evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
All diagnostic services (including non- patien t laboratory tests) provided to a Medicare beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital) on the date of the beneficiarys inpatient admission or during the 3 calendar days (or, in the case of a non- subsection (d) hospital, 1 calendar day) immediately preceding the date of admission are required to be included on the Part A bill for the inpatient stay.   Outpatient non- diagnostic services that are related to an inpatient admission must be bundled with the Part A billing for the inpatient stay.  An outpatient service is related to the admission if it is clinically associated with the reason for a patients inpatient admission.  In accordance with section 102 of Pub. L. 111- 192, for services furnished on or after June 25, 2010, all outpatient non- diagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are de emed related to the admission, and thus, must be billed to Part A with the inpatient stay.  Also, outpatient non- diagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholl y operated by the hospital) on the first, second, and third calendar days for a subsection (d) hospital paid under the IPPS (first calendar day for non- subsection (d) hospitals) preceding the date of a beneficiarys inpatient admission are deemed related t o the admission, and thus, must be billed to Part A with the inpatient stay, unless the hospital attests to specific non -diagnostic services as being unrelated to the hospital claim (that is, the preadmission non- diagnostic services are clinically distinct  or independent from the reason for the beneficiarys admission).  Outpatient non- diagnostic services provided during the payment window that are unrelated to the admission, and are covered by Part B, may be separately billed to Part B.  The June 25, 2010 effective date of section 102 of Pub. L. 111- 192 applies to outpatient services provided on or after June 25, 2010.
(Medicare Claims Processing Manual)
In the event that there is no Part A coverage for the inpatient stay, the hospital may bill Part B for the services provided to the benefic iary prior to the point of inpatient admission (i.e., the time of formal  admission pursuant to the inpatient admission order) that would otherwise be included in the payment window for Part A payment, including services requiring an outpatient status.  Cer tain Part B inpatient services provided to the beneficiary after the point of inpatient admission (i.e., the time of formal admission pursuant to the inpatient admission order) may also be billed to Part B when Part A payment cannot be made.  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10 Medical and Other Health Services Furnished to Inpatients of Participating Hospital" for a full description of this policy.   A hospital may attest to specific non -diagnostic services as being unrelated to  the hospital Part A claim (that is, the preadmission non- diagnostic services are clinically distinct or independent from the reason for the beneficiarys admission) by adding a condition code 51 (definition 51 -  Attestation of Unrelated Outpatient Non-diagnostic Services) to the separately billed outpatient non- diagnostic services claim.  Providers may submit outpatient claims with condition code 51 starting April 1, 2011, for outpatient claims that have a date of service on or after June 25, 2010.  Outpatient claims with a date of service on or after June 25, 2010, that did not contain condition code 51 received prior to April 1, 2011, will need to be adjusted by the provider if they were rejected by FISS or CWF.   20 - Reporting Hospital Outpatient Services Using Healthcare Common Procedure Coding System (HCPCS)  (Rev. 1, 10- 03-03) A3-3626.4, HO -442.6  20.1 - General  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)
(Medicare Claims Processing Manual)
20.1 - General  (Rev. 1657, Issued: 12- 31-08, Effective: 01- 01-09, Implementation: 01- 05-09)  Reporting of HCPCS codes is required of acute care hospitals including those paid under alternate payment systems, e.g., Maryland, long -term care hospitals.  HCPCS codes are also required of rehabilitation hospitals, psychiatric hospitals, hospital -based RHCs, hospital -based FQHCs, and CAHs reimbursed under Method I I (HCPCS required to be billed for fee reimbursed services).  This also includes all -inclusive rate hospitals.  HCPCS includes the American Medical Associations Current Procedural Terminology, 4th Edition, (CPT -4) for physician services and CMS develope d codes for certain nonphysician services.  All of the CPT-4 is contained within HCPCS, and is identified as Level I CPT codes consist of five numeric characters.  The CMS developed codes are known as Level II.  Level II codes are five- character codes that  begin with an alpha character that is followed by either numeric or alpha characters.   Hospital -based and independent ESRD facilities must use HCPCS to bill for blood and blood products, and to bill for drugs and clinical laboratory services paid outside the composite rate.  In addition, the hospital is required to report modifiers as applicable and as described in 20.6.   The CAHs are required to report HCPCS only for Part B services not paid to them on a reasonable cost basis, e.g., screening mammographies and bone mass measurements.
