evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
 X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;    Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;    Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of  such devices;    Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patients physical condition;    Outpatient physical therapy, outpatient speech language pathology services, and outpatient occupational therapy (see Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 10, Covered Medical and Other Health Services, 220.1.4);    Screening mammography services;    Screening pap smears and pelvic exams;    Influenza, pneumococcal pneumonia, and hepatitis B vaccines;    Some colorectal screening;    Prostate screening;    Ambulance services;    Hemophilia clotting factors.
(Medicare Benefit Policy Manual)
 Influenza, pneumococcal pneumonia, and hepatitis B vaccines;    Some colorectal screening;    Prostate screening;    Ambulance services;    Hemophilia clotting factors.    Epoetin Alfa (EPO) for ESRD beneficiaries when given in conjunction with dialysis.   See Pub. 100- 04, Medicare Claims Processing Manual chapter 6, for information on billing for these services.  See 70.1 of this chapter for the conditions under which diagnostic services and radiological therapy furnished by SNFs are covered.  For coverage of total parenteral nutrition (TPN) and enteral nutrition (EN) as a prosthetic device, see Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, and the Medicare National Coverage Determinations Manual, chapter 1, Part 3, 180.2.  Rental or purchase of durable medical equipment from SNFs for use in the patients home (other than a hospital or SNF, as discussed in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, 110.1.D) is covered under Part B in accordance with the provisi ons of Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 80 (also see Pub. 100- 04, Medicare Claims Processing Manual, chapter 7, 60, for the related SNF billing instructions).  DME rendered to Part A inpati ents of a SNF is covered as part of the prospective payment system and is not separately payable.  For coverage of provider ambulance services, see Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B".  Drugs, biologicals, and blood are not covered under Part B when furnished by a SNF.   70.1 - Diagnostic Services and Radiological Therapy  (Rev. 1, 10- 01-03)  A3-3137.1, SNF -260.1
(Medicare Benefit Policy Manual)
70.1 - Diagnostic Services and Radiological Therapy  (Rev. 1, 10- 01-03)  A3-3137.1, SNF -260.1   Diagnostic x- ray and radiological therapy may be provided directly by a SNF if, as part of its compliance with the conditions of participation, the SNF has a radiological department, which meets the same standards required of a hospital furnishing such services under the program, or if the SNF meets the portable x- ray supplier standards.  Portable x -ray services provided by a SNF under arrangements are covered only if furnished by an approved supplier.  When a SNF furnishes laboratory services directly, it must have a Clinical Laboratory Improvement Act (CLIA) number or a CLIA certificate of waiver.  SNFs may bill for laboratory services rendered under arrangement for tests NOT on the CLIA waived list.   70.2 - Ambulance Service  (Rev. 1, 10- 01-03)  A3-3138, SNF -260.C   For requirements relating to provider ambulance service, see the Medicare Benefit Policy Manual, Chapter 10, Ambulance Services.   70.3 - Inpatient Physical Therapy, Occupational Therapy, and Speech -Language Pathology Services  (Rev. 37, Issued:  08 -12-05; Effective/Implementation:  09 -12-05)  Under Part A, physical therapy, occupational therapy, and speech pathology services are included in the SNF PPS rate for cost reporting periods beginning on or after July 1, 1998.  For inpatient Part B residents and outpatient services, payment for such se rvices is under a fee schedule.  The SNF must bill for physical therapy, occupational therapy, or speech -language pathology services for Part A residents beginning with its first cost reporting period that starts on or after July 1, 1998, and for Part B for services furnished on or after July 1, 1998.  The SNF (rather than an outside provider/supplier such as an approved clinic or rehabilitation agency, or a participating hospital) bills Medicare.  Payment is made directly to the SNF.  The patient is respon sible only for applicable Part A coinsurance or the Part B deductible and coinsurance amounts.  See also the Medicare Benefit Policy Manual, Chapter 1, Inpatient Hospital Services.
(Medicare Benefit Policy Manual)
70.4 - Services Furnished Under Arrangements With Providers  (Rev. 261, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  The SNF may arrange with others to furnish covered services such as physical therapy, occupational therapy, or speech- language pathology services. The SNF (rather than an outside provider/supplier, another SNF or a HHA) bills Medicare, and payment is made directly to the SNF. When such arrangements are made, SNF receipt of payment for the arranged services (as with services provided directly) relieves the beneficiary or any other person of further liability to pay for them. See Pub. 100- 01, Medicare General  Information, Eligibility, and Entitlement Manual, chapter 5, section 10.3, for a general discussion of services furnished under arrangements.   The specific details of the ensuing payment arrangement between the SNF and the outside supplier (such as the actual payment amount and timeframe) represent a private, marketplace transaction that is negotiated between the parties themselves and falls outside the purview of CMS. This means, for example, that payments by the SNF to an outside supplier for bundled services furnished to the SNFs Part A resident under an arrangement made with the outside supplier are not governed by the specific Medicare fee schedule amounts or claims processing timeframes that would apply to services billed to Medicare separately under Part B; however, in order for the arrangement itself to be valid, the SNF must, in fact, make payment to its supplier for services rendered. See Pub. 100-04, Medicare Claims Processing Manual, chapter 6, sections 10.4ff. for additional information on arrangements between SNFs and their suppliers.
