Wednesday, November 9, 2016

Critical Access Hospital modifiers AK, GF, SB, AH and AE

Payment to the CAH for each outpatient visit (reassigned billing) will be the sum of the following:

• For facility services, not including physician or other practitioner services, payment will be based on 101 percent of the reasonable costs of the services. List the facility service(s) rendered to outpatients using the appropriate revenue code. The A/B MAC will pay 101 percent of the reasonable costs for the outpatient services less applicable Part B deductible and coinsurance amounts, plus:

• Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.

The A/B MAC (A) uses the Medicare Physician Fee Schedule (MPFS) amounts to pay for all the physician/nonphysician practitioner services rendered in a CAH that elected the optional method. Payment is based on the lesser of the actual charge or the facility-specific MPFS amount less deductible and coinsurance times 1.15; and

•AK - Service rendered in a CAH by a non-participating physician

For a non-participating physician service, a CAH must place modifier AK on the claim. Payment is based on the lesser of the actual charge or a reduced fee schedule amount of 95 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the non-participating physician reduction (0.95) minus (deductible and coinsurance] times 1.15.

•GF - Services rendered by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA)

GF - Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA). (The “GF” modifier is not to be used for CRNA services. If a claim is received and it has the “GF” modifier for certified registered nurse anesthetist (CRNA) services, the claim is returned to the provider.) Also, while this national “GF” modifier includes CRNs, there is no benefit under Medicare law that authorizes payment to CRNs for their services. Accordingly, if a claim is received and it has the “GF” modifier for CRN services, no Medicare payment should be made.

Services billed with the “GF” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the nonphysician practitioner services reduction (0.85) minus (deductible and coinsurance)] times 1.15.

•SB - Services rendered in a CAH by a certified nurse-midwife

For dates of service prior to January 1, 2011, certified nurse-midwife services billed with the “SB” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 65 percent. Payment is calculated as follows:
For dates of service on or after January 1, 2011, Medicare covers the services of a certified nurse-midwife. The “SB” modifier is used to bill for the services and payment is based on the lesser of the actual charge or 100 percent of the MPFS. MPFS Payment is calculated as follows:

• [(facility-specific MPFS amount) minus (deductible and coinsurance)] times 1.15.

• AH - Services rendered in a CAH by a clinical psychologist

Payment for the services of a clinical psychologist is based on the lesser of the actual charge or 100 percent of the MPFS. Payment is calculated as follows:

• [(facility-specific MPFS amount) minus (deductible and coinsurance)] times 1.15.

• AE - Services rendered in a CAH by a nutrition professional/registered dietitian.

Services billed with the “AE” modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:

• [(facility-specific MPFS amount times the registered dietitian reduction (0.85) minus (deductible and coinsurance)] times 1.15.

Outpatient services, including ASC type services, rendered in an all-inclusive rate provider should be billed using the 85X type of bill (TOB). Non-patient laboratory specimens are billed on TOB 14X.

MPFS rates contained in the HHH abstract file are used for payment of all physician/professional services rendered in a CAH that has elected the optional method. If a HCPCS code has a facility rate and a non-facility rate, the facility rate is paid. See Chapter 23 of Pub. 100-04, section 50.1 for the record layout for the HHH abstract file.

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