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Last updated: 3/1/10
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Name of issue
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Date first posted
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Regions/states affected
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Description of issue
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Document sources
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Facility vs. Non-Facility Reimbursement (Inpatient)
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12/7/09
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All Region D States
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Under the physician fee schedule, some procedures have a separate Medicare fee schedule for a physician's professional services when provided in a facility and a nonfacility. The CMS furnishes both fees in the MPFSDB update. Professional fees, when the services are provided in a facility, are applicable to procedures furnished in the facilities.
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CMS Pub 100-04; Chapter 12, § 20.4.2
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Global vs. TC/PC
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11/17/09
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All Region D States
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An overpayment exists when providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or professional (modifier 26) components for the same service.
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CMS Pub 100-04; Ch. 1, § 120 CMS Pub 100-04; Ch. 12, § 20.2 CMS Pub 100-04; Ch. 13, § 20.1 - 20.2.3 CMS Pub 100-04; Ch. 16, § 80.2.1
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Knee orthotic bundling
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10/22/09
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All Region D states
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Some knee orthotic addition codes cannot be billed separately because of bundling or medical necessity when billed with a specific knee orthotic base code
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LCD L27058, LCD Article A47178
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J2505 (injection, Pegfilgrastim, 6 mg)
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8/4/2009
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All Region B & Region D states, plus Ala., Colo., Fla., Ga., N.C. N.M. S.C. & Texas
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Units billed must represent the number of multiples of 6 mg (which equal 1 unit) administered, not total number of milligrams
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CMS Pub. 100-04, Transmittal 949
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Once-in-a-lifetime procedures
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8/4/2009
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All Region B & Region D states, plus Ala., Colo., Fla., Ga., N.C. N.M. S.C. & Texas
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Once-in-a-lifetime procedures can't be billed more than once per patient
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CMS Pub. 100-08, chap. 3, sec. 3.6.
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Untimed codes
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8/4/2009
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All Region B & Region D states, plus Ala., Fla., Ga., N.C. & S.C.
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For untimed codes, a "1" must be entered in the units bill column per date of service
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CMS Pub. 100-04, Transmittal 1019, CMS Pub 100-04, chap. 5, sec. 20.2
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Pharmacy supply and dispensing fees
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9/21/2009
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All Region A states
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Pharmacy supply and dispensing fees must be billed along with an oral anti-cancer, oral anti-emetic, inhalation or immunosuppressive drug on the same date of service
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CMS Pub. 100-04, chap. 17, sec. 80.7, MAC Jurisdiction A LCD L11499, LCD L5057, LCD L5058, LCD L11531.
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Wheelchair bundling
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8/31/2009
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All Region A, Region B, Region C & Region D states
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Some codes for wheelchair bases and options are bundled with other codes and are not separately payable
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CMS Pub. 100-03, chap. 1, sec. 280.1 & 280.3, LCD L11473
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Urological bundling
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8/31/2009
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All Region A, Region C & Region D states
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Some codes are bundled with others and are not separately payable
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CMS Pub. 100-03, chap. 1, sec. 230.17, LCD 5080
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Clinical Social Worker (CSW) services
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8/20/2009
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Fla., Mass., Maine, N.H., R.I. & Vt.
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Part B does not cover CSW services rendered during an inpatient hospital stay
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CMS Pub. 100-02, chap. 15, sec. 170
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Pediatric codes exceeding age parameters
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8/4/2009
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All Region D states, plus Ala., Fla., N.C. & S.C.
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Pediatric codes can't be applied to patients who exceed that age
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AMA CPT Book, 2007, 2008 or 2009 editions
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Bronchoscopy services
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8/4/2009
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All Region B & Region D states, plus Ala., Ga. & S.C.
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Bronchoscopy services should be billed a maximum of 1 unit per patient, per date of service
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Federal Register, vol. 7, no. 251, pg. 8
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IV hydration therapy
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8/4/2009
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All Region B & Region D states, plus Ala., Fla., Ga. & S.C.
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IV hydration should be billed a maximum of 1 unit per patient, per date of service
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CMS Pub. 100-4, chap. 12, pg. 31-32; CMS Transmittal 419, pg. 7
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Blood transfusions
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8/4/2009
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All Region B & Region D states plus Ala., Fla., Ga. & S.C.
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Blood transfusions should be billed a maximum of 1 unit per patient, per date of service
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Federal Register, vol. 67, no. 212, pg. 2; CMS Pub 100-04, chap. 4, sec. 231.8
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