evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Payment for professional medical services furnished in a CAH to CAH outpatients is made by the A/B MAC (B)  on a fee schedule, charge, or other fee basis, as would apply if the services h ad been furnished in a hospital outpatient department. For purposes of CAH payment, professional medical services are defined as services provided by a physician or other practitioner, e.g., a physician assistant that could be billed directly to a A/B MAC (B)  under Part B of Medicare or a nurse practitioner that could be billed directly to a A/B MAC (B) under Part B of Medicare.   In general, payment for professional medical services, under the cost -based CAH payment plus professional services billed to the A/B MAC (B)  method should be made on the same basis as would apply if the services had been furnished in the outpatient departm ent of a hospital.   Bill type 85X is used for all outpatient services including services approved as ASC services. Non-patient laboratory specimens (those not meeting the criteria for reasonable cost payment in 250.6) will be billed on a 14X type of bill .   (See Section 250.6 -  Clinical Diagnostic Laboratory Tests Furnished by CAHs.)   250.1.1 - Special Instructions for Non -covered Time Increments in Standard Method Critical Access Hospitals (CAHs)  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Impleme ntation: 04 -05-10)  CAHs sometimes bill outpatient therapy services using HCPCS that by definition give specific time increments like those discussed in Chapter 5, sections 20 and 40.  However, standard method CAHs are not subject to payment on a fee basis  under the Medicare Physician Fee Schedule, therefore these CAHs should follow the instructions below if there is a need to bill non- covered increments.
(Medicare Claims Processing Manual)
When HCPCS codes required for reporting do not specify an increment of billing in their definition (i. e., 15 minute intervals), the unit for the line item is 1, and CAHs should follow the general instructions given for billing non- covered charges in Chapter 1, section 60, either by the line item or on no payment claims.  Several of the outpatient therapy H CPCS codes, however, are defined in specific time increments, and units reported on line items should be consistent with these definitions. In such cases, when both covered and non- covered increments are provided in the same visit on the same date of servi ce, CAHs should bill as follows:     Report covered and non- covered units in separate line items, even when part of the same visit, with one line item for all covered and non- covered increments in a visit, and another for all non- covered increments in that sa me visit;   Use ABN- related modifiers when appropriate to explain non- coverage and payment liability of specific lines (i.e., - GY, see Chapter 1, section 60 for details on these modifiers);    Do not report non- covered line items that are part of a partially covered service on a separate no payment claim (i.e., using condition code 21).  Instead, always report them on the same claim with the separate lines for the covered portion of the service. No payment claims received for the same date, same beneficiary, s ame provider and same therapy service as a for -payment claim will be rejected. A distinct reason code will make providers aware of the reason for the rejection, and they can correct their billing to have covered and non- covered portions of the same service on the same claim;    Do not report non- covered line items as part of the required reporting of value codes 50, 51 and 52 for covered visits (i.e., where all increments are non- covered and there are no covered charges for the line item, since these line items are either part of an already counted partially covered visit, or an entirely non -covered visit); and    Never split a single increment into a covered and non- covered portion.
(Medicare Claims Processing Manual)
 Never split a single increment into a covered and non- covered portion.   250.2 - Optional Method for Outpatient Services:  Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional Services  (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)  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  A CAH may elect to be paid for outpatient services in any cost reporting period under this method by filing a written election with the A/B MAC (A) on an annual basis at least 30 days before start of the Cost Reporting period to which the election applies.  An election of this payment method, once made for a cost reporting period, remains in effect for all of that period for the CAH.   Effective for cost reporting periods beginning on or after October 1, 2010 if a CAH elected the optional method for its most recent cost reporting period beginning before October 1, 2010 or chooses to elect the optional method on or after October 1, 2010, that election remains in place until it is terminated, an annual election is no longer required.  If a CAH elects the optional method on or after October 1, 2010, it must submit its request in writing to its A/B MAC (A) at least 30 days before the start of the first cost reporting period for which the election is effective.  That election will not terminate  unless the CAH submits a termination request to its A/B MAC (A) at least 30 days before the st art of its next cost reporting period.   The Medicare Prescription Drugs, Improvement, and Modernization Act (MMA) of 2003, changed the requirement that each practitioner rendering a service at a CAH that has elected the optional method, reassign their bill ing rights to that CAH.  This provision allows each practitioner to choose whether to reassign billing rights to the CAH or file claims for professional services through their A/B MAC (B).  The reassignment will remain in effect for that entire cost report ing period.
