evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
A Medicare- dependent, small rural hospital (MDH) is a hospital that is paid under the Medicare hospital inpatient prospective payment system (IPPS) and meets the criteria for MDH status as specified at 42 CFR 412.108 (Title 42 of the Code of Federal Regula tions, Section 412.108  Special treatment:  Medicare -dependent, small rural hospitals).  A hospital may be designated as an MDH effective with cost reporting periods beginning on or after April 1, 1990, and ending on or before March 31, 1993, and for disch arges occurring on or after October 1, 1997, and before October 1, 2011.   C. - Payment to SCHs and MDHs   SCHs and MDHs are paid based on either the Federal rate or their hospital -specific (HSP) rate, whichever will result in the greatest payment.  The HSP rate is the hospitals rate based on their updated costs per discharge for a particular fiscal year (FY) as specified in statute.  Like all IPPS hospitals paid, SCHs and MDHs are paid for their discharges based on the diagnosis -related DRG classification and weights regardless of whether payment based on the Federal rate or the hospitals HSP rate results in the greatest payment.
(Medicare Claims Processing Manual)
SCHs will be paid based on their HSP rate for either FY 1982, 1987, 1996 (for cost reporting periods beginning on or after October 1, 2000) or 2006 (for cost reporting periods beginning on or after January 1, 2009) if this results in a greater payment than the Federal rate.  For more detail, see 42 CFR 412.92(d) and 42 CFR 412.73, 412.75, 412.77, and 412.78, respectively, for determining the HSP rates for FYs 1982, 1987, 1996 and 2006.  MDHs will be paid based on their HSP rate for either FY 1982, 1987, or 2002 (for cost reporting periods beginning on or after October 1, 2006) if this results in a greater payment than the Federal rate.  For more detail, see 42 CFR 412.108(c) and 42 CFR 412.73, 412.75, and 412.79, respectively, for determining the HSP rates for FYs 1982, 1987, and 2002.  In addition, qualifying SCHs and MDHs that experience a significant decrease in its number of discharges may receive an additional payment as specified at 42 CFR 412.92(e) and 42 CFR 412.108(d), respectively.  In general, the HSP rates for both SCHs and MDHs are updated annually.  The HSP rates are updated for inflation by the applicable market basket increase for each FY after the base period year, and are also adjusted by a budget neutrality factor to account for the annual DRG reclassification and recalibration for each year from FY 1993 forward, regardless of the year of the base period.  (For reference purposes, the budget neutrality adjustment factors are listed below at the end of this section.)  For the i nflation update, beginning FY 2005, if the hospital did not submit quality data, the market basket update is reduced by a percentage specified in statute for the applicable FY consistent with section 1886(b)(3)(B)(viii) of the Act.
(Medicare Claims Processing Manual)
Applicable Fiscal Year  Budget Neutrality Adjustment Factors  1993  0.999851  1994  0.999003  1995  0.998050  1996  0.999306  1997  0.998703  1998  0.997731  1999  0.998978  2000  0.997808  2001  0.997174  Applicable Fiscal Year  Budget Neutrality Adjustment Factors  2002  0.995821  2003  0.993111  2004  1.002608  2005  0.999876  2006  0.998993  2007  0.997395  2008  0.995743  2009  0.998795  2010  0.997941   D. - Claims Processing   The Qualifying DSH Percent uses the following provider type codes to enable Pricer to calculate the appropriate rates for these facilities:    14 for a MDH that is not an RRC;    15 for a MDH that is also an RRC;    16 for a rebased SCH that is not an RRC; and    17 for a rebased SCH that is also an RRC.   The A/B MAC (A) calculates the HSP rate and determines the greatest HSP rate (for SCHs, FY 1982, 1987, 1996 or 2006; for MDHs, FY 1982, 1987 or 2002).  Then the A/B MAC (A) updates the HSP rate to the applicable FY and enters that amount in the PPS Facility Specific Rate of the Provider -Specific File (PSF), for the applicable effective date.  The HSP rate is to be entered even if the Federal rate is expected to result in higher payments than the applicable HSP rate.  Preloading the applicable HSP rate befor e the effective date is acceptable as long as the correct effective date is used for the PSF record.  The A/B MAC (A) leaves the field blank if the hospital was not in operation during any of the applicable HSP base years.   Pricer will calculate the payment based on the higher of the Federal rate or the HSP rate.  Where the HSP rate is higher, Pricer reports the amount of the difference in the hospital -specific field.  The A/B MAC (A) carries this amount forward in the hospit al-specific payment field to its PS&R record for use at cost settlement.