(Medicare Benefit Policy Manual)
The arrangement must also comply with the fraud and abuse laws (see Pub. 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 1, section 20.3, and Pub. 100- 04, Medicare Claims Processing Manual, chapter 6, section 80.5). Quest ions about the interpretation and enforcement of the statutory anti -kickback provisions in section 1128B(b) of the Social Security Act should be directed to the attention of the Industry Guidance Branch in HHSs Office of the Inspector General (OIG); see the regulations at 42 CFR Part 1008 and the OIG website at https://oig.hhs.gov/compliance/advisory-opinions/index.asp.      Transmittals Issued for this Chapter
(Medicare Benefit Policy Manual)
Rev #  Issue Date  Subject  Impl Date  CR#  R12283BP  10/05/2023  Internet Only Manual Updates to Pub. 100-02 and 100-04 to Implement Consolidated Appropriations Act 2023 Changes for Skilled Nursing Facility (SNF)  01/08/2024  13271  R10880BP  08/06/2021  Internet Only Manual Updates to Pub. 100- 01, 100-02, and 100-04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF) 11/08/2021  12009  R261BP  10/04/2019  Manual Updates for CR11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) 11/05/2019  11454  R249BP  11/02/2018  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018 Q4) 12/04/2018  11004  R242BP  03/16/2018  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018) 06/19/2018  10512  R228BP  10/13/2016  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (SNF)  10/18/2016  9748 R227BP  09/16/2016  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (SNF)   Rescinded and replaced by Transmittal 228  10/18/2016  9748 R211BP  10/16/2015  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions (2015) 11/16/2015  9336 R204BP  03/13/2015  Updates to the Medicare Internet -Only Manual Chapters for Skilled Nursing Facility (SNF) Providers 06/15/2015  8997 R183BP  04/04/2014  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions  05/05/2014  8669 R182BP
(Medicare Benefit Policy Manual)
R183BP  04/04/2014  Internet Only Manual Updates to Pub. 100- 01, 100-02 and 100-04 to Correct Errors and Omissions  05/05/2014  8669 R182BP  03/21/1014  Implementing the Part B Inpatient Payment Policies from CMS -1599-F 04/21/2014  8666 R179BP  01/14/2014  Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius 01/07/2014  8458 R176BP  12/13/2013  Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius  Rescinded and replaced by Transmittal 179 01/07/2014  8458 R161BP  10/26/2012  Manual Updates to Clarify SNF Claims Processing  04/01/2013  8044 R155BP  04/20/2012  Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and Recertifications  02/13/2012  7701 R153BP  1/13/2012 Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and Recertifications  Rescinded and replaced by Transmittal 155 02/13/2012  7701 R89BP  05/16/2008  Medical and Other Health Services Furnished to SNF Patients  06/16/2008  5991 R73BP  06/29/2007  Coverage Requirements for Therapy Services Provided in a Skilled Nursing Facility 10/01/2007  5532 R58BP  11/09/2006  Swing Bed Hospital Updates 12/11/2006  5114 R57BP  11/08/2006  Clarification/Update to Chapter 8, Pub. 100-02 12/14/2006  4220 R54BP  09/15/2006  Clarification/Update to Chapter 8, Pub. 100-02 12/14/2006  4220 R40BP  11/18/2005  Skilled Nursing Facility Prospective Payment System  02/16/2006  4079 R37BP  08/12/2005  Conforming Changes for Change
(Medicare Benefit Policy Manual)
8, Pub. 100-02 12/14/2006  4220 R40BP  11/18/2005  Skilled Nursing Facility Prospective Payment System  02/16/2006  4079 R37BP  08/12/2005  Conforming Changes for Change Request 3648 to Pub. 100-02 09/12/2005  3912 R1BP  10/01/2003  Introduction to the Benefit Policy Manual N/A N/A Back to top of Chapter
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 9 - Coverage of Hospice Services Under  Hospital Insurance   Table of Contents  (Rev. 12385, Issued:  11-30-23)
(Medicare Benefit Policy Manual)
Transmittals for Chapter 9  10 - Requirements -  General  20 - Certification and Election Requirements  20.1 -  Timing and Content of Certification  20.2 -  Election, Revocation, and Discharge  20.2.1 -  Hospice Election  20.2.1.1  Hospice Election  Statement  20.2.1.2 Hospice Election Statement Addendum  20.2.1.3 Hospice Notice of Election  20.2.2 -  Hospice Revocation  20.2.3 -  Hospice Discharge 20.2.4- Hospice Notice of Termination or Revocation 20.3 -  Election by Skilled Nursing Facility (SNF) and Nursing Facilities (NFs) Residents and Dually Eligible Beneficiaries  20.4 -  Election by Managed Care Enrollees  30 - Coinsurance  30.1 -  Drugs and Biologicals Coinsurance  30.2 -  Respite Care Coinsurance  40 - Benefit Coverage  40.1 -  Covered Services  40.1.1 -  Nursing Care  40.1.2 -  Medical Social Services  40.1.3 -  Physicians' Services  40.1.3.1 -  Attending Physician Services  40.1.3.2 -  Nurse Practitioners as Attending Physicians  40.1.3.3 -  Physician Assistants as Attending Physicians  40.1.4 -  Counseling Services  40.1.5 -  Short -Term Inpatient Care  40.1.6 -  Medical Appliances and Supplies  