Hospital
Part A providers billing for molecular services must register for a DEX Z-code identifier. Effective March 1, 2017, hospitals were required to add the DEZ Z-Code identifier in block 80 of the UB04 claim form or on line SV202-7 of the 8371 electronic claim. Providers submitting institutional claims are required to submit claims with DEX Z-Codes.
Last Reviewed: 12/19/2024
The hospital may submit Part B inpatient claim 12x TOB for Part B services that were furnished during the inpatient admission and would have been payable had the beneficiary originally been treated as outpatient with the exception of services specifically requiring outpatient status (outpatient visits, emergency department visits, observation services).
The hospital may submit Part B outpatient claim 13x TOB for outpatient services provided before the inpatient admission (within the three-day payment window) such as outpatient visits, emergency visits and observation services.
Reminder: A medically denied 11x TOB needs to be in the claim history in order for the 12x and 13x to process appropriately.
Last Reviewed: 12/19/2024
If a patient elects hospice, a timely-filed hospice notice of elections (NOEs) shall be filed within five (5) calendar days after the hospice admission date. A timely-filed NOE is one that is submitted to and accepted by the Medicare contractor within five (5) calendar days after the hospice election. The practical meaning of “submitted to and accepted by the Medicare contractor” is that the NOE was not returned to the provider for correction.
Example: The date of hospice election is October 1. A timely-filed NOE would be submitted and accepted by the Medicare contractor on or before October 6.
In instances where the NOE is not timely-filed, Medicare shall not cover and pay for the days of hospice care from the hospice admission date to the date the NOE is submitted to, and accepted by, the Medicare contractor. The provider shall be liable for these days, and the provider shall not bill the beneficiary for them.
Example: The date of hospice election is October 1. The NOE was not submitted and accepted by the Medicare contractor until October 10. Provider-liable days would be October 1 through October 9.
An individual or patient representative may revoke the election of hospice care at any time in writing; however, a hospice cannot “revoke” a patient’s election. To revoke the election of hospice care, the individual must file a document with the hospice provider that includes:
- A signed statement that the individual revokes the election for Medicare coverage of hospice care for the remainder of that election period
- The effective date of that revocation
- A designated effective date earlier than the date that the revocation is made
The individual forfeits hospice coverage for any remaining days in that election period. Please note that an oral revocation of benefits is not acceptable.
Upon revoking the election of Medicare coverage of hospice care for a particular election period, the individual is no longer covered under the Medicare hospice benefit, and resumes Medicare coverage of the benefits waived when hospice care was elected. An individual may, at any time, elect to receive hospice coverage for any other hospice election periods that he or she is eligible to receive.
CMS billing guidance is:
- When a beneficiary elects hospice during an inpatient stay:
- Bill traditional Medicare for period before hospice election
- Patient status code is 51 (discharge to hospice medical facility)
- Discharge date is the effective date of hospice election
- Bill hospice for period of care after hospice election
- When a patient revokes hospice during an inpatient stay:
- Bill hospice for period up to hospice revocation
- Bill traditional Medicare for period after hospice revocation
- Admission date is same as the hospice revocation date
- Statement 'from' date is the same as the hospice revocation date
Reference:
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual Chapter 9, Section 20 (PDF)
Last Reviewed: 12/19/2024
The JW modifier is meant for drug wastage that wasn't given to the patient, only from single dose vial drugs. The provider must submit the drug and dosage administered on one claim line and include the waste on another claim line appending the JW modifier.
The JW modifier will not bypass CMS Medically Unlikely Edits (MUE). If services are denied, a provider will need to appeal.
Last Reviewed: 12/19/2024
Radium Ra-223 is FDA approved for the treatment of individuals with castration-resistant prostate cancer. For dates of service beginning January 1, 2015, hospital outpatient departments should bill Medicare for Radium Ra-223, using HCPCS code A9606. The revenue code 0636 should also appear on the claim. In addition to needing the dosage noted on the claim, the provider also needs to indicate that bone metastases are present and that visceral metastases are absent in the Remarks field on the UB-04 or its electronic equivalent.
Last Reviewed: 12/19/2024
Outpatient Prospective Payment System (OPPS) guidance concerning alternate codes may be found on the Hospital Outpatient PPS web page of the CMS website.
Last Reviewed: 12/19/2024
For long stay cases, prospective payment system (PPS) hospitals may submit interim bills to Medicare for every 60 days. The provider must submit an adjustment to cancel the original interim bill and re-bill the stay from the admission date through the discharge date.
For example, a beneficiary is inpatient for 130 days. The first claim is a 112 type of bill (TOB) for 60 days. An admission claim is for no less or no more than 60 days. The second claim is a 117 adjustment TOB for no more than 120 days. This adjustment cancels the admission 112 TOB and replaces it. The third claim submitted to report the discharge is also a 117 adjustment TOB for 130 days. A final discharge adjustment will be for no more than 180 days, if needed.
Last Reviewed: 12/19/2024
Beginning in calendar year (CY) 2014, payment for most laboratory tests (except for molecular pathology tests) will be packaged under the Outpatient Prospective Payment System (OPPS). The general rule for OPPS hospitals is laboratory tests should be reported on a 13x TOB. There are limited circumstances described below in which hospitals can separately bill for laboratory tests. For these specific situations the Centers for Medicare & Medicaid Services (CMS) expanded the use of the 14x TOB to allow separate billing and payment at CLFS rates for hospital outpatient laboratory tests.
Laboratory tests may be (or must be for a non-patient specimen) billed on a 14x TOB in the following circumstances:
- Non-patient laboratory specimen tests (non-patient continues to be defined as a beneficiary that is neither an inpatient nor an outpatient of a hospital, but that has a specimen that is submitted for analysis to a hospital and the beneficiary is not physically present at the hospital)
- When the hospital only provides laboratory test to the patient (directly or under arrangement) and the patient does not also receive other hospital outpatient services during that same encounter
- When the hospital provides a laboratory test (directly or under arrangement) during the same encounter as other hospital outpatient services that is clinically unrelated to the other hospital outpatient services, and the laboratory test is ordered by a different practitioner than the practitioner who ordered the other hospital outpatient services provided in the hospital outpatient setting. In this case the lab test would be billed on a 14X claim and the other hospital outpatient services would be billed on a 13X claim.
It will be the hospital’s responsibility to determine when laboratory tests may be separately billed on the 14X claim under these limited exceptions. In addition, laboratory tests for molecular pathology tests described by CPT codes in the ranges of 81200 through 81383, 81400 through 81408, and 81479 are not packaged in the OPPS and should be billed on a 13X type of bill.
Reference: MLN Matters Article SE1412
Last Reviewed: 12/19/2024