(Medicare Claims Processing Manual)
20.7 - Billing Applicable to PPS  (Rev. 1, 10- 01-03)  20.7.1- Stays Prior to and Discharge After IPPS Implementation Date  (Rev. 1, 10- 01-03)  A3-3610.4, HO -415.7  When the admission is before the hospital's PPS effective date and the discharge is later than that date (transition claims), the Medicare payment for the period before PPS is on a reasonable cost basis and the payment for the period after PPS is on a DRG basis.  The hospital must submit two bills.  The first bill is for the period before the PPS effective date and is processed and paid in accordance with requirements in effect before the hospital's PPS effective date.  The second bill is processed under PPS but the amount of payment on the first bill is subtracted from it.  A/B MACs (A) make the adjustment by subtracting the interim payment from the prospective payment (before any deduction for deductible or coinsurance) for  the inpatient operating costs applicable to the days in the prior period.  The interim payment applicable to the prior period is adjusted to exclude estimated costs related to capital and direct medical education, kidney acquisition costs, and for bad debts for uncollectible deductible and coinsurance.  A/B MACs (A) will make an estimate if necessary.   For hospitals previously receiving interim payment on the basis of an average cost per diem or under PIP, the A/B MAC (A) determines and removes a per diem amount for the excluded costs for that period from the interim payments before reducing the prospect ive payment amount applicable to the discharge in the subsequent period under PPS.  Similarly, for hospitals that received a percentage of billed charges, the portion of the percentage applicable to the excluded cost items is removed.  The net percentage t o the charges billed in the prior period (cut -off bill) is applied.  The resulting amount is subtracted from the PPS payment applicable to the discharge in the subsequent period.   For transition claims, payment must not exceed the higher of what would have been paid under PPS including the outlier adjustment or  any earlier cost payment.  The final amount is not reduced to less than zero.  No further adjustments are appropriate.
(Medicare Claims Processing Manual)
For transition claims, payment must not exceed the higher of what would have been paid under PPS including the outlier adjustment or  any earlier cost payment.  The final amount is not reduced to less than zero.  No further adjustments are appropriate.   The interim payments used to reduce the prospective payment amounts are considered to represent fairly the inpatient operating costs incurred and fair payment for the portion of the stay occurring in the prior period.  Therefore, the adjustment is final an d not subject to further modification.  On bills covering two cost reporting periods:    Each bill includes charges and covered days that apply to the period covered.  The cut -off bill for the cost period is completed per Chapter 25.    The PPS bill contains principal diagnosis and surgical procedures for the entire stay.    The PPS bill shows the admission date, but the period covered begins with the first day of the new accounting year.    Where discharge is on the first day of the new accounting year, a PPS bill is still due.  Some payment may be due the provider, and the open admission must be closed on CMS' records.  There are no accommodation charges on the day of discharge; the hospital  will report ancillary charges for the day of discharge on the prior bill.    Coinsurance days and related amounts are applied separately to each bill, i.e., the proper deduction for coinsurance days reported on the second bill is taken from that bill.  20.7.2 - Split Bills (Rev. 1, 10- 01-03)  A3-3610.6, HO -415.9  Under PPS, split billing is not needed for cost reporting purposes; however, it is necessary to show on the bill the coinsurance days in each calendar year for proper application of the coinsurance amount.  For admissions prior to the cost reporting year under IPPS with a discharge after the beginning of the prospective payment year, the DRG payment for the discharge is reduced by the cost of services furnished in the prior period.   The hospital uses the day or charge statistics on the bill representing the portion of the stay in the prior period to determine the cost of the services furnished.  Split bills are not needed at the end of the government's fiscal year or the calendar year  as changes in DRG prices are determined by the date of discharge.  This is shown in value codes 09 (first year coinsurance) and 11 (second year coinsurance).  (See Chapter 25.)
