 32504, , 19307, 38500, 38510, 38520, 38525, 38530, 38542, 38740, , , 43281, , , 43632, 43633, , , 44145, 44150, , , , , , , , 57421,

11 TYP - PT NUL DN LL PTBL PY OD (BD ON 2013 PT NUL, NTNT-ONLY NUL, D L PONG NUL ) DD-ON OD PY OD() , 59514, 59515, 59618, 59620, , 60502, 60505, 60212, 60220, 60225, 60240, 60252, 60254, 60260, 60270, , 61312, 61313, 61322, 61323, 61340, 61570, 61571, , , , , 61210, , , , , 63173, 63185, 63190, , , 64886, , 65875, 65920, 66985, 66986, 67036, 67039, 67040, 67041, 67042, 67043, 67112,

12 TYP - PT NUL DN LL PTBL PY OD (BD ON 2013 PT NUL, NTNT-ONLY NUL, D L PONG NUL ) DD-ON OD PY OD() , , , , , 64831, , , , , based on nternet Only anual, edicare laims Processing anual, Publication , hapter 12, ection (llowable djustments) , 75559,75561, , 77056, G0204, G , G , , , , , 88331, , , 90471, 90473, G0008, G0009, G , 90471, 90473, G0008, G0009, G , 90792, 90832, 90834, 90837, 90833, 90836, 90838, , , , , , , , 90834, , 92924, 92928, 92933, 92937, 92941, , 92928, 92933, 92937, 92941, , 92933, 92937, 92941, , 92937, 92941, 92943

13 TYP - PT NUL DN LL PTBL PY OD (BD ON 2013 PT NUL, NTNT-ONLY NUL, D L PONG NUL ) DD-ON OD PY OD() , 92928, 92933, 92937, 92941, , 92924, 92928, 92933, 92937, 92941, 92943, 92975, , 93563, , 92924, 92928, 92933, 92937, 92941, 92943, , 92920, 92924, 92928, 92933, 92937,92941, 92943, , 93563, , 93304, 93312, 93314, 93315, 93317, 93350, 93351, 8921, 8922, 8925, 8926, 8928, , 93304, 93308, 93312, 93314, 93315, 93317, 93350, 93351, 8921, 8922, 8924, 8925, , 8928, , 76826, 76827, 76828, 93303, 93304, 93308, 93312, 93314, 93315, 93317, 93350, 93351, , 8922, 8924, 8925, 8926, 8928, , , 93453, , 93653, , , 93563, 93564, 93580, , , , 93453, 93456, 93457, 93460, 93461, , , 93453, 93456, 93457, 93460, 93461, , 92924, 92928, 92933, 92937, 92941, 92943, 92975, , 93563, , , 93653, , 93653, 93654, , 93620, 93653, 93654, , 93654, , 93453, , 93532, 93580, 93581, 93621, 93622, 93653, 93654, , 94060, 94070, 94375, , 95822, , , 95925, 95926, 95927, 95928, 95929, , 95938, , 95822, , , 95925, 95926, 95927, 95928, 95929, , 95938, , , , 97813

14 TYP - PT NUL DN LL PTBL PY OD (BD ON 2013 PT NUL, NTNT-ONLY NUL, D L PONG NUL ) DD-ON OD PY OD() , , , , , , , , , , , , , , , T 0075T 0079T 0078T 0081T 0080T 0092T T T T 77058, 77059, 8903, 8904, 8905, 8906, 8907, T T T T 0171T 0174T 71010, 71020, 71021, 71022, T 0188T 0190T T 0195T 0205T 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975, , 93563, T 0213T 0215T 0213T 0217T 0216T 0218T 0216T 0222T 0219T-0221T 0229T 0228T 0231T 0230T 0241T 0240T 0289T 65710, 65730, 65750, T 65710, 65730, 65750, T 92920, 92924, 92928, 92933, 92937, 92941, 92943, 92975, , 93563, T 0291T 0294T 33230, 33231, 33240, , T 0299T 0309T , 92933, 92937, 92941, 92943, 9600, 9602, 9604, 9606, , 92937, 92941, 92943, 9602, 9604, 9606, , , 92928, 92933, 92937, 92941, 92943, 9600, 9602, 9604, 9606, 9607 G0247 G0245, G0246 G , G , G G , 95822, , , 95925, 95926, 95927, 95928, 95929, , 95938, G