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Part A Ancillary Services

Payment may be made under Part B for some medical and health services when furnished by a hospital (including Critical Access Hospitals) to an inpatient of the hospital, but only if payment for these services cannot be made under Part A.

Hospitals must bill Part B inpatient services on a 12X Type of Bill (TOB). Inpatient Part B services include inpatient ancillary services that do not require an outpatient status and are not strictly provided in an outpatient setting.

Services that require an outpatient status and are provided only in an outpatient setting are not payable inpatient Part B services, including Clinic Visits, Emergency Department Visits, and Observation Services (this is not a complete listing). These outpatient services are billed separately on a 13X TOB.

Part B payment may be made for ancillary services if:

The patient is not entitled to Medicare Part A
The admission was disapproved as not reasonable and necessary (and waiver of liability payment was not made)
The day(s) of the otherwise covered stay during which the services were provided was not reasonable and necessary (and no payment was made under waiver of liability)
No Part A payment is made at all for the inpatient stay because the patient’s benefits were exhausted before admission

Billable Services

The following services are billable on a 12X inpatient Part A ancillary claim:

Diagnostic X-ray tests, diagnostic laboratory and other diagnostic tests
X-ray, radium and radioactive isotope therapy, including materials and services of technicians
Acute dialysis of a hospital inpatient with or without end stage renal disease (ESRD)
Surgical dressings, splints, casts and other devices used for the reduction of fractures and dislocations
Prosthetic devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue) or replace all or part of the functions of a permanently inoperative or malfunctioning internal body organ, including replacement or repair of such devices
Leg, arm, back and neck braces, trusses, and artificial legs, arms and eyes, including adjustments, repairs and replacements required because of breakage, wear, loss or change in the patient’s physical condition
Outpatient physical therapy, outpatient speech-language pathology services and outpatient occupational therapy
Ambulance services
Screening mammography services
Screening Pap smear
Influenza, pneumococcal pneumonia and hepatitis B vaccines
Colorectal screening
Bone mass measurements
Diabetes self-management
Prostate screening
Hemophilia clotting factors (for hemophilia patients competent to use these factors without supervision)
Immunosuppressive drugs
Oral anti-cancer drugs
Oral drug prescribed for use as an acute anti-emetic as part of an anti-cancer chemotherapeutic regimen
Epoetin Alfa (EPO)

Non-billable Services

The revenue codes shown in the charts below represent services that are not billable as Part A ancillary services and should not be submitted on a 12X inpatient Part A ancillary claim.

Revenue Codes - Not Allowed When Inpatient Claim Denied for Medical Necessity

010X

011X

012X

013X

014X

015X

016X

017X

018X

019X

020X

021X

022X

023X

024X

029X

0390

0399

045X

050X

051X

052X

054X

055X

056X

057X

058X

059X

060X

0630

0631

0632

0633

0637

064X

065X

066X

067X

068X

072X

0762

082X

083X

084X

085X

088X

089X

0905

0906

0907

0912

0913

093X

0941

0943

0944

0945

0946

0947

0948

095X

0960

0961

0962

0963

0964*

0969

097X

098X

099X

100X

210X

310X

 

Revenue Codes - Not Allowed Other Circumstances**

010X

011X

012X

013X

014X

015X

016X

017X

018X

019X

020X

021X

022X

023X

024X

0250

0251

0252

0253

0256

0257

0258

0259

0261

0269

0270

0273

0277

0279

029X

0339

0360

0370

0374

038X

039X

041X

045X

0472

0479

049X

050X

051X

052X

53X

0541

0542

0543

0544

0546

0547

0548

0549

055X

057X

058X

059X

060X

0630

0631

0632

0633

0637

064X

065X

066X

067X

068X

072X

0762

078X

079X

082X

083X

084X

085X

088X

0905

0906

0907

0912

0913

093X

0940

0941

0943

0944

0945

0946

0947

0948

0949

095X

0960

0961

0962

0964*

0969

097X

098X

099X

100X

210X

310X

*In the case of revenue code 0964, this is used by hospitals that have a CRNA exception.

**Other circumstances includes services furnished by a participating hospital to an inpatient of the hospital who is not entitled to benefits under Part A, has exhausted his or her Part A benefits, or receives services not covered under Part A.

The Common Working File (CWF) will edit to ensure that Diabetic Self-Management Training (DSMT) services are not billed on a 12X TOB.

References

CMS IOM Publication 100-02, Benefit Policy Manual, Chapter 6, Section 10.2

CMS IOM Publication 100-04, Claims Processing Manual, Chapter 4, Section 240


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Last modified:  02/22/2018