evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Hospitals  150 -  Hospitals That Do Not Provide Outpatient Services  160 -  Clinic and Emergency Visits  160.1- Critical Care Services  170 -  Hospital and CMHC Reporting Requirements for Services Performed on the Same Day 180 -  Accurate Reporting of Surgical and Medical Procedures  and Services  180.1 -  General Rules  180.2 -  Selecting and Reporting Procedure Codes  180.3 -  Unlisted Service or Procedure  180.4 -  Proper Reporting of Condition Code G0 (Zero)  180.5 -  Proper Reporting of Condition Codes 20 and 21 180.6 -  Emergency Room (ER) Services That Span Multiple Service Dates  180.7 -  Inpatient -only Services  190  Payer Only Codes Utilized by Medicare  200 -  Special Services for OPPS Billing  200.1 -  Billing for Corneal Tissue  200.2 -  Hospital Dialysis Services For Patients with and without End Stage Renal Disease (ESRD)  200.3 -  Billing Codes for Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS)  200.3.1 -  Billing Instructions for IMRT Planning and Delivery  200.3.2 -  Billing for Multi- Source Photon (Cobalt 60- Based) Stereotactic Radiosurgery (SRS) Planning and Delivery  200.4 -  Billing for Amniotic Membrane  200.5 -  Reserved  200.6 -  Billing and Payment for Alcohol and/or Substance Abuse Assessment and Intervention Services  200.7 -  Billing for Cardiac Echocardiography Services  200.7.1 -  Cardiac Echocardiography Without Contrast  200.7.2 -  Cardiac Echocardiography With Contrast  200.8 -  Billing for Nuclear Medicine Procedures  200.9 -  Billing for Sometimes Therapy Services that May be Paid as Non -Therapy Services for Hospital Outpatients  200.10 -  Billing for Cost Based Payment for Certified Registered Nurse Anesthetists (CRNA) Services Furnished by Outpatient Prospective Payment System (OPPS) Hospitals  200.11  Billing Advance Care Planning (ACP)  230 -  Billing and Payment for Drugs and Drug Administration  230.1 -  Coding and Payment for Drugs and Biologicals  and Radiopharmaceuticals  230.2 -  Coding and Payment for Drug Administration 231 -  Billing and Payment for Blood, Blood Products, and Stem Cells and Related Services Under the Hospital Outpatient Prospective Payment System (OPPS)  231.1 -  When a Provider Paid Under the OPPS Does Not Purchase the Blood or Blood Products That It Procures from a Community Blood Bank, or When a Provider Paid Under the
(Medicare Claims Processing Manual)
Under the Hospital Outpatient Prospective Payment System (OPPS)  231.1 -  When a Provider Paid Under the OPPS Does Not Purchase the Blood or Blood Products That It Procures from a Community Blood Bank, or When a Provider Paid Under the OPPS Does Not Assess a Charge for Blood or Blood Products Supplied by the Providers Own Blood Bank Other Than Blood Processing and Storage  231.2 -  When a Provider Paid Under the OPPS Purchases Blood or Blood Products from a Community Blood Bank or When a Provider Paid Under the OPPS Assesses a Charge for Blood or Blood Products Collected By Its Own Blood Bank That Reflects More Than Blood Processing and Storage  231.3 -  Billing for Autologous Blood (Including Salvaged Blood) and Directed Donor Blood 231.4 -  Billing for Split Unit of Blood  231.5 -  Billing for Irradiation of Blood Products  231.6 -  Billing for Frozen and Thawed Blood and Blood Products  231.7 -  Billing for Unused Blood 231.8 -  Billing for Transfusion Services  231.9 -  Billing for Pheresis and Apheresis Services  231.10 -  Billing for Autologous Stem Cell Transplants  231.11 -  Billing for Allogeneic Stem Cell Transplants  231.12 -  Correct Coding Initiative (CCI) Edits  240 -  Inpatient Part B Hospital Services  240.1 -  Editing of Hospital Part B Inpatient Services : Reasonable and Necessary Part A Hospital Inpatient Denials  240.2 -  Editing Of Hospital Part B Inpatient Services: Other Circumstances in Which Payment Cannot Be Made under Part A  240.3 -  Implantable Prosthetic Devices  240.4 -  Indian Health Service/Tribal Hospital Inpatient Social Admits  240.5 -  Payment of Part B Services in the Payment Window for Outpatient Services Treated as Inpatient Services when Part A Payment Cannot Be Made  240.6 -  Submitting Provider -Liable No -Pay Part A Claims and Beneficiary Liability  250 -  Special Rules for Critical Access Hospital Outpatient Billing  250.1 -  Standard Method -  Cost -Based Facility Services, With Billing of A/B MAC (B) for Professional Services  250.1.1 -  Special Instructions for Non- covered Time Increments in Standard Method Critical Access Hospitals (CAHs)  250.2 -  Optional Method for Outpatient Services: Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional Services  250.2.1 -  Billing and Payment in a Physician Scarcity Area (PSA)