(Medicare Claims Processing Manual)
The individual practitioner must certify, using the Form CMS -855R, if he/she wishes to reassign their billing rights.  The CAH must then forward a copy of Form CMS -855R to the A/B MAC (A), and the A/B MACs (B) must have the practitioner sign a n attestation that clearly states that the practitioner will not bill the A/B MAC (A) or A/B MAC (B) for any services rendered at the CAH once the reassignment has been given to the CAH.  This attestation will remain at the CAH.   For CAHs that elected th e optional method before November 1, 2003, the provision is effective beginning on or after July 1, 2001.  For CAHs electing the optional method on or after November 1, 2003, the provision is effective for cost reporting periods beginning on or after July 1, 2004.  Under this election, a CAH will receive payment from their A/B MAC (A) for professional services furnished in that CAHs outpatient department. Professional services are those furnished by all licensed professionals who otherwise would be entitle d to bill the A/B MAC (B) under Part B.   Payment to the CAH for each outpatient visit (reassigned billing) will be the sum of the following:    For facility services, not including physician or other practitioner services, payment will be based on 101 percent of the reasonable costs of the services.  List the facility service(s) rendered to outpatients using the appropriate revenue code.  The A/B MAC will pay 101 percent of the reasonable costs for the outpatient services less applicable Part B deducti ble and coinsurance amounts, plus:    Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.   The A/B MAC (A) uses the Medicare Physician Fee Schedule (MPFS) amounts to pay for all the physician/nonphysician practitioner services rendered in a CAH that elected the optional method.  Payment is based on the lesser of the actual charge or the facili ty-specific MPFS amount less deductible and coinsurance times 1.15; and
(Medicare Claims Processing Manual)
 AK -  Service rendered in a CAH by a non -participating physician    For a non -participating physician service, a CAH must place modifier AK on the claim.  Payment is based on the lesser  of the actual charge or a reduced fee schedule amount of 95 percent. Payment is calculated as follows:    [(facility -specific MPFS amount times the non -participating physician reduction (0.95) minus (deductible and coinsurance] times 1.15.    GF -  Services rendered by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA)   GF - Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA).  (The GF modifier is not to be used for CRNA services.  If a claim is received and it has the GF modifier for certified registered nurse anesthetist (CRNA) services, the claim is returned to the provider.)  Also, while this national GF modifier inclu des CRNs, there is no benefit under Medicare law that authorizes payment to CRNs for their services.  Accordingly, if a claim is received and it has the GF modifier for CRN services, no Medicare payment should be made.   Services billed with the GF modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent.  Payment is calculated as follows:    [(facility -specific MPFS amount times the nonphysician practitioner services reduction (0.85) minus (deductible and c oinsurance)] times 1.15.   SB - Services rendered in a CAH by a certified nurse- midwife  For dates of service prior to January 1, 2011, certified nurse -midwife services billed with the SB modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 65 percent.  Payment is calculated as follows:   For dates of service on or after January 1, 2011, Medicare covers the services of a certified nurse- midwife.  The SB modifier is used to bill for the services and payment is based on the lesser of the actual charge or 100 percent of the MPFS.  MPFS Payme nt is calculated as follows :
(Medicare Claims Processing Manual)
 [(facility -specific MPFS amount) minus (deductible and coinsurance)] times 1.15.  AH -  Services rendered in a CAH by a clinical psychologist  Payment for the services of a clinical psychologist is based on the lesser of the actual charge or 100 percent of the MPFS.   Payment is calculated as follows:    [(facility -specific MPFS amount) minus (deductible and coinsurance)] times 1.15.    AE - Services rendered in a CAH by a nutrition professional/registered dietitian.  Services billed with the AE modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent. Payment is calculated as follows:    [(facility -specific MPFS amount times the registered dietitian reduction (0.85) minus (deductible and coinsurance)] times 1.15. Outpatient services, including ASC type services, rendered in an all- inclusive rate provider should be billed using the 85X type of bill (TOB).  Non- patient laboratory specimens are billed on TOB 14X.  MPFS rates contain ed in the HHH abstract file are used for payment of all physician/professional services rendered in a CAH that has elected the optional method.  If a HCPCS code has a facility rate and a non -facility rate, the facility rate is paid.  See Chapter 23 of Pub. 100-04, section 50.1 for the record layout for the HHH abstract file.  Physician Fee Schedule Payment Policy Indicator File   The information on the Physician Fee Schedule Payment Policy Indicator file is used to identify endoscopic base codes, payment policy indicators, global surgery indicators, diagnostic imaging family indicators, or the preoperative, intraoperative and postoperative percentages that are needed to determine if payment adjustment rules apply to a specific CPT code and the associated pricing modifier(s). See Chapter 12 of Pub. 100-04 for more information on payment policy indicators and payment adjustment rules.  See Chapter 23 of Pub. 100-04, section 50.6 for the record layout of the Payment Policy Indicator file.   Health Professional Shortage Area (HPSA) Incentive Payments for Physicians