40.1.7 -  Hospice Aide and Homemaker Services  40.1.8 -  Physical Therapy, Occupational Therapy, and Speech -Language Pathology 40.1.9 -  Other Items and Services  40.2 -  Special Services  40.2.1 -  Continuous Home Care (CHC)  40.2.2 -  Respite Care  40.2.3 -  Bereavement Counseling  40.2.4 -  Special Modalities  40.3 -  Contracting With Physicians  40.4 -  Core Services  40.4.1 -  Contracting for Core Services  40.4.1.1 -  Contracting for Highly Specialized Nursing Services  40.4.2 -  Waiver for Certain Core Staffing Requirements  40.4.2.1 -  Waiver for Certain Core Nursing Services  40.5 -  Non -Core Services  50 - Limitation on Liability for Certain Hospice Coverage Denials  60 - Provision of Hospice Services to Medicare/Veterans Eligible Beneficiaries  70  Hospice Contracts with An Entity for Services not Considered Hospice Services  70.1 -  Instructions for the Contractual Arrangement  80  Hospice Pre- Election Evaluation and Counseling Services
(Medicare Benefit Policy Manual)
60 - Provision of Hospice Services to Medicare/Veterans Eligible Beneficiaries  70  Hospice Contracts with An Entity for Services not Considered Hospice Services  70.1 -  Instructions for the Contractual Arrangement  80  Hospice Pre- Election Evaluation and Counseling Services  80.1  Documentation  80.2 -  Payment  90 - Caps and Limitations on Hospice Payments  90.1 -  Limitation on Payments for Inpatient Care  90.2 -  Aggregate Cap on Overall Reimbursement to Medicare- certified Hospices  90.2.1 -  New Hospices  90.2.2 -  Counting Beneficiaries for Calculation  90.2.3 -  Changing Aggregate Cap Calculation Methods  90.2.4 -  Other Issues  90.2.5 -  Updates to the Cap Amount  90.3 -  Administrative Appeals10 - Requirements - General  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)
(Medicare Benefit Policy Manual)
Hospice care is a benefit under the hospital insurance program.  To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill.  An individual is considered to be terminally ill if the medical prognosis is that the individuals life expectancy is 6 months or less if the illness runs its normal course.  Only care provided by (or under arrangements made by) a Medicare certified hospice is covered under the Medicare hospice benefit.   The hospice admits a patient only on the recommendation of the medical director in consultation with, or with input from, the patient's attending physician (if any).   In reaching a decision to certify that the patient is terminally ill, the hospice medical director must consider at least the following information:  (1) Diagnosis of the terminal condition of the patient. (2) Other health conditions, whether related or unrelated to the terminal condition.  (3) Current clinically relevant information supporting all diagnoses.
(Medicare Benefit Policy Manual)
Section 1814(a)(7)  of the Social Security Act (the Act) specifies that certification of terminal illness for hospice benefits shall be based on the clinical judgment of the hospice medical director or physician member of the interdisciplinary group (IDG) and the individual s attending physician, if he/she has one, regarding the normal course of the individuals illness.  No one other than a medical doctor or doctor of osteopathy can certify or re -certify a terminal illness.  Predicting of life expectancy is not always exact.   The fact that a beneficiary lives longer than expected in itself is not cause to terminate benefits. Attending physician is further defined in section 20.1 and 40.1.3.1.  An individual (or his authorized representative) must elect hospice care to receive it.  The first election is for a 90 -day period.  An individual may elect to receive Medicare coverage for two 90- day periods, and an unlimited number of 60- day periods.  If the individual (or authorized representative) elects to receive hospice care, he or she must file an election statement with a particular hospice.  Hospices obtain election statements from the individual and file a Notice of Election with the Medicare contractor, which transmits them to the Common Working File (CWF) in electronic format.  Once the initial election is processed, CWF maintains the beneficiary in hospice status unt il a final claim indicates a discharge (alive or due to death) or until an election termination is received.  For the duration of the election of hospice care, an individual must waive all rights to Medicare payments for the following services:    Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice); and    Any Medicare services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition, or services that are equivalent to hospice care, except for services provided by:   1.  The designated hospice (either directly or under arrangement);   2.  Another hospice under arrangements made by the designated hospice; or   3.  The individuals attending physician, who may be a nurse practitioner (NP) or a physician assistant (PA), if that physician, NP, or PA is not an employee of the designated hospice or receiving compensation from the hospice for those services.