(Medicare Claims Processing Manual)
Access Hospitals (CAHs)  250.2 -  Optional Method for Outpatient Services: Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional Services  250.2.1 -  Billing and Payment in a Physician Scarcity Area (PSA)  250.2.2 -  Zip Code Files  250.3 -  Payment for Anesthesia in a Critical Access Hospital 250.3.1 -  Anesthesia File  250.3.2 -  Physician Rendering Anesthesia in a Hospital Outpatient Setting  250.3.3 -  Anesthesia and CRNA Services in a Critical Access Hospital (CAH)  250.3.3.1 -  Payment for CRNA Pass -Through Services  250.3.3.2 -  Payment for Anesthesia Services by a CRNA (Method II CAH only)  250.4 -  CAH Outpatient Services Part B Deductible and Coinsurance  250.5 -  Medicare Payment for Ambulance Services Furnished by Certain CAHs  250.6 -  Clinical Diagnostic Laboratory Tests Furnished by CAHs  250.7 -  Payment for Outpatient Services Furnished by an Indian Health Service (IHS) or Tribal CAH  250.8 -  Coding for Administering Drugs in a Method II CAH  250.8.1 -  Coding for Low Osmolar Contrast Material (LOCM)  250.8.2 -  Coding for the Administration of Other Drugs and Biologicals  250.9 -  Coding Assistant at Surgery Services Rendered in a Method II CAH  250.9.1 -  Use of Payment Policy Indicators for Determining Procedures Eligible for Payment of Assistants at Surgery  250.9.2 -  Payment of Assistant at Surgery Services Rendered in a Method II CAH  250.9.3 -  Assistant at Surgery Medicare Summary Notice (MSN) and Remittance Advice (RA) Messages  250.9.4 -  Assistant at Surgery Services in a Method II CAH Teaching Hospital  250.9.5 -  Review of Supporting Documentation for Assistants at Surgery Services in a Method II CAH  250.10 -  Coding Co- surgeon Services Rendered in a Method II CAH  250.10.1 -  Use of Payment Policy Indicators for Determining Procedures Eligible for Payment of Co- surgeons  250.10.2 -  Payment of Co- surgeon Services Rendered in a Method II CAH  250.10.3 -  Co-surgeon Medicare Summary Notice (MSN) and Remittance Advice (RA) Messages  250.10.4 -  Review of Supporting Documentation for Co- surgeon Services in a Method II CAH  250.11 -  Coding
(Medicare Claims Processing Manual)
-  Co-surgeon Medicare Summary Notice (MSN) and Remittance Advice (RA) Messages  250.10.4 -  Review of Supporting Documentation for Co- surgeon Services in a Method II CAH  250.11 -  Coding Bilateral Procedures Performed in a Method II CAH  250.11.1 -  Use of Payment Policy Indicators for Determining Bilateral Procedures Eligible for 150 Percent Payment Adjustment  250.11.2 -  Payment of Bilateral Procedures Rendered in a Method II CAH  250.12 -  Primary Care Incentive Payment Program (PCIP) Payments to Critical Access Hospitals (CAHs) Paid Under the Optional Method 250.12.1 -  Definition of Primary Care Practitioners and Primary Care Services  250.12.2 -  Identifying Services Eligible for the PCIP  250.12.3 -  Coordination with Other Payments  250.12.4 -  Claims Processing and Payment for CAHs Paid Under the Optional Method 250.13 -  Health Professional Shortage Areas (HPSA) Surgical Incentive Payment Program (HSIP) for Surgical Services Rendered in Critical Access Hospitals (CAHs) Paid under the Optional Method 250.13.1 Overview of the HSIP  250.13.2  - HPSA Identification  250.13.3 -  Coordination with Other Payments  250.13.4 -  General Surgeon and Surgical Procedure Identification for Professional Services Paid under the Physician Fee Schedule (PFS)  250.13.5 -  Claims Processing and Payment  250.14 -  Payment of Licensed Clinical Social Workers (LCSWs) in a Method II CAH 250.15 -  Coding and Payment of Multiple Surgeries Performed in a Method II CAH 250.16 -  Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Imaging Procedures Rendered by Physicians  250.17 -  Payment of Global Surgical Split Care in a Method II CAH Submitted with Modifier 54 and/or 55 260 -  Outpatient Partial Hospitalization Services  260.1 -  Special Partial Hospitalization Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals  260.1.1 -  Bill Review for Partial Hospitalization Services Received in Community Mental Health Centers (CMHC)  260.2 -  Professional Services Related to Partial Hospitalization  260.3 -  Outpatient Mental Health Treatment Limitation for Partial Hospitalization Services  260.4 -  Reporting Service Units for Partial Hospitalization  260.5 -  Line Item Date of Service Reporting for Partial Hospitalization  260.6 -  Payment for Partial Hospitalization Services                                                          261 -  Intensive Outpatient Program Services  261.1 -  Special Intensive Outpatient Program Billing Requirements for Hospitals, Community Mental Health