(Medicare Claims Processing Manual)
Section 1833 (m) of the Social Security Act, provides incentive payments for physicians who furnish services in areas designated as HPSAs under section 332(a)(1)(A) of the Public Health Service (PHS) Act.  This statute recognizes geographic-based, primary medical care and mental health HPSAs, are areas for receiving a 10 percent bonus payment.  The Health Resources and Services Administration (HRSA), within the Department of Health & Human Services, is responsible for designating shortage areas.   Physicians, including psychiatrists, who provide covered professional services in a primary medical care HPSA, are entitled to an incentive payment.  In addition, psychiatrists furnishing services in mental health HPSAs are eligible to receive bonus payments.  The bonus is payable for psychiatric services furnished in either a primary care HPSA, or a mental health HPSA.  Dental HPSAs remain ineligible for the bonus payment.   Physicians providing services in either rural or urban HPSAs are eligible for a 10 percent incentive payment.  It is not enough for the physician merely to have his/ her office or primary service location in a HPSA, nor must the beneficiary reside in a HPSA, although, frequently, this will be the case.  The key to eligibility is where the service is actually provided (place of service).  For example, a physician providing a service in his/her office, the patients home, or in a hospital, qualifies for the incentive payment as long as the specific location of the service provision is within an area designed as a HPSA.  On the other hand, a physician may have an office in a HPSA, but go outside the office (and the designated HPSA area) to provide the service.  In this case, the physician would not be eligible for the incentive payment.
(Medicare Claims Processing Manual)
If the CAH electing the Optional Method (Method II) is located within a primary medical care HPSA, and/or mental health HPSA, the physicians providing (outpatient) professional services in the CAH are eligible for HPSA physician incentive payments. Therefore, payments to such a CAH for professional services of physicians in the outpatient de partment will be 115 percent times  the amount payable under fee schedule times  110 percent.  An approved Optional Method CAH that is located in a HPSA County should notify you of its HPSA designation in writing .  Once you receive the information, place an indicator on the provider file showing the effective date of the CAHs HPSA status. The CMS will furnish quarterly lists of mental health HPSAs to A/B MACs (A).   The HPSA incentive payment is 10 percent of the amount actually paid, not the approved amount.  Do not include the incentive payment in each claim.  Create a utility file so that you can run your paid claims file for a quarterly log.  From this log you will send a quarterly report to the CAHs for each physician payment, one month following the end of each quarter.  The sum of the 10% of line Reimbursement column should equal the payment sent along with the report to the CAH.  If any of the claims included on the report are adjusted, be sure the adjustment also goes to the report.  If an adjustment  request is received after the end of the quarter, any related adjustment by the A/B MACs (A) will be included on next quarters report.  The CAHs must be sure to keep adequate records to permit distribution of the HPSA bonus payment when received.  If an area is designated as both a mental health HPSA and a primary medical care HPSA, only one 10 percent bonus payment shall be made for a single service.   250.2.1 - Billing and Payment in a Physician Scarcity Area (PSA)  (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)
(Medicare Claims Processing Manual)
Section 413a of the MMA 2003 requires that a new 5 percent bonus payment be established for physicians in designated physician scarcity a reas.  The payment should be made on a quarterly basis and placed on the quarterly report that is now being produced for the HPSA bonus payments.  Section 1861(r)(1), of the Act, defines physicians as doctors of medicine or osteopathy.  Therefore, dentists , chiropractors, podiatrists, and optometrists are not eligible for the  physician scarcity bonus as either primary care or specialty physicians.  Only the primary care designations of general practice, family practice, internal medicine, and obstetrics/gyn ecology, will be paid the bonus for the ZIP codes designated as primary care scarcity areas.  All physician provider specialties are eligible for the specialty physician scarcity bonus except the following:  oral surgery (dentist only); chiropractic; optom etry; and podiatry.  The bonus is payable for dates of service January 1, 2005, through December 31, 2007.  T he Medicare, Medicaid, and State Childrens Health Insurance Program (SCHIP) Extension Act of 2007 amended 1833(u)(1) of the Social Security Act and has extended payment of that bonus through June 30, 2008.  One of the following modifier(s) must accompany the HCPCS code to indicate type of physician:   AG -  Primary Physician  AF - Specialty Physician   Modifiers AG and AF are not required for dates of service on or after January 1, 2005. Modifier AR, physician providing services in a physician scarcity area, may be required for claims with dates of service on or after January 1, 2005 to receive the PSA bonus. Refer to 250.2.2 of this chapter for more i nformation on when modifier AR is required.   There may be situations when a CAH is not located in a bonus area but its outpatient department is in a designated bonus area, or vice versa.  If a CAH has an off -site outpatient department/clinic the off -site d epartments complete address, including the ZIP code, must be placed on the claim as the service facility.  The FISS must look at the service facility ZIP code to determine if a bonus payment is due.
