evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Indian Health Service hospitals continue to bill  for surgeries utilizing bill type 83X.  For other hospitals outpatient surgery subject to the ASC payment limit with dates of service prior to August 1, 2000, is reported on bill type 83X, and surgeries performed August 1, 2000 and later are reported with bill type 13X.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims on TOB 83X for ASCs.  All IHS ASC providers must submit their claims to the designated A/B MAC (B).    180.2 - Selecting and Report ing Procedure Codes  (Rev. 1, 10- 03-03) A-01-50, A3- 3626.4.B.3   Using medical records as basic sources, hospitals report HCPCS surgical procedure codes for outpatient surgery in FL 44 adjacent to the revenue code for the operating room or other room used fo r the surgery.  The bill includes the hospitals charges for the surgery as well as all other services provided on the day the procedure was performed.  When multiple surgical procedures are performed at the same session, it is not necessary to bill separa te charges for each procedure.  It is acceptable to bill a single charge under the revenue code that describes where the procedure was performed (e.g., operating room, treatment room, etc.) on the same line as one of the surgical procedure CPT/HCPCS codes and bill the other procedures using the appropriate CPT/HCPCS code and the same revenue code, but with 0 charges in the charge field.   In the past, some hospitals billed a single emergency room (ER) visit charge, which included charges for any surgical procedures that were performed in the ER at the time of the ER visit.  Under the OPPS, CMS requires hospitals to bill a separate charge for ER visits and surgical procedures effective with claims with dates of service on or after July 1, 2001.  If a surgica l procedure is performed in the ER, the charge for the procedure must be billed with the emergency room revenue code.  If an ER visit occurs on the same day, a charge should be billed for the ER visit and a separate charge should be billed for the surgical  procedure(s) performed.  As described above, a single charge may be billed for all surgical procedures if more than one is performed in the ER during the same session.
(Medicare Claims Processing Manual)
EXAMPLE:  The following is an example of how a claim should be completed under these r eporting requirements:   Date of  Service  Revenue  Code  HCPCS  Modifier Charges  7/5/2001 0450 99283 25 $150 7/5/2001 0450 12011  $300 7/5/2001 0450 12035   7/5/2001 0250   $70 7/5/2001 0270   $85  The charge for both surgical procedures in this example  is reflected in the $300 charge shown on the line with procedure code 12011.    180.3 - Unlisted Service or Procedure  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)
(Medicare Claims Processing Manual)
180.3 - Unlisted Service or Procedure  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)   An unlisted HCPCS code represents an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code.  The CPT code book lists a number of unlisted service or procedure codes, which can be found at the end of a section or subsection.  Alternatively, a summary list of the unlisted C PT codes can be found in the Guidelines section for each chapter of the CPT code book.  The long descriptors for these codes start with the term Unlisted and the last 2 digits of the codes often end in 99.  Under the OPPS, CMS generally assigns the unlisted service or procedure codes to the lowest level APC within the most appropriate clinically related series of APCs.  Payment for items reported with unlisted codes is often packaged.  For non-OPPS payment purposes, when an unlisted service or procedure code is reported, a report describing the service or procedure shall be submitted with the claim.  Pertinent information includes a definition or description of the nature, extent, and need for the procedure or service, as well as the providers time, effort, and equipment necessary to provide the service.  When a Medicare contractor receives a claim with an unlisted HCPCS code for non -OPPS payment, the contractor shall verify that no existing HCPCS code adequately describes the procedure or service.  U nlisted codes should be reported only if no other specific HCPCS codes adequately describe the procedure or service.  If an unlisted code is submitted on a claim and the contractor has verified that the code submitted is correct, the contractor pays the cl aim using the unlisted code, based on the applicable non- OPPS payment methodology.  However, if it is determined that an unlisted code was submitted in error because the procedure or service is described by a specific HCPCS code, the contractor shall advis e the hospital or CAH of the appropriate code and process the claim.  If a procedure or service reported with an unlisted code is reported frequently, the contractor shall advise the provider that a request for a specific CPT code or alphanumeric HCPCS cod e should be made.
