Other Circumstances in Which Payment Cannot Be Made Under

10.2 - Other Circumstances in Which Payment Cannot Be Made Under Part A (Rev. 182, Issued: 03-21-14, Effective: 10-01-13, Implementation: 04-21-14) Part B payment could be made to a hospital for the medical and other health services listed in this section for inpatients enrolled in Part B if: • No Part A prospective payment is made at all for the hospital stay because of patient exhaustion of benefit days before or during the admission; or • The patient was not otherwise eligible for or entitled to coverage under Part A (see chapter 16, §180 of this manual for services received as a result of non- covered services). Beginning in 2014, for hospitals paid under the OPPS these Part B inpatient services are separately payable under Part B, and are excluded from OPPS packaging if the primary service with which the service would otherwise be bundled is not a payable Part B inpatient service. The following inpatient services are payable under the OPPS: • Diagnostic x-ray tests, diagnostic laboratory tests, 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). The charge for hemodialysis is a charge for the use of a prosthetic device, billed in accordance with Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, §200.2, “Hospital Dialysis Services for Patients With and Without End Stage Renal Disease (ESRD).” • Screening pap smears; • Influenza, pneumococcal pneumonia, and hepatitis B vaccines; • Colorectal screening; • Bone mass measurements; • 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 used as part of an anti-cancer chemotherapeutic regimen; and • Epoetin Alfa (EPO) that is not covered under the ESRD benefit. The following inpatient services are payable under the non-OPPS Part B fee schedules or prospectively determined rates listed: • Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations (DMEPOS fee schedule); • Prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices and including one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of intraocular lens (DMEPOS fee schedule, except for implantable prosthetic devices paid at the applicable rate under Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, §240.3, “Inpatient Part B Hospital Services - Implantable Prosthetic Devices”); • Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including replacements if required because of a change in the patient’s physical condition (DMEPOS fee schedule); • Physical therapy services, speech-language pathology services, and occupational therapy services (see Chapter 15, §§220 and 230 of this manual, “Covered Medical and Other Health Services”) (applicable rate based on the Medicare Physician Fee Schedule); • Ambulance services (ambulance fee schedule); and • Screening mammography services (Medicare Physician Fee Schedule). Hospitals may also be paid under Part B for services included in the payment window prior to the point of inpatient admission for outpatient services treated as inpatient services (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, §10.12, “Payment Window for Outpatient Services Treated as Inpatient Services”), including services requiring an outpatient status. The hospital can only bill for services that it provided directly or under arrangement in accordance with Part B payment rules. Outpatient therapeutic services furnished at an entity that is wholly owned or wholly operated by the hospital and is not part of the hospital (such as a physician’s office), may not be billed by the hospital to Part B. Reference labs may be billed only if the referring laboratory does not bill for the laboratory test (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, §40.1, “Laboratories Billing for Referred Tests”). The services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions. Claims for these services must be filed no later than the close of the period ending 12 months or 1 calendar year after the date of service (see Pub. 100-04, Medicare Claims Processing Manual, Chapter 1, §70, “Time Limitations for Filing Part A and Part B Claims”). See Pub. 100-04, Medicare Claims Processing Manual, chapter 4, §240 for required bill types.