evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 Only procedures performed during the covered level of care are shown on the bill.  If a no payment bill for the noncovered level of care has been processed, the hospital prepares and forwards a new initial bill.   40.2.2 - Charges to Beneficiaries for Part A Services  (Rev. 1495; Issued:  05- 02-08; Effective Date:  10 -01-08; Implementation Date:  10- 06-08)  The hospital submits a bill even where the patient is responsible for a deductible which covers the entire amount of the charges for non- PPS hospitals, or in PPS hospitals, where the DRG payment amount will be less than the deductible.   A hospital receiving payment for a covered hospital stay (or PPS hospital that includes at least one covered day, or one treated as covered under guarantee of payment or limitation on liability) may charge the beneficiary, or other person, for items and se rvices furnished during the stay only as described in subsections A through H.  If limitation of liability applies, a beneficiary's liability for payment is governed by the limitation on liability notification rules in Chapter 30 of this manual.  For related notices for inpatient hospitals, see CMS Transmittal 594, Change Request3903, dated June 24, 2005.  A. - Deductible and Coinsurance   The hospital may charge the beneficiary or other person for applicable deductible and coinsurance amounts.  The deductible is satisfied only by charges for covered services.  The A/B MAC (A) deducts the deductible and coinsurance first from the PPS payment .  Where the deductible exceeds the PPS amount, the excess will be applied to a subsequent payment to the hospital.  (See Chapter 3 of the Medicare General Information, Eligibility, and Entitlement Manual for specific policies.)   B. - Blood Deductible   The Part A blood deductible provision applies to whole blood and red blood cells, and reporting of the number of pints is applicable to both PPS and non- PPS hospitals. (See Chapter 3 of the Medicare General Information, Eligibility, and Entitlement Manual for specific policies.)  Hospitals shall report charges for red blood cells using revenue code 381, and charges for whole blood using revenue code 382.  C. - Inpatient Care No Longer Required
(Medicare Claims Processing Manual)
C. - Inpatient Care No Longer Required   The hospital may charge for services that are not reasonable and necessary or that constitute custodial care.  Notification may be required under limitation of liability.  See CMS Transmittal 594, Change Request3903, dated June 24, 2005, section V. of the attachment, for specific notification requirements.  Note this transmittal will be placed in Chapter 30 of this manual at a future point.  Chapter 1, section 150 of this manual also contains related billing information in addition to that provided below.  In general, after proper notification has occurred, and assuming an expedited decision is received from a Quality Improvement Organization (QIO), the following entries are required on the bill the hospital prepares:   Occurrence code 3l (and date) to indicate the date the hospital notified the patient in accordance with the first bullet above;   Occurrence span code 76 (and dates) to indicate the period of noncovered care for which it is charging the beneficiary;    Occurrence span code 77 (and dates) to indicate the period of noncovered care for which the provider is liable, when it is aware of this prior to billing; and    Value code 3l (and amount) to indicate the amount of charges it may bill the beneficiary for days for which inpatient care was no longer required.  They are included as noncovered charges on the bill.  D. - Change in the Beneficiary's Condition   If the beneficiary remains in the hospital after receiving notice as described in subsection C, and the hospital, the physician who concurred in the hospital's determination, or the QIO, subsequently determines that the beneficiary again requires inpatient hospital care, the hospital may not charge the beneficiary or other person for services furnished after the beneficiary again required inpatient hospital care until proper notification occurs (see subsection C).  If a patient who needs only a SNF level of care remains in the hospital after the SNF bed becomes available, and the bed ceases to be available, the hospital may continue to charge the beneficiary.  It need not provide the beneficiary with another notice w hen the patient chose not to be discharged to the SNF bed.   E. - Admission Denied
(Medicare Claims Processing Manual)
E. - Admission Denied   If the entire hospital admission is determined to be not reasonable or necessary, limitation of liability may apply. See 2005 CMS transmittal 594, section V. of the attachment, for specific notification requirements.  NOTE:   This transmittal will be placed in Chapter 30 of this manual at a future point.   In such cases the following entries are required on the bill:    Occurrence code 3l (and date) to indicate the date the hospital notified the beneficiary.    Occurrence span code 76 (and dates) to indicate the period of noncovered care for which the hospital is charging the beneficiary.    Occurrence span code 77 (and dates) to indicate any period of noncovered care for which the provider is liable (e.g., the period between issuing the notice and the time it may charge the beneficiary) when the provider is aware of this prior to billing.    Value code 3l (and amount) to indicate the amount of charges the hospital may bill the beneficiary for hospitalization that was not necessary or reasonable.  They are included as noncovered charges on the bill.  F. - Procedures, Studies and Courses of Treatment That Are Not Reasonable or Necessary   If diagnostic procedures, studies, therapeutic studies and courses of treatment are excluded from coverage as not reasonable and necessary (even though the beneficiary requires inpatient hospital care) the hospital may charge the beneficiary or other perso n for the services or care according the procedures given in CMS Transmittal 594, Change Request3903, dated June 24, 2005.  