CMS Pub. 100-04, ch. 18, § 140.3

The A/B MAC (A) will pay for AWV services only when submitted on one of the following types of bill (TOBs):

12X, 13X, 22X, 23X, 71X, 77X, and 85X. Type of facility and setting determines the basis of payment:

• For services performed on a 12X TOB and 13X TOB, hospital inpatient Part B and hospital outpatient, payment

shall be made under the MPFS.

• For services performed in a skilled nursing facility, TOB 22X and TOB 23X, make payment based on the MPFS.

• For services performed on a 71X TOB, rural health clinic (RHC) or 77X TOB, Federally Qualified Health Center

(FQHC), payment is made based on an all-inclusive rate and the AWV does not qualify for separate payment with

another encounter.

• For services performed on an 85X TOB, Critical Access Hospital (CAH), pay based on reasonable cost.

• For services performed on an 85X TOB, CAH Method II, payment is based on the MPFS.

• For inpatient or outpatient services in hospitals in Maryland, make payment according to the Health Services Cost

Review Commission.

Only CAHs paid under the optional method are paid for professional services for the AWV (in addition to the facility

payment) when those charges are reported under revenue codes 096X, 097X, or 098X.