evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
NOTE:  The tables of APCs and devices to which the offset reductions apply, and the full and partial offset amounts, are available on the CMS Web site at: www.cms.hhs.gov/HospitalOutpatientPPS/.   61.4 - Billing and Payment for Brachytherapy Sources  (Rev. 1445, Issued:  02-08-08; Effective:  01-01- 08; Implementation:  03 -10-08)  61.4.1 - Billing for Brachytherapy Sources - General  (Rev. 2718, Issued: 06- 07-13, Effective: 07-01-13, Implementation: 07-01-13)  Brachytherapy sources (e.g., brachytherapy devices or seeds, solutions) are paid separately from the services to administer and deliver brachytherapy in the OPPS, per section 1833(t)(2)(H) of the Act, reflecting the number, isotope, and radioactive intensity of devices furnished, as well as stranded versus non-stranded configurations of sources.  Therefore, providers must bill for brachytherapy sources in addition to the brachytherapy services with which the sources are applied, in order to receive payment for the sources.  The separately payable sources are found in Addendum B of the most recent OPPS annual update published on the CMS web site.  New sources meeting the OPPS definition of a brachytherapy source may be add ed for payment beginning any quarter, and the new source codes and descriptors are announced in recurring update notifications.  Each unit of a billable source is identified by the unit measurement in the respective sources long descriptor.  Seed-like sources are generally billed and paid per source based on the number of units of the source HCPCS code reported, including the billing of the number of sources within a stranded configuration of sources.  Providers therefore must bill the number of units of a source used with the brachytherapy service rendered.  61.4.2 - Definition of Brachytherapy Source for Separate Payment   61.4.2 - Definition of Brachytherapy Source for Separate Payment   (Rev. 1445, Issued:  02-08-08; Effective:  01-01-08; Implementation :  03-10-08)
(Medicare Claims Processing Manual)
Brachytherapy sources eligible for separate billing and payment must be radioactive sources, meaning that the source contains a radioactive isotope.  Separate brachytherapy source payments reflect the number, isotope, and radioactive intensit y of sources furnished to patients, as well as stranded and non-stranded configurations.  61.4.3 - Billing of Brachytherapy Sources Ordered for a Specific Patient  (Rev. 1445, Issued:  02-08-08; Effective:  01-01- 08; Implementation:  03 -10-08)  A hospital may report and charge Medicare and the Medicare beneficiary for all brachytherapy sources that are ordered by the physician for a specific patient, acquired by the hospital, and used in the care of the patient.  Specifically, brachytherapy sources prescribed by the physician in accordance with high quality clinical care, acquired by the hospital, and actually implanted in the patient may be reported and charged.  In the case where most, but not all, prescribed sources are implanted in the patient, CMS will  consider the relatively few brachytherapy sources that were ordered but not implanted due to specific clinical considerations to be used in the care of the patient and billable to Medicare under the following circumstances.  The hospital may charge for all  sources if they were specifically acquired by the hospital for the particular patient according to a physicians prescription for the sources that was consistent with standard clinical practice and high quality brachytherapy treatment, in order to ensure that the clinically appropriate number of sources was available for the implantation procedure, and they were not implanted in any other patient.  Those sources that were not implanted must have been disposed of in accordance with all appropriate requireme nts for their handling.  In general, the number of sources used in the care of the patient but not implanted would not be expected to constitute more than a small fraction of the sources actually implanted in the patient.  Under these circumstances, the be neficiary is liable for the copayment for all the sources billed to Medicare.   61.4.4 - Billing for Brachytherapy Source Supervision, Handling and Loading Costs  (Rev. 1445, Issued:  02- 08-08; Effective:  01- 01-08; Implementation:  03 -10-08)  Providers should report charges related to supervision, handling, and loading of radiation sources, including brachytherapy sources, in one of two ways:
(Medicare Claims Processing Manual)
Providers should report charges related to supervision, handling, and loading of radiation sources, including brachytherapy sources, in one of two ways:   1. Report the charge separately using CPT code 77790 (Supervision, handling, loading of radiation source), in additi on to reporting the associated HCPCS procedure code(s) for application of the radiation source;   2. Include the supervision, handling, and/or loading charges as part of the charge reported with the HCPCS procedure code(s) for application of the radiation s ource.  Do not bill a separate charge for brachytherapy source storage costs. These costs are treated as part of the department's overhead costs.   61.4.5 - Payment for New Brachytherapy Sources  (Rev. 2718, Issued: 06- 07-13, Effective: 07- 01-13, Implementation: 07 -01-13)  Not otherwise specified (NOS) brachytherapy source codes are available for payment of new brachytherapy sources for which source codes have not yet been established: C2698 (Brachytherapy source, stranded, not otherwise specified, per source), and C2699 (Brachytherapy source, non -stranded, not otherwise specified, per source).  The payment rates for these NOS codes are based on a rate equal to the lowest stranded or non -stranded payment rate for such sources, respectively, on a per  source basis (as opposed, for example, to per mCi).  Once CMS establishes a new HCPCS code for a new source, the new code will be assigned to its own APC, with the payment rate set based on consideration of external data and other relevant information, until claims data are available for the standard OPPS rate making methodology.