The following bill entries apply to these circumstances:    Occurrence code 32 (and date) to indicate the date the hospital provided the notice to the beneficiary.    Value code 3l (and amount) to indicate the amount of such charges to be billed to the beneficiary.  They are included as noncovered charges on the bill.  G. - Nonentitlement Days and Days after Benefits Exhausted   If a hospital stay exceeds the day outlier threshold, the hospital may charge for some, or all, of the days on which the patient is not entitled to Medicare Part A, or after the Part A benefits are exhausted (i.e., the hospital may charge its customary charges for services furnished on those days).  It may charge the beneficiary for the lesser of:
(Medicare Claims Processing Manual)
 The number of days on which the patient was not entitled to benefits or after the benefits were exhausted; or    The number of outlier days.  (Day outliers were discontinued at the end of FY 1997.)   If the number of outlier days exceeds the number of days on which the patient was not entitled to benefits, or after benefits were exhausted, the hospital may charge for all days on which the patient was not entitled to benefits or after benefits were exhausted.  If the number of days on which the beneficiary was not entitled to benefits, or after benefits were exhausted, exceeds the number of outlier days, the hospital determines the days for which it may charge by starting with the last day of the stay (i .e., the day before the day of discharge) and identifying and counting off in reverse order, days on which the patient was not entitled to benefits or after the benefits were exhausted, until the number of days counted off equals the number of outlier days .  The days counted off are the days for which the hospital may charge.   H. - Contractual Exclusions   In addition to receiving the basic prospective payment, the hospital may charge the beneficiary for any services that are excluded from coverage for reasons other than, or in addition to, absence of medical necessity, provision of custodial care, non- entitlement to Part A, or exhaustion of benefits.  For example, it may charge for most cosmetic and dental surgery.   I. - Private Room Care   Payment for medically necessary private room care is included in the prospective payment.  Where the beneficiary requests private room accommodations, the hospital must inform the beneficiary of the additional charge.  (See the Medicare Benefit Policy Manual, Chapter 1.) When the beneficiary accepts the liability, the hospital will supply the service, and bill the beneficiary directly.  If the beneficiary believes the private room was medically necess ary, the beneficiary has a right to a determination and may initiate a Part A appeal.   J. - Deluxe Item or Service
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J. - Deluxe Item or Service   Where a beneficiary requests a deluxe item or service, i.e., an item or service which is more expensive than is medically required for the beneficiary's condition, the hospital may collect the additional charge if it informs the beneficiary of the additional charge.  That charge is the difference between the customary charge for the item or service most commonly furnished by the hospital to private pay patients with the beneficiary's condition, and the charge for the more expensive item or service requested.  If the beneficiary believes that the more expensive item or service was medically necessary, the beneficiary has a right to a determination and may initiate a Part A appeal.   K - Inpatient Acute Care Hospital Admission Followed By a Death or Discharge Prior To Room Assignment   A patient of an acute care hospital is considered an inpatient upon issuance of written doctors orders to that effect.  If a patient either dies or is discharged prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim.  If a patient leaves of their own volition prior to being assigned and/or occupying a room, a hospital may enter an appropriate room and board charge on the claim as well as a patient status code 07 which indicates they left against medical advice.  A hospital is not required to enter a room and board charge, but failure to do so may have a minimal impact on future DRG weight calculations.   40.2.3 - Determining Covered and Noncovered Charges - Pricer and PS&R  (Rev. 1, 10- 01-03)  Accommodation charges for days covered by Medicare are covered charges.  Ancillary charges incurred on these days are also covered charges as long as these services are covered under Medicare.  The A/B MAC (A) enters them into its PS&R unless it or the QIO denies them as exclusions from coverage or as medically unnecessary.  For PPS hospitals, the A/B MAC (A) counts these charges for Pricer unless the charges are included as pass- through costs.  The A/B MAC (A) does not count for Pricer or the PS&R:   Charges the provider has shown as noncovered.  (If the provider has complied with the notice requirements in Chapter 30, it may bill the beneficiary.);   Services on noncovered days;
(Medicare Claims Processing Manual)
