January 3, 2001

Medi-896-01

TO: ALL MEDICARE PROVIDERS

SUBJECT: REMITTANCE ADVICE MODIFICATIONS

PRIMARY INTERESTS: BUSINESS OFFICE MANAGERS

EFFECTIVE DATE: DECEMBER 1, 2000

Attached is a copy of the Health Care Financing Administration's Program Memorandum A-00-98

(12/21/00). This PM contains information about modifications being made to both the hardcopy and electronic remittance advices.

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER STAFF. NO COST COPIES ARE ALSO AVAILABLE FROM OUR WEB SITE AT riverbendgba.com

Please refer any questions to our office toll free at 877-296-6189.

I. The following replaces the remittance advice instructions in A-00-36, Change Request 1229.

Standard Paper Remittance Advice Changes (not changed from A-00-36, Change Request 1229)

• The reference to HCPCS changed to "procedure code" as other code sets such as the national Drug Code (NDC) may begin to be used in addition to HCPCS in the future.
• The DRG operating amount and the DRG capital amount will no longer be reported separately. A combined DRG operating and capital amount will now be reported in the SPR to correspond to reporting of this information in the 835.
• A summary data element has been added for transitional outpatient payments (TOP), a monthly provider payment which will be issued as warranted to supplement line item payments for services paid under OPPS.
• Date fields in the SPR have been expanded to enable reporting of the century. Some, but not all, SPR dates previously accommodated century reporting.
• Although previously implemented, the hemophilia add on has been added to the format document.

As with inpatient PPS, only summary data will be reported in the SPR for OPPS. The standard systems maintainers will report detailed service line data only in version 3051.4A.01 and later 835 electronic remittance advice transactions. The Fiscal Intermediary Standard System (FISS) will continue to report claim level summary data without service line information in the version 3030M and 3051.3A 835 transactions. Providers on FISS who wish to receive service line data must upgrade to the 835 version 3051.4A.01 transaction format.

Attachment 2 contains field characteristics for the 2000 version of the SPR and maps the SPR to version 3051.4A.01 of the 835. The FISS maintainer must expand the flat files for the supported 835 versions at the claim or line levels as appropriate to include OPPS-specific data elements (described below). The FISS maintainer must furnish relevant mapping information between those data elements and the SPR and the supported versions of the 835 (see "FISS mapping required" notations in the implementation guide replacement pages in Attachment 4).

Electronic remittance advice format requirements:

• Report the amount of any outlier Pricer determines payable for the outpatient claim in a claim adjustment reason code segment (2-020-CAS) with reason code 70 (cost outlier) and a negative amount to reflect the additional payment supplementing the usual allowed rate.

• 2-100.A-REF and REF02 modified to allow service line reporting of an Ambulatory Surgical Center (ASC), Ambulatory Payment Classification (APC), or a Health Insurance Prospective Payment System (HIPPS) code. (This service level REF loop was not available for use in versions 3051.3A or 3030M.)
• 2-100.B-REF modified to allow service line reporting of any applicable ASC, APC, or HIPPS payment percentage. (This service level REF loop was not available for use in versions 3051.3A or 3030M.)
• 2-110.A-AMT modified to allow service line reporting of the allowed amount for APC and HIPPS payments. (This service level AMT segment was not available for use in versions 3051.3A or 3030M.)
• The standard provider level adjustment reason codes in Appendix B of the implementation guide have been expanded to include the X12 835 code BN, bonus, for reporting of a transitional outpatient payment.

• Report the amount Pricer determines payable for an outpatient service (before addition of any outlier), whether APC, AWP, or other rate, as the allowed amount for a service in version 3051.4A.01. The type of bill in CLP08 identifies whether a service is an outpatient hospital, community mental health center, home health, or other category of intermediary processed claim. In multiple payment option situations, Medicare routinely uses the highest rate permitted by law to determine payment. A remittance advice does not typically identify which of the possible cost bases is being used for payment.
• Report services for which Pricer does not report an APC number, but which are considered to be included in the payment for one or more APCs, with group code CO (contractual obligation) and reason code 97 (payment included in the allowance for another service/procedure) in version 3051.4A.01. If a non-APC service on the same claim is denied for another reason, such as not reasonable and necessary (CO 50), report the specific reason code that applies to that denial rather than CO 97.
• Use the 835 version 3051.4A.01 bundling methodology to report APC payment when multiple HCPCS are included in a single APC. When bundling services in an APC grouping, report service line information back to a provider in the same way as billed so the provider can automatically identify the services involved and post payment to patient accounts. Report each procedure code billed in a version 3051.4A.01 remittance advice, even if bundled for payment into a single APC. However, report the payment for all of the services in a single APC on the line for the first listed service in that APC. Since the payment for the entire APC will be higher than for that procedure code alone, enter group code OA (other adjustment) and reason code 94 (processed in excess of charges) for the amount of the excess (difference between the billed amount for the service and the allowed rate for the APC) as a negative amount to enable the line and claim to balance. Report the remaining procedures for that APC on subsequent lines of the remittance advice with group code CO and reason code 97 for each. Repeat the process if there are multiple APCs for the same claim.

The FISS maintainer must change the PC-print software to correspond to these changes to Medicare’s version 3030M, 3051.3A, and 3051.4A.01 implementation guides as noted, and to the Medicare SPR. PC-print must report the APC number for services for which an APC number is reported in version 3051.4A.01. Providers who use a pre-3051.4A.01 version of the 835 will not have any APC numbers reported by their PC-print. The FISS maintainer must make the revised PC-print software available to all intermediaries for their internal testing and to share with providers who receive 835 transactions.

II. The following changes apply to the home health PPS remittance advice:

• Enter 1 in 835 version 3051.4A.01 data element SVC05 as the covered units of service for the RAP. (This replaces R.2.A.4 of AB-00-65, CR 514.)
• Report the amount of any outlier Pricer determines payable for the home health claim in a claim adjustment reason code segment (2-020-CAS) with reason code 70 (cost outlier) and a negative amount to reflect the additional payment supplementing the usual allowed rate. Since this is a claim level segment, this must be reported in all supported versions of the 835, i.e., versions 3030M, 3051.3A and 3051.4A.01.