evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Certain inpatient CAH ancillary services are covered under Medicare Part B when coverage is no longer provided under Medicare Part A due t o benefits exhausted, the beneficiary is determined to be receiving a non -covered level of care, or is not eligible for Medicare Part A benefits. Chapter 4, 240 of Pub. 100- 04, Medicare Claims Processing Manual contains information on the physician servic es and the nonphysician medical and other health services covered under Medicare Part B when furnished by a participating IHS provider to an inpatient of the CAH, but only if payment for these services cannot be made under Medicare Part A.   The IHS CAHs ar e paid for covered inpatient Medicare Part B ancillary services based upon 101 percent of an all inclusive facility specific per diem rate that is established on a yearly basis from prior year cost report information. Medicare Part B deductible and coinsur ance amounts are applied to inpatient Medicare Part B ancillary services, but are waived by the IHS.   100.7.2.1 - A/B MAC (A) - CAH Ancillary Services - Medicare Part B - Claims Processing (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  All charges, except therapies, telehealth originating site facility fee , PPV, influenza virus and hepatitis B vaccines are combined and reported under revenue code 024X (all -inclusive ancillary) on TOB 12X (hospital inpatient Part B). The MSN is  suppressed.   See 100.10 and 100.11 of this chapter, for more information on the payment of vaccines and their administration and therapy services.   100.8 - A/B MAC (A) - CAH Swing -bed - Medicare Part A - Payment Policy (Rev. 1325; Issued:  08- 29-07; Eff ective:  01 -01-08; Implementation:  01 -07-08)
(Medicare Claims Processing Manual)
The IHS CAH swing -bed services are paid 101 per cent of an all inclusive facility specific per diem rate. Medicare Part A coinsurance is applied to IHS CAH swing -bed inpatient bills, but is waived by the IHS.   100.8.1 - A/B MAC (A) - CAH Swing-bed - Medicare Part A - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X (hospital swing -bed). Technical criteria for swing -bed admissions apply (i.e., 3 day qualifying hospital stay, 30 day transfer requirements, etc.) but CAH swing -bed providers are not required to report revenue code 0022 or HIPPS codes. The MSN is suppr essed.   For more information on the technical criteria for Medicare Part A coverage of SNF services see Chapter 8, 20 in Pub. 100- 02, Medicare Benefit Policy Manual.   100.8.2 - A/B MAC (A) - CAH Swing-bed - Inpatient Ancillary Claims - Medicare Part B - Payment Policy  (Rev. 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  The IHS CAHs are paid for covered inpatient Medicare Part B ancillary services based upon 101 percent of an all inclusive facility specific per diem rate that is  established on a yearly basis from prior year cost report information. Medicare Part B deductible and coinsurance amounts are applied to inpatient Medicare Part B ancillary services, but are waived by the IHS.   100.8.2.1 - A/B MAC (A) - CAH Swing -bed - Inpatient Ancillary Claims - Medicare Part B - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)
(Medicare Claims Processing Manual)
The IHS CAH swing -bed Medicare Part B inpatient ancillary bills revert to inpatient Medicare Part B ancillary bills  and are submitted under the regular hospital (or CAH) provider number (not the swing -bed provider number) with revenue code 0240 (all inclusive ancillary) on TOB 12X (inpatient Part B). The MSN is suppressed.  100.9 - A/B MAC (A) - CAH Outpatient - Medica re Part B - Payment Policy (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS CAHs are paid for covered outpatient services based on 101 percent of an all inclusive facility specific per visit rate that is established on a yearly basis from prior year cost report information for both facilities electing Standard Method I and Optional Method II billing.   For services provided in IHS CAHs, deductible and coinsurance amounts are applied by Medicare, but are waived by the IHS.   Third party payers may be billed for applicable deductible and coinsurance amounts.   See Chapter 4, 250.1 and 250.2 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on the payment of Method I and II CAH outpatient claims.  See  100.10 and 100.11 of this chapter, for more information on the payment of vaccines and their administration and therapeutic services.   100.9.1 - A/B MAC (A) - CAH Outpatient - Medicare Part B - Claims Processing  (Rev. 1776, Issued: 07- 24-09, Effective: 01- 01-09, Implementation: 01- 04-10)  All charges, except therapies, telehealth originating site facility fee , PPV, influenza virus vaccine, hepatitis B vaccine, and hospital -based ambulance services are combined and reported under revenue code 0510 (clinic  visit) on TOB 85X (CAH).   Non-patient lab specimens are billed on TOB 14X (hospital other).   The MSN is suppressed.
