CMS Pub. 100-04, ch. 4, § 250.1

A/B MAC (B) for Professional Services

(Rev. 2581, Issued: 11-02-12, Effective: 04-01-13, Implementation: 04-01-13)

Effective for cost reporting periods beginning on or after January 1, 2004, payment for

outpatient CAH services under this method will be made for the lesser of: 1) 80 percent of

101 percent of the reasonable cost of the CAH in furnishing those services, or 2) 101 percent

of the reasonable cost of the CAH in furnishing those services, less applicable Part B

deductible and coinsurance amounts.

Payment for professional medical services furnished in a CAH to CAH outpatients is made

by the A/B MAC (B) on a fee schedule, charge, or other fee basis, as would apply if the

services had been furnished in a hospital outpatient department. For purposes of CAH

payment, professional medical services are defined as services provided by a physician or

other practitioner, e.g., a physician assistant that could be billed directly to a A/B MAC (B)

under Part B of Medicare or a nurse practitioner that could be billed directly to a A/B MAC

(B) under Part B of Medicare.

In general, payment for professional medical services, under the cost-based CAH payment

plus professional services billed to the A/B MAC (B) method should be made on the same

basis as would apply if the services had been furnished in the outpatient department of a

hospital.

Bill type 85X is used for all outpatient services including services approved as ASC services.

Non-patient laboratory specimens (those not meeting the criteria for reasonable cost payment

in §250.6) will be billed on a 14X type of bill.

(See Section 250.6 - Clinical Diagnostic Laboratory Tests Furnished by CAHs.)