(Medicare Benefit Policy Manual)
Medicare services for a condition completely unrelated to the terminal condition for which hospice was elected remain available to the patient if he or she is eligible for such care.   20 - Certification and Election Requirements  (Rev. 1, 10- 01-03) A3-3141, HO -204  20.1 - Timing and Content of Certification  (Rev. 246, Issued: 09- 14-18, Effective: 12 -17- 18, Implementation: 12- 17-18)  For the first 90 -day period of hospice coverage, the hospice must obtain, no later than 2 calendar days after hospice care is initiated, (that is, by the end of the third day), oral or written certification of the terminal illness by the medical director of the hospice or the physician member of the hospice IDG, and the individuals attending physician if the individual has an at tending physician.  No one other than a medical doctor or doctor of osteopathy can certify or re -certify an individual as terminally ill, meaning that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course.  Nurse practitioners and physician assistants cannot certify or re -certify an individual as terminally ill. In the event that a beneficiarys attending physician is a nurse practitioner or a physician assistant, the hospice medical director or the physician member of the hospice IDG certifies the individual as terminally ill.
(Medicare Benefit Policy Manual)
The attending physician is a doctor of medicine or osteopathy who is legally authorized to practice medicine or surgery by the state in which he or she performs that function, a nurse practitioner, or physician assistant, and is identified by the individua l, at the time he or she elects to receive hospice care, as having the most significant role in the determination and delivery of the individuals medical care.  A nurse practitioner is defined as a registered nurse who performs such services as legally au thorized to perform (in the state in which the services are performed) in accordance with State law (or State regulatory mechanism provided by State law) and who meets training, education, and experience requirements described in 42 CFR 410.75.  A PA is defined as a professional who has graduated from an accredited physician assistant educational program who performs such services as he or she is legally authorized to perform (in the State in which the services are performed) in accordance with  State law (or State regulatory mechanism provided by State law) and who meets the training, education, and experience requirements as the Secretary may prescribe.  The PA qualifications for eligibility for furnishing services under the Medicare program ca n be found in the regulations at 42 CFR 410.74 (c).   Note that a rural health clinic or federally qualified healthcare clinic (FQHC) physician can be the patients attending physician but may only bill for services as a physician under regular Part B rules.  These services would not be considered rural health clinic or FQHC services or claims (e.g., the physicians do not bill under the rural health clinic provider number but they bill under their own provider number) .  Initial certifications may be completed up to 15 days before hospice care is elected. Payment normally begins with the effective date of election, which is the same as the admission date.  If the physician forgets to date the certification, a notarized sta tement or some other acceptable documentation can be obtained to verify when the certification was obtained.
(Medicare Benefit Policy Manual)
For the subsequent periods, recertifications may be completed up to 15 days before the next benefit period begins.  For subsequent periods, the hospice must obtain, no later than 2 calendar days after the first day of each period, a written certification s tatement from the medical director of the hospice or the physician member of the hospices IDG.  If the hospice cannot obtain written certification within 2 calendar days, it must obtain oral certification within 2 calendar days.  When making an oral certi fication, the certifying physician(s) should state that the patient is terminally ill, with a prognosis of 6 months or less.  Because oral certifications are an interim step sometimes needed while all the necessary documentation for the written certification is gathered, it is not necessary for the physician to sign the oral certification.  Hospice staff must make an appropriate entry in the patient's medical record as soon as they receive an oral certification.  The hospice must obtain written certification of terminal illness for each benefit period, even if a single election continues in effect.  A written certification must be on file in the hospice patients record prior to submission of a claim to the Medicare contractor.  Clinical information and other documentation that support the medical prognosis must accompany the certification and must be  filed in the medical record with the written certification.  Initially, the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice's eligibility assessment.   A complete written certification must include:  1.  the statement that the individuals medical prognosis is that their life expectancy is 6 months or less if the terminal illness runs its normal course;   2.  specific clinical findings and other documentation supporting a life expectancy of 6 months or less;   3.  the signature(s) of the physician(s), the date signed, and the benefit period dates that the certification or recertification covers (for more on signature requirements, see Pub. 100- 08, Medicare Program Integrity Manual, chapter 3, section 3.3.2.4).