(Medicare Claims Processing Manual)
PPS days on the cost report are allocated to the year of the discharge.  Hospitals not on IPPS, LTCHPPS, or IRFPPS continue to submit split bills at the end of their fiscal years and allocate the days to the hospital year in which they occurred.   When split billing applies, DRG payments are made only on bills that show a discharge date and status.  No DRG payment is made on PPS bills that show "still patient" status.   The hospital may not split a bill for the periods before and after the onset of capital PPS that fall into the same billing period.  Capital payment issued for an inpatient hospital stay that begins prior to and ends after the onset of capital PPS is the amount determined by Pricer for that DRG.  No reasonable cost capital pass through payment is payable for the portion of the stay that pre -dates capital PPS.   20.7.3 - Payment for Blood Clotting Factor Administered to Hemophilia Inpatients  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)
(Medicare Claims Processing Manual)
Section 6011 of Public Law (P.L.) 101- 239 amended 1886(a)(4)  of the Social Security Act (the Act) to provide that prospective payment system (PPS) hospitals receive an additional payment for the costs of administering blood clotting factor to Medicare hemophiliacs who are hospital inpatients.  Section 6011(b) of P.L. 101.239 specified that the payment be based on a predetermined price per unit of clotting factor multiplied by the number of units provided.  This add- on payment originally was effective for blood clotting factors furnished on or after June 19, 1990, and before December 19, 1991.  Section 13505 of P. L. 103- 66 amended 6011 (d) of P.L. 101- 239 to extend the period covered by the add- on payment for blood clotting factors administered to Medicare inpatients with hemophilia through September 30, 1994.  Sect ion 4452 of P.L. 105- 33 amended 6011(d) of P.L. 101- 239 to reinstate the add -on payment for the costs of administering blood- clotting factor to Medicare beneficiaries who have hemophilia and who are hospital inpatients for discharges occurring on or after  October 1, 1998.   A/B MACs (B) shall process non- institutional blood clotting factor claims.   The A/B MACs (A) shall process institutional blood clotting factor claims payable under either Part A or Part B.  A. - Inpatient Bills   Under the Inpatient Prospective Payment System (IPPS), hospitals receive a special add -on payment for the costs of furnishing blood clotting factors to Medicare beneficiaries with hemophilia, admitted as inpatients of PPS hospitals. The clotting factor add- on payment is calculated using the number of units (as defined in the HCPCS code long des criptor) billed by the provider under special instructions for units of service.
(Medicare Claims Processing Manual)
The PPS Pricer software does not calculate the payment amount. The Fiscal Intermediary Shared System (FISS) calculates the payment amount and subtracts the charges from those submitted to Pricer so that the clotting factor charges are not included in cost outlier computations.  Blood clotting factors not paid on a cost or PPS basis are priced as a drug/biological under the Medicare Part B Drug Pricing File effective for the specific date of service.  As of January 1, 2005, the average sales price (ASP) plus 6 percent shall be use d.  If a beneficiary is in a covered Part A stay in a PPS hospital, the clotting factors are paid in addition to the DRG/HIPPS payment (For FY 2004, this payment is based on 95 percent of average wholesale price.) For a SNF subject to SNF/PPS, the payment is bundled into the SNF/PPS rate.  For SNF inpatient Part A, there is no add- on payment for blood clotting factors.  The codes for blood- clotting factors are found on the Medicare Part B Drug Pricing File.  This file is distributed on a quarterly basis.  For discharges occurring on or after October 1, 2000, and before December 31, 2005, report HCPCS Q0187 based on 1 billing unit per 1.2 mg.  Effective January 1, 2006, HCPCS code J7189 replaces Q0187 and is defined as 1 billing unit per 1 microgram (mcg).   The examples below include the HCPCS code and indicate the dosage amount specified in the descriptor of that code. Facilities use the units field as a multiplier to arrive at the dosage amount.   EXAMPLE 1   HCPCS  Drug  Dosage  J7189  Factor VIIa  1 mcg   Actual dosage: 13,365 mcg  On the bill, the facility shows J7189 and 13,365 in the units field (13,365 mcg divided by 1 mcg = 13,365 units).  NOTE:   The process for dealing with one international unit (IU) is the same as the process of dealing with one microgram.   EXAMPLE 2   HCPCS  Drug  Dosage  J9355  Trastuzumab  10 mg   Actual dosage: 140 mg