(Medicare Claims Processing Manual)
Hospitalization  260.5 -  Line Item Date of Service Reporting for Partial Hospitalization  260.6 -  Payment for Partial Hospitalization Services                                                          261 -  Intensive Outpatient Program Services  261.1 -  Special Intensive Outpatient Program Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals  261.1.1 -  Bill Review for Intensive Outpatient Program Services Received in Community Mental Health Centers (CMHC)  261.2 -  Professional Services Related to Intensive Outpatient Program  261.3 -  Outpatient Mental Health Treatment Limitation for Intensive Outpatient Program Services  261.4 -  Reporting Service Units for Intensive Outpatient Program  261.5 -  Line Item Date of Service Reporting for Intensive Outpatient Program  261.6 -  Payment for Intensive Outpatient Program Services
(Medicare Claims Processing Manual)
300.5.1 -  Rural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs) Special Billing Instructions  300.6 -  Common Working File (CWF) Edits  310 -  Lung Volume Reduction Surgery  320 -  Outpatient Intravenous Insulin Treatment (OIVIT)  320.1 -  HCPCS Coding for OIVIT  320.2 -  Medicare Summary Notices (MSN), Reason Codes, and Remark Codes  10 - Hospital Outpatient Prospective Payment System (OPPS)  (Rev. 1, 10- 03-03) A-01-93  10.1 - Background  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    Section  1833(t)  of the Social Security Act (the Act) as amended by 4533 of the  Balanced Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare PPS for:    Hospital outpatient services, including partial hospitalization and intensive outpatient  services;     Certain Part B services furnished to hospital inpatients who have no Part A coverage;     Partial hospitalization and intensive outpatient  services furnished by CMHCs;     Hepatitis B vaccines and their administration, splints, cast, and antigens provided by HHAs that provide medical and other health services;     Hepatitis B vaccines and their administration provided by CORFs; and     Splints, casts, and antigens provided to hospice patients for treatment of nonterminal illness.    The Balanced Budget Refinement Act of 1999 (BBRA) contains a number of major provisions that affect the development of the OPPS.  These are:     Establish payments under OPPS in a budget neutral manner based on estimates of amounts payable in 1999 from the Part B Trust Fund and as beneficiary coinsurance under the system in effect prior to OPPS (Although the base rates were calculated using the 1999 amounts, these amounts are increased by the hospital inpatient market basket, minus one percent, to arrive at the amounts payable in the year 2000.  See 10.3 for Benefits and Improvement Protection Act (BIPA) changes in market basket updates.);     Extend the 5.8 percent reduction in operating costs and 10 percent reduction in capital costs (which had been due to sunset on December 31, 1999) through the first date the OPPS is implemented;
(Medicare Claims Processing Manual)
 Transitional corridor provision for transitional outpatient payments (TOPs) for providers that did not file 1996 cost reports; and     Special transitional corridor treatment for childrens hospitals.    The Secretary has the authority under  1883(t)  of the Act to determine which services are included (with the exception of ambulance services for which a separate fee schedule is applicable starting April 1, 2002).  Medicare will continue to pay for clinical diagnostic laboratory services, orthotics, pr osthetics (except as noted above), and for take -home surgical dressings on their respective fee schedules.  Medicare will also continue to pay for chronic dialysis using the composite rate (certain CRNA services, PPV , and influenza vaccines and their admin istration, orphan drugs, and ESRD drugs and supplies are not included in the composite rate), for screening mammographies based on the current payment limitation, which changes to payment under the Medicare Physician Fee Schedule (MPFS), effective January 1, 2002, and for outpatient rehabilitation services (physical therapy including speech language pathology and occupational therapy) under the MPFS.  