evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 Upgrades from a bid item in one product category (category S) to a bid item in another product category (category U) In this case, Medicare payment is only made to a contract supplier for the product category U on an assignment -related basis.  Medicare payment would be equal to 80 percent of lower of the actual charge or the fee schedule amount for the medically necess ary bid item in product category S.  Upgrade Scenarios for Beneficiaries Who Do Not Reside In a CBA, But Travel to a CBA From  the Medically Necessary Item To the Upgraded Item Must be Furnished by Assignment Mandatory (Y/N)  Medicare Payment Based Upon  Bid Item  Non-Bid Item Contract Supplier Y Lower of the Actual Charge or Fee Schedule Amount for the Medically Necessary Item  Non-Bid Item Bid Item  Contract Supplier N Lower of the Actual Charge or Fee Schedule Amount for the Medically Necessary Item  Bid Item in Product Category S Bid Item in Product Category U Contract Supplier for Category U Y Lower of the Actual Charge or Fee Schedule Amount for the Medically Necessary Item   Beneficiary Liability under the Competitive Bidding Program   Under the competitive bidding program, a beneficiary has no financial liability to a non contract supplier that furnishes an item included in the competitive bidding program for a competitive bidding area, unless, prior to receiving the item, the beneficiary selects  Option 1 on the ABN and signs the notice.  Similarly, beneficiaries who receive an upgraded item from a non -contract supplier in a competitive bidding area are not financially liable for the item unless, prior to giving the beneficiary the upgraded item, the supplier obtains a valid ABN on which the enrollee has selected Option 1 and signed the notice.  In the case of upgrades, for a beneficiary to be liable for the extra cost of an item that exceeds their medical needs, the beneficiary must, select Option  1 and sign a valid ABN prior to receiving the item.  See Chapter 20, section 120 of the Medicare Claims Processing Manual for additional information on ABN upgrades.  40.12 - Billing Procedures Related to Downcoding under the Competitive Bidding Program  (Rev. 1532, Issued: 06- 11-08, Effective: 07-01-08, Implementation: 07-07-08)
(Medicare Claims Processing Manual)
The following downcoding guidelines describe situations where Medicare reduces the level of payment for the prescribed item based on a medical necessity partial denial of coverage for the additional, not medically necessary, expenses associated with the prescribed item. For beneficiaries who reside in a CBA and for whom Medicare determines that the prescribed item should be downcoded to an item that is reasonable and necessary unde r Medicares coverage requirements, the subsequent scenarios and chart detail the type of supplier that can furnish the item and the payment for the item.    Downcodes from a non- bid item to a bid item  In this situation, Medicare payment will be made to any Medicare enrolled supplier on an assigned or unassigned basis.  Medicare payment will be equal to 80 percent of the single payment amount for the medically necessary bid item.    Downcodes from a bid item to a non- bid item Medicare payment in this downcoding scenario will be made to a contract supplier on an assignment -related basis.  Medicare payment will be equal to 80 percent of the lower of the actual charge or the fee schedule amount for the medically necessary non -bid item.    Downcodes from a bid item in one product category (category U) to a bid item in another product category (category S)  In this case, Medicare payment will be made to a contract supplier for the product category U on an assignment -related basis.  Medicare payment would be equal t o 80 percent of the single payment amount for the medically necessary bid item in product category S.   Downcoding Scenarios for Beneficiaries Residing in a CBA   From  a Higher Level of Service Item  To a Medically Necessary Item Must be Furnished by Assignment Mandatory (Y/N)  Medicare Payment Based Upon  Non-Bid Item Bid Item  Any Medicare Enrolled Supplier  N Single Payment Amount for the Medically Necessary Item  Bid Item  Non-Bid Item Contract Supplier Y Lower of the Actual Charge or Fee Schedule Amount for the Medically Necessary Item  Bid Item in Product Category U Bid Item in Product Category S Contract Supplier for Category U Y Single Payment Amount for Category S for the Medically Necessary Item
(Medicare Claims Processing Manual)