(Medicare Claims Processing Manual)
EXAMPLE 2   HCPCS  Drug  Dosage  J9355  Trastuzumab  10 mg   Actual dosage: 140 mg   On the bill, the facility shows J9355 and 14 in the units field (140 mg divided by 10mg = 14 units).  When the dosage amount is greater than the amount indicated for the HCPCS code, the facility rounds up to determine units. When the dosage amount is less than the amount indicated for the HCPCS code, use 1 as the unit of measure.   EXAMPLE 3   HCPCS  Drug  Dosage  J3100  Tenecteplase  50 mg   Actual Dosage: 40 mg  The provider would bill for 1 unit, even though less than 1 full unit was furnished.  At times, the facility provides less than the amount provided in a single use vial and there is waste, i.e.; some drugs may be available only in packaged amounts that exceed the needs of an individual patient. Once the drug is reconstituted in the hospital s pharmacy, it may have a limited shelf life. Since an individual patient may receive less than the fully reconstituted amount, we encourage hospitals to schedule patients in such a way that the hospital can use the drug most efficiently. However, if the hospital must discard the remainder of a vial after administering part of it to a Medicare patient, the provider may bill for the amount of drug discarded plus the amount administered.  Example 1:   Drug X is available only in a 100- unit size. A hospital schedules three Medicare patients to receive drug X on the same day within the designated shelf life of the product. An appropriate hospital staff member administers 30 units to each patient.  The rem aining 10 units are billed to Medicare on the account of the last patient.  Therefore, 30 units are billed on behalf of the first patient seen and 30 units are billed on behalf of the second patient seen. Forty units are billed on behalf of the last patien t seen because the hospital had to discard 10 units at that point.   Example 2:   An appropriate hospital staff member must administer 30 units of drug X to a Medicare patient, and it is not practical to schedule another patient who requires the same drug. For example, the hospital has only one patient who requires drug X, or the hospital sees the patient for the first time and did not know the patients condition. The hospital bills for 100 units on behal f of the patient, and Medicare pays for 100 units.
(Medicare Claims Processing Manual)
When the number of units of blood clotting factor administered to hemophiliac inpatients exceeds 99,999, the hospital reports the excess as a second line for revenue code 0636 and repeats the HCPCS code.  One hundred thousand fifty (100,050) units are repo rted on one line as 99,999, and another line shows 1,051.   Revenue Code 0636 is used.  It requires HCPCS.  Some other inpatient drugs continue to be billed without HCPCS codes under pharmacy.   No changes in beneficiary notices are required.  Coverage is applicable to hospital Part A claims only.  Coverage is also applicable to inpatient Part B services in SNFs and all types of hospitals, including CAHs.  Separate payment is not made to SNFs for beneficiaries in an inpatient Part A stay.   B. - A/B MAC (A) Action   The contractor is responsible for the following:    It accepts HCPCS codes for inpatient services;    It edits to require HCPCS codes with Revenue Code 0636.  Multiple iterations of the revenue code are possible with the same or different HCPCS codes.  It does not edit units except to ensure a numeric value;    It reduces charges forwarded to Pricer by the charges for hemophilia clotting factors in revenue code 0636.  It retains the charges and revenue and HCPCS codes for CWF; and    It modifies data entry screens to accept HCPCS codes for hospital (including CAH) swing bed, and SNF inpatient claims (bill types 11X, 12X, 18x, 21x and, 22x).   The September 1, 1993, IPPS final rule (58 FR 46304) states that payment will be made for the blood clotting factor only if diagnosis code for hemophilia is included on the bill.  Inpatient blood- clotting factors are covered only for beneficiaries with hemophilia. One of the following hemophilia diagnosis codes must be reported on the claim for payment to be made for blood clotting factors.   Table 1 -  Effective for discharges September 1 1993 through the implementation of ICD -10
(Medicare Claims Processing Manual)