(Medicare Claims Processing Manual)
Non-patient lab specimens are billed on TOB 14X (hospital other).   The MSN is suppressed.   See Chapter18, 10 of Pub. 100- 04, Medicare Claims Processing Manual, for detailed billing instructions for vaccines. See Chapter 5 of Pub. 100- 04 for detailed billing instructions for therapy services. See Chapter15 of Pub. 100- 04 for detailed billing instructions for ambulance services.  100.9.1.1 - A/B MAC (A) - CAH Election of Method I or Method II (Rev. 1040, Issued: 08- 25-06, Effective : 09-11-06, Implementation: 09- 11-06)  See Chapter 4, 250 of Pub. 100- 04, Medicare Claims Processing Manual, for information on the election of Standard Method I or Optional Method II IHS CAH billing for professional services.   100.10 - A/B MAC (A) - Vacc ines and Vaccine Administration - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Effective January 1, 2006, IHS providers, including CAHs are paid separately from the AIR for certain vaccines and their administ ration. See Chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual for more information on the payment of PPV, influenza virus, and hepatitis B vaccines. The administration of vaccines is paid based on the MPFS.   The Medicare Part B deductible and co insurance does not apply to PPV and influenza vaccines. The Medicare Part B deductible and coinsurance are applied to the hepatitis B vaccine, but are waived by the IHS.   100.10.1 - A/B MAC (A) - Vaccines and Vaccine Administration - Claims Processing (Rev . 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  These vaccines are reported on TOB 12X, 13X, 83X, or 85X along with the appropriate revenue codes and HCPCS codes as found in billing instructions in Chapter 18, 10.2 of Pub. 100- 04, Medicare Claims Processing Manual.   No clinic visit shall be billed if vaccine and its administration are the only service received.  Vaccines and their administration may be billed with or without a clinic visit.   The MSN is suppressed.
(Medicare Claims Processing Manual)
No clinic visit shall be billed if vaccine and its administration are the only service received.  Vaccines and their administration may be billed with or without a clinic visit.   The MSN is suppressed.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs (TOB 83X).  All IHS ASC providers must submit their claims to the A/B MAC (B).   100.11 - A/B MAC (A) - Pulmonary Rehabilitation, Physical Therapy, Occupational Therapy, Speech -Language Pathology and Diagnostic Audiology Services -  Payment Policy  (Rev. 3897, Issued: 10- 27-17, Effective: 01- 01-10, Implementation: 04- 02-18)   Effective January 1, 2006, IHS providers are paid separately from the  AIR for physical therapy, OT, speech -language pathology and diagnostic audiology services. Payment for services to IHS providers on TOB 12X or 13X is made based on the MPFS. Payment for services to IHS CAHs on TOB 85X is made based on reasonable cost.  Effective January 1, 2010, IHS providers are paid separately from the AIR for Pulmonary Rehabilitation services. Payment for services to IHS providers on TOB 13X is made based on the MPFS. Payment for services to IHS CAHs on TOB 85X is made based on reasonabl e cost.  100.11.1 - A/B MAC (A) - Physical Therapy, Occupational Therapy, Speech -Language Pathology and Diagnostic Audiology Services - Claims Processing (Rev. 1325; Issued:  08- 29-07; Effective:  01- 01-08; Implementation:  01 -07-08)  Therapy services and d iagnostic audiology services are reported on TOB 12X, 13X, 83X or 85X using the appropriate revenue code and HCPCS codes.   No clinic visit shall be billed if a therapy service or a diagnostic audiology service is the only service received. These services m ay be billed with or without a clinic visit.   The MSN is suppressed.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims for IHS ASCs (TOB 83X). All IHS ASC providers must submit their claims to th e A/B MAC (B).