(Medicare Claims Processing Manual)
61.5 - Billing for Intracoronary Stent Placement  (Rev. 2611, Issued: 12- 14-12, Effective: 01- 01-13, Implementation, 01- 07-13)   Since CY 2003, under the OPPS, we assign coronary stent placement procedures to separate APCs based on the use of nondrug -eluting or drug -eluting stents (APC 0104 (Transcatheter Placement of Intracoronary Stents) or APC 0656 (Transcatheter Placement of Intracoronary Drug -Eluting Stents), respectively).  I n order to effectuate this policy, we created HCPCS G -codes G0290 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and G0291 (Transcatheter placement  of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel) for drug -eluting intracoronary stent placement procedures that parallel existing CPT codes 92980 (Transcatheter pla cement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and 92981 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any  method; each additional vessel), which are used to describe nondrug- eluting intracoronary stent placement procedures. For CY 2012 and years prior, CPT codes 92980 and 92981 have been assigned to APC 0104, while HCPCS codes G0290 and G0291 have been assigned to APC 0656.   Effective January 1, 2013, the AMAs CPT Editorial Panel is deleting CPT codes 92980 and 92981 and replacing them with the following new CPT codes:    CPT code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)
(Medicare Claims Processing Manual)
 CPT code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)    CPT code 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));    CPT code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);    CPT code 92934 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));    CPT code 92937 (Percutaneous translumina l revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed;  single vessel);     CPT code 92938 (Perc utaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));    CPT code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary  artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);
(Medicare Claims Processing Manual)
 CPT code 92943 (Percutaneous transluminal revascularization of chronic total occlusion, coronary a rtery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty;  single vessel); and    CPT code 92944 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty;   each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary  procedure)).   In order to maintain the existing policy of differentiating payment for intracoronary stent placement procedures involving nondrug -eluting and drug -eluting stents, we are deleting HCPCS codes G0290 and G0291 and replacing them with the following new HCPCS C -codes to parallel the new CPT codes:    HCPCS code C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch);    HCPCS code C9601 (Perc utaneous transcatheter placement of drug -eluting intracoronary stent(s), with coronary angioplasty when performed;  each additional branch of a major coronary artery (List separately in addition to code for primary procedure));    HCPCS code C9602 (Percutane ous transluminal coronary atherectomy, with drug eluting intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);     HCPCS code C9603 (Percutaneous transluminal coronary atherectomy, with drug- eluting intracoron ary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));
(Medicare Claims Processing Manual)
 HCPCS code C9604 (Percutaneous transluminal revascularization of or through coronary arter y bypass graft (internal mammary, free arterial, venous), any combination of drug -eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);    HCPCS code C9605 (Percutaneous transluminal revasculari zation of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug -eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed;  each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));    HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass gr aft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);    HCPCS code C9607 (Percutaneous transluminal revascularization of chronic total occlusion, coronary art ery, coronary artery branch, or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty; single vessel); and    HCPCS code C9608 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty;  each additional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).
(Medicare Claims Processing Manual)
CPT codes 92928, 92933, 92929, 92934, 92937, 92938, 92941, 92943, and 92944 should be used to describe nondrug -eluting intracoronary stent placement procedures and are assigned to APC 0104.  HCPCS codes C9600, C9601, C9602, C9603, C9604, C9605, C9606, C9607, and C9608 are assigned to APC 0656.  70 - Transitional Corridor Payments  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)   The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) established transitional payments to limit providers losses under the OPPS; the additional payments are for 3 1/2 years for community mental health centers (CMHCs) and most hospitals, and permanent for cancer hospitals effective August 1, 2000.  Section 405 of BIPA provides that childrens hospitals described in 1886(d)(1)(B)(iii) are held harmless permanently for purposes of calculating TOP amounts, retroactive to August 1, 2000.  Some rural hospitals are also held harmless for several years after the implementation of the OPPS, as discussed in detail below.  Contractors determine TOPs eligibility and calculate interim TOPs.   Beginning September 1, 2000, and every month thereafter until further notice, the shared system maintainers must provide contractors with software that gathers all data required to calculate a TOP amount for each hospital and CMHC.  The software must calculate and pay the TOP amount for OPPS services on claims processed during the preceding month, maintain an audit trail (including the ability to generate a hardcopy report) of these TOP amounts, and transfer to the PS&R system any necessary data.  TOP amounts should be paid before the next month begins and they are not subject to normal payment floor requirements.  Several items contained in the Inpatient or Outpatient Provider Specific File (IPSF or OPSF) are needed to determine TOP eligibility for each hospital or CMHC.  They are:    The provider number;   Fiscal year begin date;    The provider type;   Actual geographic location - CBSA  (from the IPSF);
(Medicare Claims Processing Manual)
 The provider number;   Fiscal year begin date;    The provider type;   Actual geographic location - CBSA  (from the IPSF);    Wage index location - CBSA  (from the IPSF); and    Bed size (from the IPSF)   Pursuant to 403 of BIPA, a TOP may be made to hospitals and CMHCs that did not file a cost repo rt for the cost reporting period ending in calendar year 1996.  The law was amended to provide that if a hospital did not file a cost report for a cost reporting period ending in calendar year 1996, the payment- to-cost ratio used in calculating a TOP will be based on the hospitals first cost report for a period ending after calendar year 1996 and before calendar year 2001.  This provision is effective retroactively to August 1, 2000.  Future updates will be issued in a Recurring Update Notification.  70.1 - Transitional Outpatient Payments (TOPs) for CY 2000 and CY 2001   (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effective for services provided between August 1, 2000, and December 31, 2001.   Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the total charges to cost by multiplying them by the outpatient cost to charge ratio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all APCs, as well as all outlier payments and transitional pass-through payments for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result  of step 1, go to step 9.  No transitional payment is due this month.
