CMS Pub. 100-04, ch. 4, § 250.1.1

Standard Method Critical Access Hospitals (CAHs)

(Rev. 1921, Issued: 02-19-10, Effective: 04-01-10, Implementation: 04-05-10)

CAHs sometimes bill outpatient therapy services using HCPCS that by definition give

specific time increments like those discussed in Chapter 5, sections 20 and 40. However,

standard method CAHs are not subject to payment on a fee basis under the Medicare

Physician Fee Schedule, therefore these CAHs should follow the instructions below if

there is a need to bill non-covered increments.

When HCPCS codes required for reporting do not specify an increment of billing in their

definition (i.e., 15 minute intervals), the unit for the line item is 1, and CAHs should

follow the general instructions given for billing non-covered charges in Chapter 1,

section 60, either by the line item or on no payment claims.

Several of the outpatient therapy HCPCS codes, however, are defined in specific time

increments, and units reported on line items should be consistent with these definitions.

In such cases, when both covered and non-covered increments are provided in the same

visit on the same date of service, CAHs should bill as follows:

• Report covered and non-covered units in separate line items, even when part of the

same visit, with one line item for all covered and non-covered increments in a visit,

and another for all non-covered increments in that same visit;

• Use ABN-related modifiers when appropriate to explain non-coverage and payment

liability of specific lines (i.e., -GY, see Chapter 1, section 60 for details on these

modifiers);

• Do not report non-covered line items that are part of a partially covered service on a

separate no payment claim (i.e., using condition code 21). Instead, always report

them on the same claim with the separate lines for the covered portion of the

service. No payment claims received for the same date, same beneficiary, same

provider and same therapy service as a for-payment claim will be rejected. A

distinct reason code will make providers aware of the reason for the rejection, and

they can correct their billing to have covered and non-covered portions of the same

service on the same claim;

• Do not report non-covered line items as part of the required reporting of value codes

50, 51 and 52 for covered visits (i.e., where all increments are non-covered and

there are no covered charges for the line item, since these line items are either part

of an already counted partially covered visit, or an entirely non-covered visit); and

• Never split a single increment into a covered and non-covered portion.