(Medicare Claims Processing Manual)
The latest list of Unlisted CPT codes for procedures and services can be found at http://www.cms.hhs.gov/HospitalOutpatientPPS/.  Select Annual Policy Files from the box at the left, then select the applicable year, and scroll down to Related Links.  Select CYXXXX Unlisted CPT Codes.   Medicare contractors shall review this list once a year since it is updated annually on or about January 1 of the calendar year.  Future updates will be issued in a Recurring Update Notification.  180.4 - Proper Reporting of Condition Code G0 (Zero)  (Rev. 1, 10-03-03)   Hospitals subject to OPPS report Condition Code G0 on FLs 24- 30 (or the corresponding electronic location) when multiple medical visits occurred on the same day in the same revenue center but the visits were distinct and constituted independent visits.  An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broke n arm and later for chest pain.   Multiple medical visits on the same day in the same revenue center may be submitted on separate claims.  Hospitals should report condition code G0 on the second claim.  Appropriate reporting of Condition Code G0 allows for accurate payment under OPPS in this situation.  The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.   To further illustrate, the following table describes ac tions the OCE takes when multiple medical visits occur on the same day in the same revenue code center:   Evaluation and Management (E&M)  Revenue Center  Condition Code  OCE Action  2 or more  Two or more E&M codes have the same revenue center  No G0  Assign medical APC to each line item with E&M code and deny all line items with E&M code except the line item with the highest APC payment  2 or more  Two or more E&M codes have the same revenue center  G0 Assign medical APC to each line item with E&M code.   180.5 - Proper Reporting of Condition Codes 20 and 21  (Rev. 1, 10- 03-03)  Hospitals and CMHCs report condition codes 20 and 21 when they realize the services are excluded from coverage but:
(Medicare Claims Processing Manual)
180.5 - Proper Reporting of Condition Codes 20 and 21  (Rev. 1, 10- 03-03)  Hospitals and CMHCs report condition codes 20 and 21 when they realize the services are excluded from coverage but:    The beneficiary has requested a formal determination (condition code 20) (claim may contain both covered and noncovered charges); or    The provider is requesting a denial notice from Medicare to bill Medicaid or other insurers (condition code 21).  The A/B MACs (A) advise hospitals and CMHCs when billing condition code 21 that a separate claim must be submitted.  Claims with condition code 21 must be submitted with all noncovered charges.    180.6 - Emergency Room (ER) Services That Span Multiple Service Dates (Rev. 2361, Issued: 11- 25-11, Effective: 01- 01-12 and 04- 01-12, Implementation; 04 -02-12)  Emergency room (ER) services provided by hospital outpatient departments (OPPS & Non-OPPS) should be billed in the following manner:    Emergency room services are reported under the 045x revenue code    The line item date of service  for the ER encounter is the date the patient entered the ER even if the patients encounter spans multiple service dates    For all other services related to the ER encounter (i.e., lab, radiology, etc) the line item date of service reported is the date the service was actually rendered   Note:  For patients in a Skilled Nursing Facility (SNF) see Chapter 6, Section 20.1.2.2 Emergency Services for special billing instructions using the ET modifier.  Chapter 6, Section 20.1.2.2 applies to hospital ER services spanning multiple service dates that are provided to patients in a Part A SNF stay and related CWF SNF consolidated billing edits.   For patients with end stage renal disease (ESRD) see Chapter 8, Section 50.1.6 for billing instructions requiring the use of  the ET modifier.  Chapter 8, Section 50.1.6 applies to hospital ER services spanning multiple service dates including laboratory services.   180.7 - Inpatient -only Services                                                           (Rev. 4513, Issued: 02- 04-2020, Effective: 01- 01- 2020, Implementation: 01- 06-2020)
(Medicare Claims Processing Manual)
Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment under the OPPS is appropriate and the Secretary has determined that the services designated to be inpa tient only services are not appropriate to be furnished in a hospital outpatient department. Inpatient only services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underly ing physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. An example of an inpatient only service is CPT code 33513, Coronary artery bypass, vein only; four coronary venous grafts. The designation of services to be inpatient -only is open to public comment each year as part of the annual rulemaking process. Procedures removed from the inpatient only list may be appropriately furnished in either the inpatient or outpatient settings and such procedures continue to be payable when furnished in the inpatient setting.  There is no payment under the OPPS for services that CMS designates to be inpatient -only services. These services have an OPPS status indicator of C in the OPPS  Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. For the most current Addendum B and for Addendum E published with the OPPS notices and regulations, see http://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/HospitalOutpatientPPS/index.html.  Excluding the handful of exceptions discussed below, CMS does not pay for an inpatient -only service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the inpatient only procedure.  There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an inpatient -only service that would be paid under the OPPS if the inpatient service had not been furnished:  Exception 1: If the inpatient -only service is defined in CPT to be a
(Medicare Claims Processing Manual)
the same day with an inpatient -only service that would be paid under the OPPS if the inpatient service had not been furnished:  Exception 1: If the inpatient -only service is defined in CPT to be a separate procedure and the other services billed with the inpatient -only service contain a procedure that can be paid under the OPPS and that has an OPPS SI=T on the same date as the inpatient -only procedure or OPPS SI = J1 on the same claim as the inpatient -only procedure, then the inpatient -only servi ce is denied but CMS makes payment for the separate procedure and any remaining payable OPPS services. The list of separate procedures is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www.cms.gov/Medicare/Coding/O utpatientCodeEdit/.  Exception 2: If an inpatient -only service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the inpatient only service with modifier CA, then CMS makes a singl e payment for all services reported on the claim, including the inpatient only procedure, through one unit of APC 5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure.  As of January 1, 2020, procedures that have been removed from the inpatient -only (IPO) list are exempt from certain medical review activities related to compliance with the 2 -midnight rule, which states that generally services are considered appropriate for inpatient hospital  admission and payment under Medicare Part A when the physician expects the patient to require a stay that crosses at least 2 midnights and admits the patient to the hospital based upon that expectation (78 FR 50913 through 50954).    Specifically, procedu res that have been removed from the IPO list are not eligible for referral to Recovery Audit Contractors (RACs) for noncompliance with the 2- midnight rule within the 2 -calendar years following their removal from the IPO list. These procedures will not be c onsidered by the Beneficiary and Family -Centered Care Quality Improvement Organizations (BFCC -QIOs) in determining whether a provider exhibits persistent
(Medicare Claims Processing Manual)
2 -calendar years following their removal from the IPO list. These procedures will not be c onsidered by the Beneficiary and Family -Centered Care Quality Improvement Organizations (BFCC -QIOs) in determining whether a provider exhibits persistent noncompliance with the 2- midnight rule for purposes of referral to the RAC nor will these procedures be reviewed by RACs for patient status within the 2 -calendar years following their removal from the IPO list.  During the 2- year exemption period, BFCC -QIOs will have the opportunity to review claims for procedures that have been recently removed from the  IPO list in order to provide education for practitioners and providers regarding compliance with the 2- midnight rule, but claims identified as noncompliant with the 2 -midnight rule will not be denied with respect to the site -of-service under Medicare Part  A. 190  Payer Only Codes Utilized by Medicare  (Rev. 4391, Issued: 09- 06-19, Effective: 07- 01-19, Implementation: 07- 01-19)