(Medicare Claims Processing Manual)
100.11.2 - A/B MAC (A)   Pulmonary Rehabilitation Services - Claims Processing  (Rev. 3897, Issued: 10- 27-17, Effective: 01- 01-10, Implementation: 04- 02-18)  Pulmonary Rehabilitation services are reported on TOB 13X or 85X using revenue code 948 and HCPCS code G0424.   No clinic visit shall be billed if a pulmonary rehabilitation service is the only service received. These services may be billed with or without a clinic visit.   The MSN is suppressed.   Note:   See Medicare Claims Processing Manual, Chapter 32  Billing R equirements for Special Services, Section 140.4 for additional billing instructions, frequency editing and limitations.   100.12 - A/B MAC - Ambulance Services  (Rev. 2102, Issued: 11- 19-10, Effective: 04- 01-11, Implementation: 04- 04-11)  Section 630 of the MMA allows for the reimbursement of ambulance services provided by IHS hospital -based ambulance providers, CAHs, and entities owned and operated by a CAH, for the 5 year period beginning January 1, 2005. Section 2902 of the Affordable Care Act indefinitely  extends Section 630 of the MMA, retroactive to January 1, 2010. Effective January 1, 2005, claims for ambulance services submitted by hospital -based ambulance providers and CAHs shall be processed by the designated A/B MAC.   All claims processing requirements in Chapter 15 of Pub. 100- 04, Medicare Claims Processing Manual, shall apply to ambulance service claims submitted by IHS hospital -based ambulance providers and ambulance service claims submitted by IHS CAHs.  100.12.1 - A/B MAC (A) - Outpatie nt Hospital -Based Ambulance Services - Medicare Part B - Payment Policy (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Medically necessary ambulance services submitted by hospital -based ambulance providers are reimbursed base d on the ambulance fee schedule.   The Medicare Part B deductible and coinsurance apply to ambulance services, but are waived by the IHS.
(Medicare Claims Processing Manual)
Medically necessary ambulance services submitted by hospital -based ambulance providers are reimbursed base d on the ambulance fee schedule.   The Medicare Part B deductible and coinsurance apply to ambulance services, but are waived by the IHS.   See Chapter 15, 30.2.4 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on the payment of ambulance claims.   100.12.1.1 - A/B MAC (A) - Outpatient Hospital -Based Ambulance Services - Medicare Part B - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Outpatient ambulance bills from hospital -based ambulance providers are submitted with revenue code 054X (ambulance) with charges for ambulance, as well as the appropriate ambulance HCPCS codes on TOB 12X or 13X.   If an outpatient encounter occurs at the same time a covered ambulance service is provided, the hospital -based ambulance providers may bill for a clinic visit (revenue code 051X) as well as the ambulance charges (revenue code 054X) and will be paid separately for each service.   The MSN is suppressed.   100.12.2 - A/B MAC (A)- CAH Ambulance Servi ces - Medicare Part B - Payment Policy  (Rev. 2102, Issued: 11- 19-10, Effective: 04- 01-11, Implementation: 04- 04-11)  For dates of service on or after December 21, 2000 and prior to January 1, 2004, medically necessary ambulance services provided by an IHS CAH or an entity that is owned and operated by the IHS CAH are paid based on 100 percent of the reasonable cost if the 35 mile rule for cost- based payment is met. In order for the 35 mile rule to be met, the IHS CAH or the entity that is owned and operated by the IHS CAH, must be the only provider or supplier of ambulance services that is located within a 35 mile drive of the IHS CAH or the entity. Those CAHs that meet the 35 mile rule for cost -based payment shall report condition code B2 (CAH ambulance att estation) on their bills.
