Billing and Payment of Certain Colorectal Cancer Screenings for Nonpatients on Type of Bill (TOB) 14X
Provider Types Affected
Providers billing Medicare fiscal intermediaries (FIs) for services related to colorectal cancer screening for nonpatients on TOB 14X
Provider Action Needed
Impact to You
This article is based on Change Request (CR) 4272 which clarifies the use of TOB 14X for a nonpatient laboratory specimen when billing for colorectal cancer screenings Healthcare Common Procedure Coding System (HCPCS) codes G0107 or G0328 when performed in a hospital setting.
What You Need to Know
Payment will be based on the Clinical Diagnostic Laboratory Fee Schedule for all hospitals, including Critical Access Hospitals (CAHs) and hospitals located in Maryland under the jurisdiction of the Health Services Cost Review Commission (HSCRC) when billed on TOB 14X. All colorectal cancer screenings billed on TOB 13X for all hospitals will continue to be paid under current payment methodologies. In addition, this instruction clarifies payment to Maryland waiver hospitals for TOB 13X for colorectal cancer screenings.
What You Need to Do
See the Background section of this article for further details regarding this change.
Background
Change Request (CR) 3835 (Transmittal 734, dated October 28, 2005, http://www.cms.hhs.gov/transmittals/downloads/R734CP.pdf  ) implements the redefined type of bill (TOB) 14X to be used by hospitals for billing of nonpatient laboratory specimens effective for dates of service on and after April 1, 2006.
The National Uniform Billing Committee (NUBC) has redefined the TOB 14X to be limited in use for nonpatient laboratory specimens.
A nonpatient is defined as a beneficiary that is neither an inpatient nor an outpatient of a hospital that has a specimen that is submitted for analysis and the beneficiary is not physically present. |
An MLN Matters article is available on CR3835 at http://www.cms.hhs.gov/MLNMatters
Articles/downloads/MM3835.pdf on the CMS Web site. |
Payment
Payment for codes G0107 and G0328, when submitted on TOB 14X, will be based on the Clinical Diagnostic Laboratory Fee Schedule for all hospitals, including Critical Access Hospitals (CAHs) and Maryland hospitals under the jurisdiction of the Health Services Cost Review Commission (HSCRC).
Special Payment Instructions for Nonpatient Laboratory Specimen (TOB 14X) for All Hospitals
Payment for colorectal cancer screenings (HCPCS Codes G0107 and G0328) to a hospital for a nonpatient laboratory specimen (TOB 14X), is the lesser of the actual charge, the fee schedule amount, or the National Limitation Amount (NLA), (including CAHs and Maryland waiver hospitals).
Part B deductible and coinsurance do not apply.
Billing Requirements for Claims
Submitted to FIs
Hospitals use the ANSI X12N 837I to bill the FI or the hardcopy form CMS-1450. Hospitals bill revenue codes and HCPCS codes as follows:
Screening Test/Procedure |
Revenue Code |
HCPCS Code |
TOB |
Fecal Occult blood test |
030X |
G0107, G0328 |
13X, 14X, 83X, 85X** |
Barium enema |
032X |
G0106, G0120, G0122 |
13X, 85X |
Flexible Sigmoidoscopy |
* |
G0104 |
13X, 83X, 85X |
Colonoscopy-high risk |
* |
G0105, G0121 |
13X, 83X, 85X |
* The appropriate revenue code when reporting any other surgical procedure.
** 14X is only applicable for nonpatient laboratory specimens. |
All colorectal cancer screenings billed on TOB 13X or 85X will continue to be paid under current payment methodologies. |
Implementation
The implementation date for the instruction is July 3, 2006.
Additional Information
For complete details, please see the official instruction issued to your carrier/DMERC/intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R821CP.pdf on the CMS Web site.
If you have any questions, please contact your intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM4272
Pub. 100-4, Transmittal# R821CP, CR# 4272
Related CR Release Date: February 1, 2006
Effective Date: April 1, 2006
Implementation Date: July 3, 2006
Do you have your NPI? National Provider Identifiers (NPIs) will be required on claims sent on or after May 23, 2007. Every health care provider needs to get an NPI. Learn more about the NPI and how to apply for an NPI by visiting http://www.cms.hhs.gov/NationalProvIdentStand/  on the CMS Web site.
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