(Medicare Claims Processing Manual)
The CAHs are required to report HCPCS only for Part B services not paid to them on a reasonable cost basis, e.g., screening mammographies and bone mass measurements.   The HCPCS codes are required for all outpatient hospital services unless specifically excepted in manual instructions.  This means that codes are required on surgery, radiology, other diagnosti c procedures, clinical diagnostic laboratory, durable medical equipment, orthotic -prosthetic devices, take -home surgical dressings, therapies, preventative services, immunosuppressive drugs, other covered drugs, and most other services.  When medical and s urgical supplies (other than prosthetic and orthotic devices as described in the Medicare Claims Processing Manual, Chapter 20, 10.1) described by HCPCS codes with status indicators other than H or N are provided incident to a physician's service by a hospital outpatient department, the HCPCS codes for these items should not be reported because these items represent supplies.  Claims containing charges for medical and surgical supplies used in providing hospital outpatient services are submitted to the  Medicare contractor providing OPPS payment for the services in which they are used.  The hospital should  include charges associated with these medical and surgical supplies on claims so their costs are incorporated in ratesetting, and payment for the supplies is packaged into payment for the associated procedures under the OPPS in accordance with 42 CFR 419.2(b)(4).   For example, if the hospital staff in the emergency department initiate the intravenous administration of a drug through an infusion pump des cribed by HCPCS code E0781 (Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient), complete the drug infusion, and discontinue use of the infusion pump before the patient leaves  the hospital outpatient department, HCPCS code E0781 should not be reported because the infusion pump was used as a supply and would be paid through OPPS payment for the drug administration service.  The hospital should include the charge associated with the infusion pump on the claim.
(Medicare Claims Processing Manual)
In another example, if hospital outpatient staff perform a surgical procedure on a patient in which temporary bladder catheterization is necessary and use a catheter described by HCPCS code A4338 (Indwelling catheter; Foley  type, two -way latex with coating (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each), the hospital should not report A4338 because the catheter was used as a supply and would be paid through OPPS payment for the surgical procedure.  The hospital should include the charge associated with the urinary catheter on the claim.   When hospital outpatient staff provide a prosthetic or orthotic device, and the HCPCS code that describes that device includes the fitting, adjustment, or other services necessary for the patients use of the item, the hospital should not bill a visit or procedure HCPCS code to report the charges associated with the fitting, adjustment, or other related services.  Instead, the HCPCS code for the device already includes the fitting, adjustment or other similar services.  For example, if the hospital outpatient staff provides the orthotic device described by HCPCS code L1830 (KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment), the hospital should only bill HCPCS code L1830 and should not bill a visit or procedure HCPCS code to describe the fitting and adjustment.  Claims with required HCPCS coding missing will be returned to the hospital for correction.   Future updates will be issued in a Recu rring Update Notification.   20.2 - Applicability of OPPS to Specific HCPCS Codes (Rev. 1536, Issued:  06- 19-08; Effective:  07- 01-08; Implementation: 07 -07-08)
(Medicare Claims Processing Manual)
20.2 - Applicability of OPPS to Specific HCPCS Codes (Rev. 1536, Issued:  06- 19-08; Effective:  07- 01-08; Implementation: 07 -07-08)  The CPT codes generally are created to describe and report physician services, but are also used by other providers/suppliers to describe and report services that they provide.  Therefore, the CPT code descriptors do not necessarily reflect the facility component of a service furnished by the hospital.  Some CPT code descriptors include reference to a physician performing a service.  For OPPS purposes, unless indicated otherwise, the usage of the term "physician" does not restrict the reporting of the code or application of related policies to physicians only, but applies to all practitioners, hos pitals, providers, or suppliers eligible to bill the relevant CPT codes pursuant to applicable portions of the Social Security Act (SSA) of 1965, the Code of Federal Regulations (CFR), and Medicare rules.  In cases where there are separate codes for the technical component, professional component, and/or complete procedure, hospitals should report the code that represents the technical component for their facility services.  If there is no separate technical component code for the service, hospitals should report the code that represents the complete procedure.  Tables describing the treatment of HCPCS codes for OPPS are published in the Federal Register annually.   20.3 - Line Item Dates of Service  (Rev. 1, 10- 03-03)  Where HCPCS is required a line item date of service is also required.  (FL 45 on Form CMS -1450).    The A/B MAC (A) will return claims to hospitals where a line item date of service is not entered for each HCPCS code reported or if the line item dates of service reported are outside of the statement-covers period.  20.4 - Reporting of Service Units  (Rev. 1, 10-03-03)  The definition of service units (FL 46 on the Form CMS-1450) where HCPCS code reporting is required is the number of times the service or procedure being reported was performed.  EXAMPLES:
(Medicare Claims Processing Manual)
If the following codes are performed once on a specific date of service, the entry in the service units field is as follows:  HCPCS Code  Service Units  90849 - Multiple -family group psychotherapy Units > 1 92265 - Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report Units > 1 95004 - Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, specify number of tests.  Units = no.  of tests performed 95861 - Needle electromyography two extremities with or without related paraspinal areas  Units > 1  6 Units > 83 min.  to < 98 min. 7 Units > 98 min.  to < 113 min. 8 Units > 113 min.  to < 128 min.  The pattern remains the same for treatment times in excess of two hours.  Hospitals should not bill for services performed for less than eight minutes.  The expectation (based on the work values for these codes) is that a providers time for each unit will average 15 minutes in length.  If hospitals have a practice of billing less than 15 minutes for a unit, their A/B MAC (A) will highlight these situations for review.   The above schedule of times is intended to provide assistance in rounding time into 15- minute increments.  It does not imply that any minute  until the eighth should be excluded from the total count as the timing of active treatment counted includes time.   The beginning and ending time of the treatment should be recorded in the patients medical record along with the note describing the treatme nt.  (The total length of the treatment to the minute could be recorded instead.)  If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time.  For example, if 24 minutes of code 97112 and 23 minutes of code 97110 were furnished, then the total treatment time was 47 minutes; so only 3 units can be billed for the treatment.  The correct coding is two units of code 97112 and one unit of code 97110, assigning more unit s to the service that took more time.
(Medicare Claims Processing Manual)
20.5 - Clarification of HCPCS Code to Revenue Code Reporting (Rev. 1487, Issued: 04- 08-08, Effective: 04-01-08, Implementation: 04-07-08)   Generally, CMS does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals assignment of cost vary. Where explicit instructions are not provided, providers should report their charges under the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.  20.6 - Use of Modifiers  (Rev. 1487, Issued: 04- 08-08, Effective: 04-01-08, Implementation: 04-07-08)  The Integrated Outpatient Code Editor (I/OCE) accepts all valid CPT and HCPCS modifiers on OPPS claims.  Definitions for the following modifiers may be found in the CPT and HCPCS guides:  Level I (CPT) Modifiers   -25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79, -91  Level II (HCPCS) Modifiers   -CA, -E1, -E2, -E3, -E4, - FA, - FB, - FC, -F1, -F2, -F3, -F4, -F5, -F6, -F7, -F8, -F9, - GA,  -GG, - GH, - GY, -GZ, -LC, -LD, - LT, - QL, - QM, - RC, - RT, - TA, -T1, -T2, -T3, -T4, -T5, - T6, -T7, -T8, - T9
(Medicare Claims Processing Manual)
As indicated in 20.6.2, modifier -50, while it may be used with diagnostic and radiology procedures as well as with surgical procedures, should be used to report bilateral procedures that are performed at the same operative session as a single line item.  Modifiers RT and LT are not used when modifier -50 applies.  A bilateral procedure is reported on one line using modifier -50.  Modifier - 50 applies to any bilateral procedure performed on both sides at the same session.  NOTE:  Use of modifiers applies to services/procedures performed on the same cal endar day.   Other valid modifiers that are used under other payment methods are still valid and should continue to be reported, e.g., those that are used to report outpatient rehabilitation and ambulance services.  Modifiers may be applied to surgical, radiology, and other diagnostic procedures.  Providers must use any applicable modifier where appropriate.  Providers do not use a modifier if the narrative definition of a code indicates multiple occurrences.  EXAMPLES:   The code definition indicates two to four lesions.  The code indicates multiple extremities.   Providers do not use a modifier if the narrative definition of a code indicates that the procedure applies to different body parts.   EXAMPLES:   Code 11600 (Excision malignant lesion, trunks, arms, or legs; lesion diameter 0.5 cm. or less)   Code 11640 (Excision malignant lesion, face, ears, eyelids, nose, lips; lesion diameter 0.5 cm. or less)  Modifiers - GN, - GO, and -GP must be used to identify the therapist performing speech language therapy, occupa tional therapy, and physical therapy respectively.   Modifier -50 (bilateral) applies to diagnostic, radiological, and surgical procedures.  Modifier -52 applies to radiological procedures.   Modifiers - 73, and - 74 apply only to certain diagnostic and surgic al procedures that require anesthesia.   Following are some general guidelines for using modifiers.  They are in the form of questions to be considered.  If the answer to any of the following questions is yes, it is appropriate to use the applicable modifie r.  1. Will the modifier add more information regarding the anatomic site of the procedure?   EXAMPLE:  Cataract surgery on the right or left eye.   2. Will the modifier help to eliminate the appearance of duplicate billing?
