CMS Pub. 100-04, ch. 19, § 100.5.1

Processing

(Rev. 2075, Issued: 10-28-10, Effective: 01-01-10, Implementation: 01-28-11)

All charges, except for therapies, telehealth originating site facility fee, PPV, influenza

virus vaccine, hepatitis B vaccine and hospital-based ambulance services are combined

and reported under revenue code 0510 (clinic visit) on TOB 13X (hospital outpatient).

Regardless of the number of times a patient is seen in a given day at a particular IHS

provider, the outpatient services should be billed only once (i.e., all-inclusive). An

exception is when a patient is seen for a clinic visit, then returns to the emergency room

later on the same day, at the same provider, for an unrelated condition (or vice versa).

Two clinic visits may be billed in this instance. The remarks section of the bill shall

include a narrative describing the situation and why two clinic visits are being billed.

When a medical visit and an emergency visit occur on the same day, condition code G0

(distinct medical visit) shall be reported on the claim.

While at least one face-to-face encounter with a physician or non-physician practitioner is

required for an initial visit to count as a billable encounter, the same is not always true of

return visits to obtain follow-up care ordered by the physician or non-physician

practitioner during the initial visit. If a physician or non-physician practitioner orders a

specific procedure or test which cannot be furnished until a later date after the date of the

initial visit with the physician or non-physician practitioner, and the procedures or tests

are medically necessary, then it is appropriate for the return encounter to be billed on the

date the procedure or test is furnished and for the provider to receive an additional AIR

payment even if the beneficiary did not interact with a physician or non-physician

practitioner during the return visit.

Examples of medically necessary reasons for return visits would include a requirement

that the beneficiary fast for 12 hours prior to an ordered test, or that a chest X-ray be

provided two weeks following the initiation of antibiotic treatment for pneumonia. In

addition, if a beneficiary must return on another day for a medically necessary test

ordered during an initial visit because the test cannot be performed on the day it is

ordered due to provider or patient constraints that cannot be overcome, the return visit

would be considered medically necessary.

See Chapter18, §10 of Pub. 100-04, Medicare Claims Processing Manual, for detailed

billing instructions for vaccines. Chapter 12 of Pub. 100-04 contains detailed billing

instructions for outpatient therapy services provided by an occupational or physical

therapist. See Chapter15 of Pub. 100-04 for detailed billing instructions for ambulance

services.

The MSN is suppressed.