(Medicare Claims Processing Manual)
This section contains the listing of payer codes designated by the National Uniform Billing Committee to be assigned by payers only.  Providers shall not submit these codes on their claims forms.  The definitions indicating Medicares usage for these syste matically assigned codes are indicated next to each code value.   Condition Codes   12-14 - Not currently used by Medicare.   15  Clean claim is delayed in CMS Processing System.   16  SNF Transition exception.  60  Operating Cost Day Outlier.   61  Operating Cost Outlier.   62  PIP Bill.   63  Bypass CWF edits for incarcerated beneficiaries. Indicates services rendered to a prisoner or a patient in State or local custody meets the requirement of 42 CFR 411.4(b) for payment.   64  Other Than Clean Claim.   65  Non -PPS Bill.   98  Data Associated With DRG 468 Has Been Validated.   EY  Lung Reduction Study Demonstration Claims.  M0  All -Inclusive Rate for Outpatient -  Used by a Critical Access Hospital electing to be paid an all -inclusive rate for outpa tient services.   M1  Roster Billed Influenza Virus Vaccine or Pneumococcal Pneumonia Vaccine (PPV). Code indicates the influenza virus vaccine or pneumonia vaccine (PPV) is being billed via the roster billing method by providers that mass immunize.   M2  Allows Home Health claims to process if provider reimbursement > $150,000.00. HHA Payment Significantly Exceeds Total Charges. Used when payment to an HHA is significantly in excess of covered billed charges.    M3  SNF 3 Day stay bypass for NG/Pioneer ACO waiver.   M4  Presence of infected wound or wound with morbid obesity    M5  Not currently used by Medicare   M6  PA Rural Health Model    M7-M9  Not currently used by Medicare.   MA  GI Bleed. (Bill Type 72x)   MA  Managed Care Enrollee (Bill Type 12x, 13x, and 76x)   MB  Pneumonia. (Bill Type 72x)   MC  Pericarditis. (Bill Type 72x)   MD -  Myelodysplastic Syndrome. (Bill Type 72x)   ME -  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 72x)   MF -  Monoclonal Gammopathy. (Bill Type 72x)   MG  Grandfat hered Tribal Federally Qualified Health Centers.
(Medicare Claims Processing Manual)
ME -  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 72x)   MF -  Monoclonal Gammopathy. (Bill Type 72x)   MG  Grandfat hered Tribal Federally Qualified Health Centers.   MH-MO  Not currently used by Medicare.   MP  PHP claim contains initial admit week   MQ  PHP claim contains final discharge week    MR-MW  Not currently used by Medicare.   MX  Wrong Surgery on Patient (Inpatient)   MY  Surgery Wrong Body Part (Inpatient)   MY  Outlier Cap Bypass (CMHC)   MZ  Surgery Wrong Patient (Inpatient)   MZ  IOCE error code bypass   UU  Not currently used by Medicare.    Occurrence Codes   23 - Date o f Cancellation of Hospice Election period.  48 - Date hospice face- to-face encounter was untimely   49  Original Notice of Election (NOE) receipt date   Occurrence Span Codes   79 - Verified non- covered stay dates for which the provider is liable.   Value Codes   17- Operating Outlier Amount  The A/B MAC (A) reports the amount of operating outlier payment amount made (either cost or day (day outliers have been obsolete since 1997)) in CWF with this code.  It does not include any capital outlier payment in this entry.   18  Operating Disproportionate Share Amount  The A/B MAC (A) REPORTS THE OPERATING DISPROPORTIONATE SHARES AMOUNT APPLICIALBE.  It uses the amount provided by the disproportionate share field in PRICER.  It does not include any PPS capital IM E adjustment entry.   19  The Medicare shared system will display this payer only code on the claim for low volume providers to identify the amount of the low volume adjustment being included in the providers reimbursement.  This payer only code 19 is als o used for IME on hospital claims.  This instruction shall only apply to ESRD bill type 72x and must not impact any existing instructions for other bill types.   19 - Operating Indirect Medical Education Amount  The A/B MAC (A) reports operating indirect medical education amount applicable.  It uses the amount provided by the indirect medical education field in PRICER.  It does not include any PPS capital IME adjustment in this entry.