(Medicare Claims Processing Manual)
For dates of service on or after January 1, 2004, ambulance services furnished by an IHS CAH or by an entity that is owned and operated by the IHS CAH are paid based on 101 percent of reasonable cost if the 35 mile rule for cost -based payment is met.   When the 35 mile rule for cost -based payment is not met, the ambulance services furnished by the IHS CAH or by the entity that is owned and operated by the IHS CAH are paid based on the ambulance fee schedule.   The IHS CAHs shall not ify the A/B MAC (A) whether the ambulance service meets or does not meet the 35 mile ambulance rule.   The Medicare Part B deductible and coinsurance apply to ambulance services, but are waived by the IHS.   See Chapter 15, 30.2.3 of Pub. 100- 04, Medicare C laims Processing Manual, for more information on the payment of ambulance claims.   100.12.2.1 - A/B MAC (A) - CAH Ambulance Services - Medicare Part B -Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Medically necessary ambulance services originating out of an IHS CAH with a hospital -based ambulance service are submitted with revenue code 054X (ambulance) with charges for ambulance, as well as the appropriate ambulance HCPCS codes on TOB 85X. IHS CAHs that meet the 35 mile rule for cost based payment shall report condition code B2 (CAH ambulance attestation) on their bills to the A/B MAC (A).   If an outpatient encounter occurs at the same time a covered ambulance service is provided, the IHS CAH may bil l for a clinic visit (revenue code 051X) as well as the ambulance charges (revenue code 054X) and will be paid separately for each service.   The MSN is suppressed.   100.12.3 - A/B MAC (A) - Ambulance Services - Medicare Part A - Payment Policy  (Rev. 1040, Issued: 08 -25-06, Effective: 09- 11-06, Implementation: 09- 11-06)
(Medicare Claims Processing Manual)
If an inpatient is transferred to another hospital for services under arrangement, the ambulance services are not billable to Medicare. Reimbursement for such services is part of the inpatie nt stay and payment is included in the IPPS payment based on the DRG.  100.13 - A/B MAC (A) - Other Screening and Preventive Services - Payment Policy  (Rev. 2075, Issued: 10- 28-10, Effective: 01- 01-10, Implementation: 01- 28-11)  Effective January 1, 2005, payment is made by the A/B MAC (A) based on the AIR to IHS providers, excluding CAHs, for screening and preventive services covered under 630 of the MMA, indefinitely extended by 2902 of the ACA.  Payment is made to CAHs based on cost. Screening and preventive services covered under 630 of the MMA, indefinitely extended by 2902 of the ACA, include:    Pelvic exam;   Glaucoma screening;   Bone mass measurements;   Prostate cancer screening;   Colorectal cancer screening;   Screening pap smear;   Screening mammography;   Cardiovascular screening blood tests;   Diabetes screening tests;   DSMT;   MNT;   Initial physician physical exam (IPPE) -  Welcome to Medicare; an d  Smoking and tobacco- use cessation (counseling/screening).   See Chapter 18, of Pub. 100- 04, Medicare Claims Processing Manual, for more information on screening and preventive services.   100.13.1 - A/B MAC (A) - Other Screening and Preventive Services - Claims Processing (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The screening and preventive services listed in 100.13 of this chapter are reported on TOB 12X, 13X, or 85X with revenue code 0510 (clinic visit).  Services for screening pap smears are only payable by the A/B MAC (A) when billed with a pelvic exam. Prostate cancer scr eening, cardiovascular screening blood tests and screening diabetes tests are only payable by the A/B MAC (A) when billed with a clinic visit.  Chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual contains more information on the payment of screening and preventive services.