Acute dialysis, e.g., for poisoning, will be paid under OPPS.  The 10 cancer centers exempt from inpatient PPS are included in this system, but are eligible for hold harmless payment under the Transitional Corridor provision.    The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments except for hospitals that provide Part B only services to their inpatients;  Critical Access Hospitals (CAHs); Indian Health Service hospitals; hospitals located in American Samoa, Guam, and Saipan; hospitals located in the Virgin Islands; and effective January 1, 2017 non- excepted off -campus provider -based departments of a hospita l. The OPPS also applies to partial hospitalization and intensive outpatient  services furnished by Community Mental Health Centers (CMHCs).    Certain hospitals in Maryland that are paid under Maryland waiver provisions are also excluded from payment under OPPS but not from reporting Healthcare Common Procedure Coding System (HCPCS) and line item dates of service.   10.1.1 - Payment Status Indicators  (Rev. 1445; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)
(Medicare Claims Processing Manual)
 33207 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular);    33208 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular);    33212 (Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular);    33213 (Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular);    33214 (Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator));    33216 (Insertion of a single transvenous electrode, permanent pacemaker or cardioverter -defibrillator);   33217 (Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter -defibrillator);   33221(Insertion of pacemaker pulse generator only; with existing multiple leads);    33222 (Revision or relocation of skin pocket for pacemaker);    33230 (Insertion of pacing cardioverter -defibrillator pulse generator only; with existing dual leads);    33231 (Insertion of pacing cardioverter -defibrillator pulse generator only; with existing multiple leads)    33233 (Removal of permanent pacemaker pulse generator);    33234 (Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular);    33235 (Removal of transvenous pacemaker electrode(s); dual lead system, atrial or ventricular);    33240 (Insertion of single or dual chamber pacing cardioverter -defibrillator pulse generator); or    33249 (Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter -defibrillator and insertion of pulse generator).   10.2.3 - Comprehensive APCs (Rev.  12421; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 02-24)
(Medicare Claims Processing Manual)
10.2.3 - Comprehensive APCs (Rev.  12421; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 02-24)   The following services are excluded from comprehensive APC packaging:   ambulance services   brachytherapy sources (status indicator U)   diagnostic and mammography screenings   physical therapy, speech- language pathology and occupational therapy services reported on a separate facility claim for recurring services   pass -through drugs, biologicals, and devices (status indicators G or H)   preventive services defined in 42 CFR 410.2   self -administered drugs (SADs) -  drugs that are usually self -administered and do not function as supplies in the provision of the comprehensive service   services assigned to OPPS status indicator F (including certain CRNA services, Hepatitis B vaccines and corneal tissue acquisition)   services assigned to OPPS status indicator L (including influenza, pneumococcal pneumonia, and COVID -19 vaccines)   certain Part B inpatient services  Ancillary Part B inpatient services payable under Part B when the primary J1 service for the claim is not a payable Medicare Part B inpatient service (for example, exhausted Medicare Part A benefits, beneficiaries with  Part B only)    services assigned to a New Technology APC   Any drug or biological described by HCPCS code C9399 (Unclassified drugs or biologicals)   10.2.4 - Reporting for Certain Outpatient Department Services (That Are Similar to Therapy Services) (Non -Therapy Outpatient Department Services) and Are Adjunctive to Comprehensive APC Procedures  (Rev. 10541; Issued: 12-31-20; Effective: 01-01-21; Implementation: 01-04 -21)  This language was originally published in the October 2016 Update of the Outpatient Perspective Payment System (OPPS) (Transmittal R3602CP). We are updating this language based on the removal of the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4 ) related to functional reporting for therapy services.