(Medicare Claims Processing Manual)
Step 3 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital, go to step 4.  If any other type of hospital, divide the resu lt of step 2 by the result of step 1, skip step 4 and perform step 5, 6, 7, or 8 as appropriate.   Step 4 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital, subtract the result of step 2 from  the result of step 1 and pay .85 times this amount.  Do not perform steps 5- 8.  Step 5 -  If the result of step 3 is equal to or greater than .9 but less than 1.0, subtract the result of step 2 from the result of step 1, and multiply the difference by .8 a nd pay .85 times this amount.   Step 6 -  If the result of step 3 is equal to or greater than .8 but less than .9, subtract .7 times the result of step 2 from .71 times the result of step 1, and pay .85 times this amount.  Step 7 -  If the result of step 3 is  equal to or greater than .7 but less than .8, subtract .6 times the result of step 2 from .63 times the result of step 1, and pay .85 times this amount.  Step 8 -  If the result of step 3 is less than .7, multiply the result of step 1 by .21 and pay .85 ti mes this amount.   Step 9 -  When the result of step 2 is greater than the result of step 1 for the final month of a providers cost report period, do nothing more.  When the result of step 2 is greater than the result of step 1 for any other month, store al l step 1 and step 2 totals and include these totals with the totals for the next months TOP calculation.    70.2 - Transitional Outpatient Payments (TOPs) for CY 2002 (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)
(Medicare Claims Processing Manual)
For services  provided during calendar years 2002, TOPs were gradually reduced for all providers except those hospitals that receive hold harmless TOPs (cancer hospitals, childrens hospitals, and rural hospitals having 100 or fewer beds).  To avoid TOP overpayments, c ontractors were instructed to revise the monthly interim TOP calculations to reflect the new calculation.   Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effective for services provided between January 1, 2002, and December 31, 2002.   Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the total charges to cost by mu ltiplying them by the outpatient cost- to- charge ratio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all  APCs, as well as all outlier payments and transitional pass-through payments for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result of step 1, go to step 8.  No transitional payment is due this month.   Step 3 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital go to step 4.  If any other type of hospital, divide the result of step 2 by the result of s tep 1, skip step 4 and perform steps 5, 6, or 7 as appropriate.   Step 4 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital, subtract the result of step 2 from the result of step 1 and pay .85 times this amount.  Do not perform steps 5- 7.  Step 5 -  If the result of step 3 is equal to or greater than  .9 but less than 1.0, subtract the result of step 2 from the result of step 1, and multiply the difference by .7 and pay .85 times this amount.
(Medicare Claims Processing Manual)
Step 6 -  If the result of step 3 is equal to or greater than  .8 but less than .9, subtract .6 times the result of step 2 from .61 times the result of step 1, and pay .85 times this amount.  Step 7 -  If the result of step 3 is less than .8, multiply the res ult of step 1 by .13 and pay .85 times this amount.   Step 8 -  When the result of step 2 is greater than the result of step 1 for the final month of a providers cost report period, do nothing more.  When the result of step 2 is greater than the result of s tep 1 for any other month, store all step 1 and step 2 totals and include these totals with the totals for the next months TOP calculation.   70.3 - Transitional Outpatient Payments (TOPs) for CY 2003 (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Impl ementation: 01 -05-09)  For services provided during calendar years 2003, TOPs continued to decrease for all providers except those hospitals that receive hold harmless TOPs (cancer hospitals, childrens hospitals, and rural hospitals having 100 or fewer be ds).  To avoid TOP overpayments, contractors were instructed to revise the monthly interim TOP calculations to reflect the new calculation.   Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effe ctive for services provided between January 1, 2003, and December 31, 2003.   Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the  total charges to cost by multiplying them by the outpatient cost to charge ratio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all APCs, as well as all outlier payments and transitional pass-through payments for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result of  step 1, go to step 7.  No transitional payment is due this month.