Table 1 -  Effective for discharges September 1 1993 through the implementation of ICD -10  ICD-9-CM code  Description  286.0  Congenital factor VIII disorder  286.1  Congenital factor IX disorder  286.2  Congenital factor XI deficiency  286.3  Congenital deficiency of other clotting factors  286.4  von Willebrands' disease   Table 2 -  Effective for discharges August 1, 2001 through the implementation of ICD -10, payment may be made if a diagnosis codes from either Table 1 or Table 2 is reported is reported:   ICD-9-CM code  Description  286.5  Hemorrhagic disorder due to intrinsic circulating anticoagulants (terminate effective September 30, 2011)  286.7  Acquired coagulation factor deficiency   Table 3 -  Effective for discharges on October 1, 2011, through the implementation of ICD -10 paymen t may be made if a diagnosis code from any of Table 1, Table 2 or Table 3 is reported:   ICD-9-CM code  Description  286.52  Acquired hemophilia  286.53  Antiphospholipid antibody with hemorrhagic disorder  286.59  Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors   Effective for discharges on or after the implementation of  ICD-10-CM, the following codes are applicable, and payment may be made for blood clotting factors only if a hemophilia code from the range D66 -  D68.4 is reported   A crosswalk of ICD 9 to ICD10 hemophilia diagnosis codes follows:
(Medicare Claims Processing Manual)
A crosswalk of ICD 9 to ICD10 hemophilia diagnosis codes follows:   ICD-9-CM Code  Description  ICD-10-CM Code  Description  286.0  Congenital factor VIII disorder  D66 Hereditary factor VIII deficiency  286.1  Congenital factor IX disorder  D67 Hereditary factor IX deficiency  286.2  Congenital factor XI deficiency  D68.1  Hereditary factor XI deficiency  286.3  Congenital deficiency of other clotting factors  D68.2  Hereditary deficiency of other clotting factors  286.4  von Willebrands' disease  D68.0  Von Willebrand's disease  286.5  Hemorrhagic disorder due to intrinsic circulating anticoagulants (terminate effective September 30, 2011)  N/A  286.52  Acquired hemophilia  D68.311  Acquired hemophilia  286.53  Antiphospholipid antibody with hemorrhagic disorder  D68.312  Antiphospholipid antibody with hemorrhagic disorder  286.59  Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors  D68.318  Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors  286.7  Acquired coagulation factor deficiency  D68.32  Antiphospholipid antibody with hemorrhagic disorder  286.7  Acquired coagulation factor deficiency  D68.4  Acquired coagulation factor deficiency   C. - Part A Remittance Advice  For remittance reporting PIP and/or non- PIP payments, the Hemophilia Add On is included in the overall claim payment (Provider Reimbursement, CLP04).    If an inpatient claim has a Hemophilia Add On payment, the payment to the provider is increased in the PLB segment with a PLB adjustment HM.  The Hemophilia Add On amount will always be included in the CLP04 Claim Payment Amount.
(Medicare Claims Processing Manual)
For remittance reporting PIP payments, the Hemophilia Add On will also be reported in the provider level adjustment (element identifier PLB) segment with the provider level adjustment reason code HM.  For remittances reporting PIP payments, the sum of inpa tient claims, CLP04, is backed out at PLB with PI/PA.  If an inpatient claim has a Hemophilia Add On payment, the payment to the provider is increased in the PLB segment with a PLB adjustment HM.   D. - Standard Hard Copy Remittance Advice   For paper remittances reporting non- PIP payments involving Hemophilia Add On, add a "Hemophilia Add On" category to the end of the "Pass Thru Amounts" listings in the "Summary" section of the paper remittance.  Enter the total of the Hemophilia Add On amounts due for the claims covered by this remittance next to the Hemophilia Add On heading.   The following reflects the remittance advice messages and associated codes that will appear when processing claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.  Group Code: OA  CARC: 94  RARC: MA103  MSN: N/A  This will be the full extent of Hemophilia Add On reporting on paper remittance notices; providers wishing more detailed information must subscribe to the Medicare Part A specifications for the ASC X12 835 remittance advice, where additional information is  available.   See chapter 22, for detailed instructions and definitions.   20.7.4 - Cost Outlier Bills With Benefits Exhausted  (Rev. 1, 10- 01-03)  PM -  A-99-17 (CR -749)  Providers under IPPS, LTCH PPS, and IRF PPS follow this scenario when benefits are exhausted.   The methodology for using benefit days and reimbursing cost outliers is based on the beneficiary having a lifetime reserve (LTR) benefit day which the beneficiary elects to use or a regular benefit (regular or coinsurance) day beginning the day after the day covered charges are incurred in an amount that results in a cost outlier payment for the provider.  Additional charges are considered covered for every day thereafter for which a beneficiary has, and elects to use, an available benefit day.