Cardiac Implants on Inpatient Part B
We keep getting a missing procedure edit on Mcare claims because implant can be billed but not the procedure. How do we get past this edit?
Example of HCPCS Codes triggering missing procedure: C1760, C1761 & C1854. All the corresponding procedures are dropping off the claim as 0481 revenue code is not allowed on Inpatient Part B claims.
Thanks!
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I think you may want to double check- 0481 is not on the excluded list for either ancillary billing scenarios.
I assume they placed a stent. Don't you need the CPT for the stent placement? maybe 92928 or C9600
Yes, we have the corresponding CPT Codes but they map to revenue codes not allowed for IP Part B Only billing. It just seems odd that CMS allows the implant HCPCS code, which triggers an edit for missing procedure, but not the corresponding procedure CPT Code. Is there any hope or is this just one of those CMS things that tends to cause one to bang her head against the wall?
The MAC should be able to access that CMS table and see 0481 is not excluded and fix it. That's their job, isn't it?
Kay, are you familiar with HCPCS C9899? I know you are Noridian, but Novitas provides a good description and example on how to report without triggering the missing procedure. You should utilize C9899 for the device. Refer to the guidance below. Hope this helps!
https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00003096
Inpatient Part B – Implantable prosthetic device checklist
Type of Bill (TOB) = 12x
Claim page 02 in the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE) or Electronic Media Claim (EMC) equivalent = HCPCS C9899 and the amount that would have been charged with the actual device code itself (this is the amount outlined on the device purchase invoice)
Among any other services rendered for this particular stay that are billable on a 12x TOB.
Do not include the “C” HCPCS code of the actual device itself on claim page 02 in FISS (or the EMC equivalent).
Claim page 04 (remarks) in FISS via Direct Data Entry DDE (or the Electronic Media Claim EMC equivalent) = Include detailed remarks outlining the HCPCS code that C9899 is representing and a description of the device itself and/or a HCPCS code that adequately describes the device, the procedure being performed, the type of implants inserted and the invoice number along with the acquisition cost for each component implanted. The shipping cost does not need to be included.
Note: For a list of revenue codes not permitted on an inpatient Part B claim, please review the CMS Internet-Only Manuals (IOMs), Claims Processing Manual, Pub. 100-04, Chapter 4, Section 240.1
Example
Hospital A admits patient for a total left knee arthroplasty (left knee replacement). Patient does not have Part A coverage, but per CMS guidelines, the hospital bills for the implantable prosthetic device. In this scenario, Hospital A would traditionally bill HCPCS C1776 with a charge as outlined on the device purchase invoice.
TOB = 121
Claim page 02 in FISS via DDE or EMC equivalent = HCPCS C9899 with total and covered charges.
Any of other services rendered that are billable on an inpatient Part B claim (12x TOB) may also be included for payment.
Claim page 04 in FISS via DDE or EMC equivalent = HCPCS C1776 as well as an equivalent narrative description of the prosthetic.