A/B MAC (A) Billing Requirements

12.3 - A/B MAC (A) Billing Requirements (Rev. 13549; Issued: 12-18-25; Effective: 01-20-26; Implementation: 01-20-26) The A/B MACs (A) shall pay for counseling to prevent tobacco use services with codes 99406 and 99407 for dates of service on or after October 1, 2016. A/B MACs (A) shall pay for counseling services billed with codes G0436 and G0437 for dates of service on or after August 25, 2010, through September 30, 2016. Deductible and coinsurance are waived. A. Claims for counseling to prevent tobacco use services should be submitted using the ASC X12 837 institutional claim format or Form CMS-1450. The applicable bill types are 12X, 13X, 22X, 23X, 34X, 71X, 77X, 83X, and 85X. Effective April 1, 2006, type of bill 14X is for non-patient laboratory specimens and is no longer applicable for counseling to prevent tobacco use services. Applicable revenue codes are as follows: Provider Type Revenue Code Rural Health Centers (RHCs) 052X Federally Qualified Health Centers (FQHCs) 052X, 0519 Indian Health Services (IHS) 0510 Critical Access Hospitals (CAHs) Method II 096X, 097X, 098X All Other Providers 0942 NOTE: When these services are provided by a clinical nurse specialist in the RHC/FQHC setting, they are considered “incident to” and do not constitute a billable visit. Payment for outpatient services is as follows: Type of Facility Method of Payment Rural Health Centers (RHCs) All-inclusive rate (AIR) for the encounter Federally Qualified Health Centers (FQHCs) FQHC Prospective Payment System (PPS) for the encounter Indian Health Service (IHS)/Tribally owned or operated hospitals and hospital- based facilities AIR IHS/Tribally owned or operated non-hospital-based facilities Medicare Physician Fee Schedule (MPFS) IHS/Tribally owned or operated Critical Access Hospitals (CAHs) Facility Specific Visit Rate Hospitals subject to the Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) Hospitals not subject to OPPS Payment is made under current methodologies Skilled Nursing Facilities (SNFs) NOTE: Included in Part A PPS for skilled patients. MPFS Home Health Agencies (HHAs) MPFS Critical Access Hospitals (CAHs) Method I: Technical services are paid at 101% of reasonable cost. Method II: technical services are paid at 101% of reasonable cost, and Professional services are paid at 115% of the MPFS Data Base Maryland Hospitals Payment is based according to the Health Services Cost Review Commission (HSCRC). That is 94% of submitted charges subject to any unmet deductible, coinsurance, and non-covered charges policies. NOTE: Inpatient claims submitted with counseling to prevent tobacco use services are processed under the current payment methodologies. In addition, payment is not allowed for inpatients whose primary diagnosis is counseling to prevent tobacco use.