 Services on noncovered days;   Charges for personal comfort and/or convenience items;   Accommodations and routine charges for the day of discharge, death, or beginning of a leave of absence, unless it is also the day of admission; and   Charges for ancillary services on the day of discharge, death, or beginning of a leave of absence if the preceding day is noncovered under 40.2.B .  MSP Issues   The A/B MAC (A) resolves any MSP issues not handled by 40.1.G  using the instructions in the Medicare Secondary Payer Manual specific for reasonable cost providers and the instructions in specifically for PPS providers.  Determining Covered and Noncovered Charges - Part B   The A/B MAC (A) counts as covered under Part B, for cost report and deductible purposes, the charges for which Part B payment may be made, except as follows:   It counts as covered for deductible, but not cost report purposes, those charges for which the provider is liable for technical reasons; and    It does not count charges for which the provider is liable because services are not medically necessary for either deductible or cost report purposes.  40.2.4 - IPPS Transfers Between Hospitals  (Rev.10952, Issued:08- 19-2021, Effective: 09-20-2021, Implementation:09-20- 2021)                                                                                        A discharge of a hospital inpatient is considered to be a transfer if the patient is admitted the same day to another hospital.  A transfer between acute inpatient hospitals occurs when a patient is admitted to a hospital and is subsequently transferred from the hospital where the patient was admitted to another hospital for additional treatment once the patient's condition has stabilized or a diagnosis established.  The following procedures apply.  See 20.2.3 for proper Pricer coding to ensure that these requirements are met.  Note:   CMS established Common Working File Edits (CWF) edits in January 2004 to ensure accurate coding and payment for discharges and/or transfers.  A. - Transfers Between IPPS Prospective Payment Acute Care Hospitals
(Medicare Claims Processing Manual)
Note:   CMS established Common Working File Edits (CWF) edits in January 2004 to ensure accurate coding and payment for discharges and/or transfers.  A. - Transfers Between IPPS Prospective Payment Acute Care Hospitals   For discharges occurring on or after October 1, 1983, when a hospital inpatient is discharged to another acute care hospital, as described in 42 CFR 412.4(b) , payment to the transferring hospital is based upon a graduated per diem rate (i.e., the prospective payment rate divided by the geometric mean length of stay for the specific MS-DRG into which the case falls; hospitals receive twice the per diem rate for the first day of the stay and the per diem rate for every following day up to the full MS-DRG amount). If the stay is less than l day, l day is paid.  A day is counted if the patient was admitted with the expectation of staying overnight.  However, this day does not count against the patient's Medicare days (utilization days), since this Medicare day is applied at the receiving hospital.  Deductible or coinsurance, where applicable, is also charged against days at the receiving hospital (see 40.1.D ).  If the patient is treated in the emergency room without being admitted and then transferred, only Part B billing is appropriate.  Payment is made to the final discharging hospital at the full prospective payment rate.  The prospective payment rate paid is the hospital's specific rate.  Similarly, the wage index values and any other adjustments are those that are appropriate for each hospital.  Where a transfer case results in treatment in the second hospital under a MS-DRG different than the MS- DRG in the transferring hospital, payment to each is based upon the MS- DRG under which the patient was treated.  For transfers on or after October 1, 1984, the transferring hospital may be paid an outlier payment.  For further information on outlier payments for transfer cases, see section 20.1.2.4 of this manual.
(Medicare Claims Processing Manual)
An exception to the transfer policy applies to MS-DRG 789.  The weighting factor for this MS- DRG assumes that the patient will be transferred, since a transfer is part of the definition.  Therefore, a hospital that transfers a patient classified into this MS -DRG is paid the full amount of the prospective payment rate associated with the DRG rather than the per diem rate, plus any outlier payment, if applicable.  Effective for discharges on or after October 1, 2003, patients who leave against medical advice (LAMA), but are admitted to another inpatient PPS hospital on the same day as they left, will be treated as transfers and the transfer payment policy will apply .  An acute care transfer occurs when a Medicare patient in an IPPS Hospital (with any MS -DRG) is:    Transferred to another acute care IPPS hospital or unit for related care (Patient Discharge Status Code 02 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 02).   Admitted to another IPPS on the same day after leaving their designated IPPS hospital against medical advice (Patient Discharge Status Code 07).    Discharged but then readmitted on the same day to another IPPS hospital (unless the readmission is unrelated to the initial discharge).     B. - Transfers from an IPPS Acute Care Hospital to Hospitals or Hospital Units Excluded from the IPPS   When patients are transferred to hospitals or units excluded from IPPS, the full inpatient prospective payment is made to the transferring hospital.  The receiving hospital is paid on the basis of reasonable costs or is made at the rate of its respective payment system  (see exceptions in paragraph C of this section).  A transfer payment is made to the transferring hospital when patients are transferred to a hospital that would ordinarily be paid under prospective payment, but that is excluded because of participation in a state or area wide cost control program.  Also, a transfer payment is made where a patient is transferred to a hospital or hospital unit that has not been officially determined as being excluded from PPS and certain hospitals that are excluded from IPPS.  These include:    An acute care hospital that would otherwise be eligible to be paid under the IPPS, but does not have an agreement to participate in the Medicare program (Patient Discharge Status Code 02 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge  Status Code 82).