(Medicare Claims Processing Manual)
For electronic claims, the service facility address sho uld be in the 2310E loop of the ASC X12 837 institutional claim format.  On the hard copy Form CMS -1450  the address should be placed in Remarks; however, the ZIP code placement will be determined by the A/B MAC (A).   250.2.2 - Zip Code Files  (Rev. 2169, Issued: 03 -03-11, Effective: 04- 01-11, Implementation: 04- 04-11)  The CMS provided a file of ZIP Codes for the primary care and specialist care Physician Scarcity Area (PSA) bonus payment.  The file is effective for claims with dates of service January 1, 2005 through June 30, 2008. Prior to January 1, 2005, CMS posted on its Web site ZIP Codes that are eligible for the bonus payment.  Through regularly scheduled bulletins and list serves, A/B MACs (A) must notify the CAH to verify their ZIP Code eligibility via the CMS Web site.   ZIP Code files for the automated payment of the Health Professional Shortage Area (HPSA) bonus payment will be developed and updated annually.  Effective for claims with dates of service on or after January 1, 2009, only services provided in areas that are designated as of December 31 of the prior year are eligible for the HPSA bonus payment.   Physicians providing services in areas that were designated as of December 31 of the prior year but not on the automated file may use the AQ modifier.  Only services provided in areas that were designated as of December 31 of the prior year but not on the automated file may use the modifier.  Services provided in areas that are designated throughout the year will not be eligible for the HPSA bonus payment until the following year, provided they are still designated on December 31.  Services provided in areas that are de -designated throughout the year will continue to be eligible for the HPSA bonus through the end of the calendar year.  The cont ractors and standard systems will be provided with a file at the appropriate time prior to the beginning of the calendar year for which it is effective.  This file will contain ZIP Codes that fully and partially fall within a HPSA bonus area for both menta l health and primary care services.  A recurring update notification will be issued for each annual update.  Contractors will be informed of the availability of the file and the file name via an email notice.
(Medicare Claims Processing Manual)
Contractors will automatically pay bonuses for  services rendered in ZIP Code areas that: 1) fully fall within a designated primary care or mental health full county HPSA; 2) are considered to fully fall in the county based on a determination of dominance made by the United States Postal Service (USPS) ; or 3) are fully within a non-full county HPSA area.  Should a ZIP Code fall within both a primary care and mental health HPSA, only one bonus will be paid on the service.  Bonuses for mental health HPSAs will only be paid when performed by psychiatrists.  For services rendered in ZIP Code areas: 1) that do not fall within a designated full county HPSA; 2) are not considered to fall within the county based on a determination of dominance made by the USPS; or 3) are partially within a non-full county HPSA, the CAH must still submit a AQ modifier to receive payment for claims.  To determine whether a modifier is needed, the CAH must review the information provided on the CMS Web site for HPSA designations to determine if their location is, indeed, within a HPSA bonus area.  For service rendered in ZIP Code areas that cannot automatically receive the bonus, it will be necessary to know the census tract of the area to determine if a bonus should be paid and a modifier submitted. Census tract data can be retrieved by visiting the U.S. Census Bureau Web site at www.Census.gov.   Special Incentive Remittance for CAHS   A Special Incentive Remittance for CAHs is generated on a quarterly basis that identifies beneficiary and claims  information for which a HPSA, PSA, Primary Care Incentive Payment Program (PCIP) or HPSA Surgical Incentive Payment Program (HSIP) payment is being made. Since there is a possibility that more than one type of incentive payment may be paid for a single service, each type of incentive payment being made is identified on the remittance as follows:   1 = HPSA  2 = PSA  3 = HPSA and PSA  4 = HSIP  5 = HPSA and HSIP  6 = PCIP  7 = HPSA and PCIP  Space = Not Applicable   See sections 250.12 through 250.12.4 for more inf ormation on PCIP payments to CAHs paid under the optional method.