(Medicare Claims Processing Manual)
1. Will the modifier add more information regarding the anatomic site of the procedure?   EXAMPLE:  Cataract surgery on the right or left eye.   2. Will the modifier help to eliminate the appearance of duplicate billing?   EXAMPLES:  Use modifier 77 to re port the same procedure performed more than once on the same date of service but at different encounters.   Use modifier 25 to report significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.   Use modifier 58 to report staged or related procedure or service by the same physician during the postoperative period.   Use modifier 78 to report a return to the operating room for a related procedure during the postoperative period.  Use modifier 79 to report an unrelated procedure or service by the same physician during the postoperative period.  3. Would a modifier help to eliminate the appearance of unbundling?   EXAMPLE:  CPT codes 90765 (Intravenous infusion, for therapy, p rophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour) and 36000 (Introduction of needle or intra catheter, vein):  If procedure 36000 was performed for a reason other than as part of the IV infusion, modifier - 59 would be appropriate .  20.6.1 - Where to Report Modifiers on the Hospital Part B Claim  (Rev. 3019, Issued: 08- 07-14, Effective: 01- 01-12, ICD -10: Upon Implementation of ICD - 10, Implementation: 09 -08-14, ICD -10: Upon Implementation of ICD - 10)   Modifiers are reported on the hardcopy Form CMS -1450 with the HCPCS code.  See Chapter 25 of this manual for related instructions.  There is space for four modifiers on the hardcopy.   See the ASC X12 837 Institutional Claim implementation guide for instructions for reporting HCPCS modifiers when using the ASC X12 837 institutional claim format.    The dash that is often seen preceding a modifier should never be reported.
(Medicare Claims Processing Manual)
See the ASC X12 837 Institutional Claim implementation guide for instructions for reporting HCPCS modifiers when using the ASC X12 837 institutional claim format.    The dash that is often seen preceding a modifier should never be reported.   When it is appropriate to use a modifier, the most specific modifier should be used first.  That is, when modifiers  E1 through E4, FA through F9, LC, LD, RC, and TA through T9 apply, they should be used before modifiers LT, RT, or - 59.  20.6.2 - Use of Modifiers -50, -LT, and -RT (Rev. 1, 10- 03-03)   Modifier - 50 is used to report bilateral procedures that are performed at the same operative session as a single line item.  Do not use modifiers RT and LT when modifier - 50 applies.  Do not submit two line items to report a bilateral procedure using modifier - 50.  Modifier - 50 applies to any bilateral procedure performed on both sides at the same operative session.   The bilateral modifier -50 is restricted to operative sessions only.   Modifier - 50 may not be used:    To report surgical procedures identified by their terminology as bilateral, or   To report surgical procedures identified by their terminology as unilateral or bilateral.   The unit entry to use when modifier - 50 is reported is one.  20.6.3 - Modifiers -LT and -RT  (Rev. 1, 10- 03-03)  Modifiers - LT or -RT apply to codes, which identify procedures, which can be perf ormed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries.  Modifiers - LT and -RT should be used whenever a procedure is performed on only one side.  Hospitals use the appropriate - RT or - LT modifier to identify which of the paired or gans was operated upon.   These modifiers are required whenever they are appropriate.
(Medicare Claims Processing Manual)
These modifiers are required whenever they are appropriate.   20.6.4 - Use of Modifiers for Discontinued Services  (Rev. 4204, Issued: 01- 17-19, Effective: 01- 01-19, Implementation: 01- 07-19)  A. General  Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable to both outpatient hospital departments and to ambulatory surgical centers.   Modifier - 73 is used by the facility to indicate that a procedure requiring anesthesia was terminated due to extenuating circumstances or to circumstances that threatened the well bei ng of the patient after the patient had been prepared for the procedure (including procedural pre -medication when provided), and been taken to the room where the procedure was to be performed, but prior to administration of anesthesia. For purposes of bill ing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, or general anesthesia. This modifier code was created so that the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) could be recognized for payment even though the procedure was discontinued.
(Medicare Claims Processing Manual)
Modifier - 74 is  used by the facility to indicate that a procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circum stances that threatened the well being of the patient. This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of ane sthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep  sedation/analgesia, and general anesthesia. T his modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion.   Coinciding with the addition of the modifiers - 73 and - 74, modifiers - 52 and - 53 were revised. Modifier - 52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. The modifier provides a me ans for reporting reduced services without disturbing the identification of the basic service. Modifier - 53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services.  The elective cancellation o f a procedure should not be reported.