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 A critical access hospital (Patient Discharge Status Code 66 or  Planned Acute Care Hospital Readmission Patient Discharge Status Code 94).    C. - Postacute Care Transfers  (Previously Special 10 DRG Rule)   For discharges occurring on or after October 1, 1998, a discharge of a hospital inpatient is considered to be a transfer for purposes of this part when the patient's discharge is assigned, as described in 42 CFR 412.4(c) , to one of the qualifying Postacute MS -DRGs referenced in paragraph (D) of this section and the discharge is made under any of the following circumstances:    To a hospital or distinct part hospital unit excluded from the inpatient prospective payment system (under subpart B of 42 CRF 412).  Facilities excluded from IPPS are inpatient rehabilitation facilities and units (Patient Discharge Status Code 62 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 90), long term care hospitals (Patient Discharge Status Code 63 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 91), psychiatric hospitals and uni ts (Patient Discharge Status Code 65 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 93), childrens hospitals, and cancer hospitals (Patient Discharge Status Code 05 or Planned Acute Care Hospital Inpatient Readmission P atient Discharge Status Code 85).   To a skilled nursing facility (Patient Discharge Status Code 03 or Planned Acute Care Hospital Inpatient Readmission Patient Discharge Status Code 83).    To Hospice care at home (Patient Discharge Status Code 50) or Hospice Medical Facility (Certified) Providing Hospice Level of Care (Patient Discharge Status Code 51).   To home under a written plan of care for the provision of home health services from a home health agency and those services begin within 3 days after the date of discharge (Patient Discharge Status Code 06 or Planned Acute Care Hospital Inpatient Readmissi on Patient Discharge Status Code 86).
(Medicare Claims Processing Manual)
Specific transfer cases under this paragraph qualify for payment under an alternative methodology.  These include transfer cases in which the patients discharge is assigned, as described in 42 CFR 412.4(f)(2), (f)(5) and (f)(6), to one of the qualifying S pecial Pay MS -DRGs referenced in paragraph (D) of this section.  For these cases, the transferring hospital is paid 50 percent of the appropriate inpatient prospective payment rate and 50 percent of the appropriate transfer payment.  Medicares IPPS Postacute care transfer policy requires hospitals to apply the correct Patient Discharge Status Code to claims where patients receive Home Health (HH) services within 3 days of discharge. This includes the resumption of HH services in place prior to the inpatient s tay.  Medicares claims processing system reviews all line item dates of service on HH claims to determine if the Postacute care transfer payment policy should apply when any HH service dates are within 3 days after the IPPS discharge date.   In addition to the correct Patient Discharge Status Code, the IPPS hospital may add one of the following condition codes to the claim, as appropriate, to receive the full MS -DRG payment:    Condition Code 42 -  used if a patient is discharged to home with HH services, but the continuing care is not related to the condition or diagnosis for which the individual received inpatient hospital services.    Condition Code 43  used if the continuing care is related, but no HH services are furnished within 3 days of hospital discharge.   If an acute care hospital submits a bill based on its belief that it is discharging a patient to home or another setting not included in the Postacute care transfer policy but subsequently learns that Postacute care was provided, the hospital should submit  an adjusted bill.    D. - Qualifying MS -DRGs   Refer to Table 5 of the applicable Fiscal Year IPPS Federal Register for the list of qualifying Postacute MS -DRGs and Special Pay Postacute MS -DRGs.   40.2.5 - Repeat Admissions  (Rev. 2627, Issued 01- 04-13, Effective 10- 01-12, Implementation 10- 01-12)  A patient who requires follow -up care or elective surgery may be discharged and readmitted or may be placed on a leave of absence.