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National Government Services, Inc.
 Medicare Monthly Review Part A and B
A Combined Part A and Part B Newsletter
MMR-2008 03AB, March 2008

MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)

Modification of Payment Window Edits in the Medicare’s Common Working File (CWF) to Look at Line Item Dates of Service (LIDOS) on Outpatient Claims

MLN Matters Number: MM5880
Related Change Request (CR) #: 5880
Related CR Release Date: February 1, 2008
Effective Date: July 1, 2008
Related CR Transmittal #: R1429CP
Implementation Date: July 7, 2008

Provider Types Affected
Hospitals submitting outpatient claims to Medicare contractors (fiscal intermediaries (FIs), and/or Part A/B Medicare Administrative Contractors (A/B MACs)) for preadmission services provided to Medicare beneficiaries

Provider Action Needed

Impact to You
This article is based on Change Request (CR) 5880 which modifies the payment window edits in the CWF to look at the LIDOS of the outpatient bill.

What You Need to Know
Currently, CWF looks at the “statement covers through” date of the outpatient claim. The modification of the payment window edits in the CWF is to look at LIDOS of the outpatient bill. This will allow providers to more easily separate out the services that occur prior to the payment window. CR 5880 also incorporates a few missing revenue codes into the Medicare Claims Processing Manual.

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

Background
Currently, the edits within Medicare’s Common Working File (CWF) system look at the “statement covers through date” of outpatient claims in order to determine what services fall within the payment window relative to an inpatient stay. Change Request (CR) 5880 modifies the payment window edits (both diagnostic and therapeutic) to look at the “Line Item Dates of Service” (LIDOS) of the outpatient bill instead of the “statement covers through date.” This modification will make it easier to distinguish between the outpatient preadmission services that should be bundled on the inpatient bill from those that may be reimbursed separately.

Effective for services on or after July 1, 2008, Medicare’s CWF will reject services for payment when the outpatient service’s LIDOS falls on the admission or any of the three days immediately prior to admission of the beneficiary to an IPPS (Inpatient Prospective Payment System) or Maryland Waiver Hospital or on the day of admission or one day prior to that admission for hospitals excluded from the IPPS, rehabilitation or an inpatient psychiatric facility.

The payment window policy is a long-standing Medicare policy. The Social Security Act (Section 1886(a)(4); see http://www.ssa.gov/OP_Home/ssact/title18/1886.htmExternal Link on the Internet) and the Code of Federal Regulations (42 CFR 412.2(c)(5) and 413.40(c)(2); see http://www.gpoaccess.gov/cfr/retrieve.htmlExternal Link on the Internet) define the operating costs of inpatient services under the prospective payment system to include certain preadmission services furnished by the admitting hospital (or by an entity wholly owned or operated by the admitting hospital or by another entity under arrangements with the admitting hospital). For details as to which services are considered preadmission services and should therefore be bundled into the inpatient bill, refer to the Medicare Claims Processing Manual (Chapter 3, Section 40.3), which is attached to CR5880. In summary, CR 5880 instructs your Medicare contractor to:

CPT Code

Descriptor

93501

Right heart catheterization

93503

Insertion and placement of flow directed catheter (e.g., Swan-Ganz) for monitoring purposes

93505

Endomyocardial biopsy

93508

Catheter placement in coronary artery (s), arterial coronary conduit (s), and/or venous coronary bypass graft (s) for coronary angiography without concomitant left heart catheterization

93510

Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous

93526

Combined right heart catheterization and retrograde left heart catheterization

93541

Injection procedure during cardiac catheterization for pulmonary angiography

93542

Injection procedure during cardiac catheterization for selective right ventricular or right atrial angiography

93543

Injection procedure during cardiac catheterization for selective left ventricular or left atrial angiography

93544

Injection procedure during cardiac catheterization for aortography

93556

Pulmonary angiography, aortography, and/or selective coronary angiography including venous bypass grafts and arterial conduits (whether native or used in bypass)

93561

Indicator dilution studies such as dye or thermal dilution, including arterial and/ or venous catheterization; with cardiac output measurement

93562

Subsequent measurement of cardiac output

Additional Information
The official instruction, CR5880, issued to your Medicare FI and A/B MAC regarding this change, may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1429CP.pdfExternal PDF on the CMS Web site. If you have any questions, please contact your Medicare FI or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zipZip File 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. CPT only copyright 2007 American Medical Association.