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Equest 6078 SUBJECT: Update to Section 12 of Chapter 10 of the Program Integrity Manual I. SUMMARY OF CHANGES: This change request adds ambulances to the list of providers and suppliers that are discussed in Pub. 100-08, chapter 10, section 12. It also furnishes clarification on the question of changes of ownership for suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). New / Revised Material Effective Date: July 1, 2008 Implementation Date: July 28, 2008 Discla.
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Maintainers FAQ
Thus, only patients with Medicare, Medicare Advantage and Tricare insurance are billed using provider-based billing.
If an item or service is being provided by an applicable provider and is being paid through the OPPS, then the PO modifier should be applied. For instance, a drug with an OPPS status indicator of “K” or a laboratory test that is packaged into an OPPS service should have the PO modifier applied.
Provider-based billing is a type of billing for services given in a hospital or hospital facility. The hospital facility may be called an outpatient center, doctor's office or practice.
As far as Medicare Advantage plans, the -PO and -PN modifiers are just modifiers that describe particular situations. Some of the Advantage plans will accept modifier -PO but it makes no payment difference. It's up to the discretion of the plan. Modifier -PN, arguably, would not apply to an Advantage plan.
However, if services reported on a particular claim form reflect items and services furnished in both an excepted and a non-excepted hospital off-campus PBD, the “PO” modifier should be used on the excepted claim lines and the “PN” modifier should be used on the non-excepted claim lines.
A change request in ACO-MS refers to adding new information or changing existing information in ACO-MS that may require CMS approval.
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