(Medicare Claims Processing Manual)
20  Total payment sent provider for capital under PPS, including HSP, F SP, outlier, old capital, DSH adjustment, IME adjustment, and any exception amount.  62   On Type of Bill 032x:  HH Visits -  Part A -  The number of visits determined by Medicare to be payable from the Part A trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.  On Type of Bills 081x 0r 082x: Number of High Routine Home Care Days -  Days that fall within the first 60 days of a routine home care hospice claim.   63  On Type of Bill 032x:  HH visits  Part B -  The number of visits determined by Medicare to be payable from the Part B trust fund to reflect the shift of payments from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.  On Typ e of Bills 081x 0r 082x: Number of Low Routine Home Care Days -  Days that come after the first 60 days of a routine home care hospice claim.  63  On Type of Bills 081x 0r 082x: Number of Low Routine Home Care Days - Days that come after the first 60 days of a routine home care hospice claim.   64 - HH Reimbursement  Part A -  The dollar amounts determined to be associated with the HH visits identified in a value code 62 amount.  This Part A payment reflects the shift of payments from the Part A to the Part B  Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   65 - HH Reimbursement  Part B -  The dollar amounts determined to be associated with the HH visits identified in a value code 63 amount.  This Part B payment reflects the shift of payments  from the Part A to the Part B Trust Fund as mandated by 1812(a)(3) of the Social Security Act.   70 - Interest Amount -  The contractor reports the amount of interest applied to this Medicare claim.   71 - Funding of ESRD Networks -  The A/B MAC (A) reports the amount the Medicare payment was reduced to help fund ESRD networks.   72- Flat Rate Surgery Charge -  The standard charge for outpatient surgery where the provider has such a charging structure.
(Medicare Claims Processing Manual)
72- Flat Rate Surgery Charge -  The standard charge for outpatient surgery where the provider has such a charging structure.   73- Sequestration adjustment amount.  74  Low volume hospital payment amount  75- Prior covered days for an interrupted stay.   76  Providers Interim Rate Providers percentage of billed charges interim rate during this billing period.  This applies to all outpatient hospital and skilled nursing facility (SNF)  claims and home health agency (HHA) claims to which an interim rate is applicable.  The contractor reports to the left of the dollar/cents delimiter. An interim rate of 50 percent is entered as follows: 50.00.  77 - Medicare New Technology Add -On Payment -  Code indicates the amount of Medicare additional payment for new technology.  78  Off-site Zip Code - When the facility zip (Loop 2310E N403 Segment) is present for the following bill types: 12X, 13X, 14X, 22X, 23X, 34X, 72X, 74X, 75X, 81X, 82X, and 85X .  The ZIP code is associated with this value and is used to price MPFS HCPCS and Anesthesia Services for CAH Method II.    79  Total payments for services applicable to the ESRD -  The Medicare shared system will display this payer only code on the claim.  The value represents the dollar amount for Medicare allowed payments applicable for the calculation in determining an outlier payment.   Q0  Pioneer Accountable Care Organization (ACO) non-model payment or Next Generation ACO non- model payment   Q1  Pione er ACO model payment amount including reduction or NG ACO payment amount including reduction   Q2  Hospice claim paid from Part B Trust Fund   Q3  Prior Authorization 25% Penalty   Q4  PA Rural Model Exclusion - Physician Service Claim Reimbursement   Q5  EHR   Q6  PQRS               Q7  Islet Isolation Add- on payment amount   Q8 - Transitional Drug Add- On Payment Adjustment (TDAPA)   Q9  Medicare Performance Adjustment (MPA)   QA-QC  Not used by Medicare   QD  Device Credit   QE-QL  Not used by Medicare   QM  MIPS adjustment amount   QN  First APC pass- through device offset   QO  Second APC pass -through device offset   QP  Third APC pass -through device offset   QQ  Terminated procedure with device offset