MIR-2006-8AB, August 2006

Billing of Temporary “C” HCPCS Codes by Non-Outpatient Prospective Payment System (Non-OPPS) Providers

Provider Types Affected
OPPS and Non-OPPS providers billing Medicare fiscal intermediaries (FIs) for hospital outpatient department services and procedures

Provider Action Needed

Impact to You
This article is based on Change Request (CR) 5027, which revises the Medicare Claims Processing Manual (Publication 100-04, Chapter 4, Section 20.7 (Billing of “C” HCPCS Codes by Non-OPPS Providers)).

What You Need to Know
CR5027 gives non-OPPS providers the option of billing under a C-code or an appropriate CPT code. CR5027 does not change existing requirements when non-OPPS provider claims require the use of a CPT or HCPCS code.

What You Need to Do
See the Background and Additional Information sections of this article for further details regarding these changes.

Background
The Evolution of C-Codes
The Centers for Medicare & Medicaid Services (CMS) established temporary Healthcare Common Procedure Coding System (HCPCS) C-codes to permit implementation of the Balanced Budget Refinement Act of 1999 (BBRA, Section 201B).

C-codes are unique temporary pricing codes established by CMS for the Prospective Payment System and are only valid for Medicare on claims for hospital outpatient department services and procedures.

Prior to October 1, 2006, C-codes could not be used to bill services payable under other payment systems, and they were used exclusively by hospitals subject to OPPS to identify:

• Items that may have qualified for transitional pass-through payment under OPPS; or
• Items or services for which an appropriate HCPCS code did not exist for the purposes of implementing the OPPS.

Since they were originally established by CMS, C-codes have evolved, and they now also target uniquely hospital services that may be provided by:

• OPPS providers;
• Other providers; or
• Providers paid under other payment systems.

Non-OPPS providers subsequently requested the option to bill using C-codes or appropriate Current Procedure Terminology (CPT) codes.

Using C-Codes
In response to this request, CMS is issuing CR5027, which instructs that (effective October 1, 2006) the following Non-OPPS providers may elect to bill using C-codes (or appropriate CPT codes) on Type of Bills (TOBs) 12X, 13X, or 85X:

• Critical access hospitals (CAHs);
• Indian Health Service Hospitals (IHS);
• Hospitals located in American Samoa, Guam, Saipan, or the Virgin Islands; and
• Maryland waiver hospitals.

Note that Method I and Method II CAHs:

• Are limited to using C-codes to bill for facility (technical) services; and
• Method II CAHs should not use C-codes to bill for professional services with revenue codes 96X, 97X, or 98X.

Payment Methodology Is Unchanged
CR5027 is not changing the payment methodology for OPPS and Non-OPPS providers:

• OPPS providers will continue to receive pass-through payment on items or services that qualify for pass-through payment; and
• Non-OPPS providers:
  • Are not eligible for pass-through payments;
  • Will be paid under their normal payment methodologies; and
  • Should comply with all existing requirements when claims require the use of a HCPCS or CPT code.

Effective October 1, 2006, processing note 0093 will be updated as follows:

“C-codes are unique temporary pricing codes that were initially established by CMS for the Hospital Outpatient Prospective Payment System (OPPS). The C-codes are used on Medicare OPPS claims but may also be recognized on claims from other providers or by other payment systems.”

Implementation
The implementation date for CR5027 is October 2, 2006.

Additional Information
Providers are encouraged to access the CMS Web site to view the quarterly HCPCS code updates at http://www.cms.hhs.gov/HCPCSReleaseCodeSets/   .

For complete details, please see the official instruction issued to your intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R976CP.pdf    on the CMS Web site.

If you have any questions, please contact your intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/apps/contacts/   on the CMS Web site.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

MLN Matters Number: MM5027
Pub. 100-4, Transmittal# R976CP, CR# 5027
Related CR Release Date: June 9, 2006
Effective Date: October 1, 2006
Implementation Date: October 2, 2006

Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/   on the CMS Web site.