Thursday, June 24, 2010

CA modifier - PO modifier and CT Modifiers

CA Modifier

Description : Procedure payable only in the inpatient setting when performed emergently on an
outpatient who dies prior to admission.

Required for Claims : Hospital Outpatient Prospective Payment System (OPPS)

Type of Bill: 13X

Coding Guidelines - CA modifier should be applied to any service that is designated with a status
indicator “C” indicating that it is an inpatient only service.

General Guidelines :

The –CA modifier is allowed when ALL of the following conditions are met:
• the status of the patient is outpatient;
• the patient has an emergent, life-threatening condition;
• a procedure on the inpatient only list is performed on an emergency basis (either in the emergency room or the operating room) to resuscitate or stabilize the patient); AND
• the patient dies without being admitted as an inpatient.

The PPS hospital can bill the claim as outpatient (type of bill 13X) with patient status code 20 (patient expired). Report the appropriate HCPCS/CPT code for the inpatient only procedure WITH the –CA modifier.

The CA modifier is only payable when the inpatient only procedure is performed emergently on an outpatient who dies prior to admission. Payment is made under APC 977 for all services on the claim that have the same date of service as the HCPCS/CPT code billed with the –CA modifier. Payment is only allowed for ONE procedure with the –CA modifier. If multiple inpatient only
procedures are submitted with modifier –CA, the claim will be returned to the provider (RTP).

Use of HCPCS Modifier - PO

Effective January 1, 2015, the definition of modifier -PO is “Services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments.” This modifier is to be reported with every HCPCS code for all outpatient hospital items and services furnished in an off-campus provider-based department of a hospital. See 42 CFR 413.65(a)(2) for a definition of “campus”.

This modifier should not be reported for remote locations of a hospital (defined at 42 CFR 413.65(a)(2)), satellite facilities of a hospital (defined at 42 CFR 412.22(h)), or for services furnished in an emergency department.

Reporting of this modifier is voluntary for CY 2015; reporting of this modifier is required beginning January 1, 2016.

Use of HCPCS Modifier – CT

Effective January 1, 2016, the definition of modifier – CT is “Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 standard.” This modifier is required to be reported on claims for computed tomography (CT) scans described by applicable HCPCS codes that are furnished on non-NEMA Standard XR-29-2013-compliant equipment. The applicable CT services are identified by HCPCS codes 70450 through 70498; 71250 through 71275; 72125 through 72133; 72191 through 72194; 73200 through 73206; 73700 through 73706; 74150 through 74178; 74261 through 74263; and 75571 through 75574 (and any succeeding codes).

This modifier should not be reported with codes that describe CT scans not listed above.

Billing of ‘C’ HCPCS Codes by Non-OPPS Providers

Prior to October 1, 2006, the “C” series of HCPCS codes 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. The C-codes could not be used to bill services payable under other payment systems. CMS realized that these C-codes evolved and also target services that are uniquely hospital services that may be provided by an OPPS provider, other providers, or be paid under other payment systems.

Effective October 1, 2006, the following non-OPPS providers may elect to bill using the C-codes or an appropriate CPT code on Types of Bill (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.

The OPPS providers shall continue to receive pass-through payment on items or services that qualify for pass through payment. Non-OPPS providers are not eligible for pass through payments.

The C-codes shall be replaced with permanent codes. Whenever a permanent code is established to replace a temporary code, the temporary code is deleted and cross-referenced to the new permanent code. Upon deletion of a temporary code, providers shall bill using the new permanent code.

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