(Medicare Claims Processing Manual)
100.13.2 - A/B MAC (A) - MNT - Payment Policy  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  Section 105 of BIPA permits Medicare coverage of MNT when furnished by a RD meeting certain requ irements. See Chapter 4, 300 through 300.6 of Pub. 100- 04, Medicare Claims Processing Manual, for more information on these requirements.  If the RD providing the services is either an IHS hospital employee or has contracted with an IHS hospital to provi de MNT services through the hospital outpatient department, the MNT services are to be provided in the hospital outpatient department or in a provider -based clinic. Payment is made by the A/B MAC (A) based upon the AIR.   Since hospital outpatient MNT servi ces provided by an RD are provided on hospital property under the auspices of the hospital, MNT services provided in the home do not fit the benefit as it is generally rendered when billing to the A/B MAC (A). The RD employed by an IHS hospital may not be paid for services provided in the beneficiarys home.  100.13.2.1 - A/B MAC (A) - MNT - Claims Processing  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The MNT services provided under the auspices of the hospital are reported to the designated A/B MAC (A) under revenue code 0510 (clinic visit). The current MNT HCPCS codes are required for the both the assessment and reassessment. The MSN is suppressed.   See Chapter 4, 300 through 300.6 of Pub. 100- 04, Medicare Claims  Processing Manual, for more information on the HCPCS codes used to bill MNT to the A/B MAC (A).  100.14 - A/B MAC (A) - Laboratory Services  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)
(Medicare Claims Processing Manual)
100.14 - A/B MAC (A) - Laboratory Services  (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)   Laboratory services furnished to IHS provider inpatients are combined with other inpatient services furnished and reported under revenue code 0100 (all -inclusive room and board plus ancillary) on TOB 11X. Payment is made for inpatient laboratory services under the PPS based upon DRGs.   Inpatient hospital laboratory ancillary services are covered under Medicare Part B when coverage is no longer provided under Medicare Part A.   The IHS providers are paid for covered inpatient hospital laboratory ancillary services based upon an AIR.  All i npatient ancillary charges are combined and reported under revenue code 024X (all -inclusive ancillary) on TOB 12X.    Laboratory services furnished to IHS provider inpatients under arrangements are combined with other inpatient services furnished and reporte d under revenue code 0100 (all -inclusive room and board plus ancillary) on TOB 11X. Payment is made for inpatient laboratory services under the IPPS based upon DRGs.   The term arrangements means arrangements that provide that Medicare payment made to the  provider that arranged for the services discharges the liability of the beneficiary or any other person to pay for those services. Medicare does not pay any provider or supplier other than the IHS provider for services furnished to a beneficiary who is an inpatient.    Charges for laboratory services furnished to outpatients of IHS providers are combined with all other outpatient charges for the same date of service and reported under revenue code 0510 (clinic visit) on TOB 13X (tribal hospitals and hospital -based clinics) Payment is made on the outpatient per visit AIR (OMB rate).    The IHS swing -bed facilities are paid according to the SNF PPS. SNF PPS payment includes payment for all medically necessary inpatient ancillaries, including laboratory services.  Revenue code 0022 and HIPPS codes are reported on the bill along with the accommodation and ancillary revenue codes. All services are itemized and billed with the appropriate revenue code that describes the service on TOB 18X.
(Medicare Claims Processing Manual)
 Charges for covered inpatie nt laboratory services provided in a CAH are combined with all other inpatient charges and reported under revenue code 0100 (all inclusive room and board plus ancillary) on TOB 11X. Payment is based on 101 percent of the all inclusive facility specific per  diem rate.    Inpatient CAH laboratory ancillary services are covered under Medicare Part B when coverage is unavailable under Medicare Part A.   Charges for inpatient CAH laboratory services are combined with charges for other inpatient ancillary services and reported under revenue code 024X (all -inclusive ancillary) on TOB 12X. Payment is based on 101 percent of an all -inclusive facility specific per diem rate.    Covered CAH outpatient laboratory service charges are combined with all other outpatient charges  for the date of service and reported under revenue code 0510 (clinic visit) on TOB 85X. Payment is based on 101 percent of the facility specific per visit rate.    Swing -bed laboratory service charges are combined with all other swing bed charges in IHS CAH s and are billed under revenue code 0100 (all -inclusive room and board plus ancillary) on TOB 18X. Payment is made on a cost based per diem amount.  100.15 - A/B MAC (A) - Drugs (Rev. 1040, Issued: 08- 25-06, Effective: 09- 11-06, Implementation: 09- 11-06)  The IHS providers, including CAHs, are paid by the A/B MAC (A) for covered drugs and biologicals provided during a covered inpatient hospital stay. All charges are combined and reported under revenue code 0100 (all -inclusive room and board plus ancillary) on TOB 11X. Payment is made to IHS/tribal hospitals under IPPS. IHS CAHs are paid 101 percent of the all inclusive facility specific per diem rate.