(Medicare Claims Processing Manual)
Effective for claims received on or after October 1, 2016  with dates of service on or after January 1, 2015, providers may report non -therapy outpatient department services (that are similar to therapy services) that are adjunctive to a C -APC procedure (SI = J1) or the specific combination of services assigned t o the Observation Comprehensive APC 8011 (SI = J2), in one of two ways:   1. Without using the therapy CPT codes and instead reporting these non -therapy services with Revenue Code 0940 (Other Therapeutic Services); or  2. Reporting non- therapy outpatient department services that are adjunctive to J1 or J2 services with the appropriate occurrence codes, CPT codes, modifiers, and revenue codes.   10.3 - Calculation of APC Payment Rates  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  The OPPS national unadjusted payment rates for APCs other than drugs and biologicals are calculated as the products of the scaled relative weight for the APC and the OPPS conversion factor.  Hospital specific payments for these APCs are derived after application of applicable adjustment factors (e.g., multiple surgery reduction, rural sole community adjustment, etc.) and the post reclassification wage index that applies to the hospital to which payment is being made.  Payment rates for se parately paid drugs and biologicals are generally established based on a percentage of the average sales price of the drug or biological.   An APCs scaled relative weight is generally calculated based on the median cost (operating and capital) of all of the services included in the APC group.  Median costs are developed from a database of the most currently available hospital outpatient claim s using the most recently filed cost report data.   The following is a simplified description of the process used to calculate the OPPS payment rates for services for which the rate is based on the median cost.    Hospital -specific, department -specific cost -to-charge ratios are used to convert billed charges to costs for each HCPCS code;
(Medicare Claims Processing Manual)
3. T-packaged services are services for which separate payment is made only if there is no service with status indicator T reported on the same claim.  When there is a claim that includes a service that is assigned status indicator T reported on the same c laim as the T -packaged service, the payment for the T -packaged service is packaged into the payment for the service(s) with status indicator T and no separate payment is made for the T -packaged service.  T -packaged services are assigned status indicator Q2 . See the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/  for identification of T -packaged codes.   4. A service that is assigned to a composite APC is a major component of a single episode of care.  The hospital receives one payment through a composite APC for multiple major separately identifiable services.  Services mapped to composite APCs are assign ed status indicator Q3.  See the discussion of composite APCs in section 10.2.1.  5. Q4 services are assigned to laboratory HCPCS codes that appear on the Clinical Laboratory Fee Schedule (CLFS).  Status indicator Q4 designates packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator J1, J2, S, T, V, Q1, Q2, or Q3. When a Q4 service is not billed on the same claim as another separately payable service then the IOCE auto matically changes their status indicator to A and separate payment is made at the CLFS payment rate.   6. J1 services are assigned to comprehensive APCs.  Payment for all adjunctive services reported on the same claim as a J1 service is packaged into payment for the primary J1 service. See the discussion of comprehensive APCs in section 10.2.3.  7. J2 services are assigned to comprehensive APCs when a specific combination of services are reported on the claim.  Payment for all adjunctive services reported on the same claim as a J2 service is packaged into payment for the J2 service when certain conditions are met.  See the discussion of comprehensive APCs in section 10.2.3.