The following scenarios and chart desc ribe situations where the prescribed item for a beneficiary that does not reside in a CBA, but travels to a CBA is downcoded to an item that is reasonable and necessary under Medicares coverage requirements.    Downcodes from a non- bid item to a bid item  In this situation, Medicare payment will be made to any Medicare enrolled supplier on an assigned or unassigned basis.  Medicare payment will be equal to 80 percent of the lower of the actual charge or the fee schedule amount for the medically necessary bi d item.    Downcodes from a bid item to a non- bid item  Medicare payment in this downcoding scenario will only be made to a contract supplier on an assignment- related basis.  Medicare payment will be equal to 80 percent of the lower of the actual charge or the fee schedule amount for the medically necessary non -bid item.    Downcodes from a bid item in one product category (category U) to a bid item in another product category (category S) In this case, Medicare payment will only be made to a contract suppli er for the product category U on an assignment -related basis.  Medicare payment will be equal to 80 percent of the lower of the actual charge or the fee schedule amount for the medically necessary bid item in product category S.   Downcoding Scenarios for Beneficiaries Who Do Not Reside In a CBA, But Travel to a CBA From  a Higher Level of Service Item  To a Medically Necessary Item Must be Furnished by Assignment Mandatory (Y/N)  Medicare Payment Based Upon  Non-Bid Item Bid Item  Any Medicare Enrolled Supplier  N Lower of the Actual Charge or Fee Schedule Amount for the Medically Necessary Item  Bid Item  Non-Bid Item Contract Supplier Y Lower of the Actual Charge or Fee Schedule Amount for the Medically Necessary Item  Bid Item in Product Category U Bid Item in Product Category S Contract Supplier for Category U Y Lower of the Actual Charge or Fee Schedule Amount for the Medically Necessary Item
(Medicare Claims Processing Manual)
50 - Special Billing Instructions for the DMEPOS Competitive Bidding Program  (Rev. 11427; Issued: 05-20- 22; Effective: 01 -01-23; Implementation: 01-03-23) NOTE:  CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase customer satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.  For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.  F or claims with dates of service prior to January 1, 2023  processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim. This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned.   Claims for competitively bid items shall be submitted under the general DMEPOS claims billing guidelines specified in Chapter 20, 110 of the Medicare Claims Processing Manual, with the following exceptions described in this section.  50.1 - Electronic Submission of Claims and Mandatory Assignment  (Rev. 2979, Issued: 06- 27-14, Effective: 01-01-12, Implementation: 07-28-14)
(Medicare Claims Processing Manual)
Under the DMEPOS Competitive Bidding Program, all claims shall be submitted electronically using the ASC X12 837 profe ssional claim format except for MSP claims. ( NOTE:   Claims with multiple MSP situations may be submitted on a paper claim.)  Exceptions to the mandatory electronic billing requirement granted under the Administrative Simplification Compliance Act (ASCA) do  not apply to DMEPOS Competitive Bidding claims.   All DMEPOS Competitive Bidding Program claims are subject to mandatory assignment. Mandatory assignment denotes that a supplier shall accept the Medicare payment as payment in full for their services.  The beneficiarys liability is limited to any applicable deductible plus the 20 percent coinsurance.  For additional information concerning mandatory assignment of claims, see Chapter 1, 30.3.1 of the Medicare Claims Processing Manual.  50.2 - New Modifiers f or DMEPOS Competitive Bidding Billing (Rev. 1544, Issued: 06- 26-08, Effective: 07-01-08, Implementation: 07-07-08)  Table 1 below describes the modifiers implemented for the DMEPOS Competitive Bidding Program.  Specific instructions for the use of each modifier for billing are included in subsequent subsections.  Table 1:  Modifiers Implemented for DMEPOS Competitive Bidding Billing   Modifier  Effective Date  Definition  KG 7/1/07  DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 1  KK 7/1/07  DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 2  Modifier  Effective Date  Definition  KU 7/1/07  DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 3  KL 7/1/07  DMEPOS Item Delivered Via Mail  KT 7/1/07  Beneficiary Resides in a Competitive Bidding Area and Trav els Outside that Competitive Bidding Area and Receives a Competitive Bid Item  KV 1/1/08  DMEPOS Item Subject to DMEPOS Competitive Bidding Program that is Furnished as Part of a Professional Service  KW 1/1/08  DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 4  KY 1/1/08  DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 5
(Medicare Claims Processing Manual)
50.3 - Billing for Items in Multiple Product Categories  (Rev. 2231, Issued: 05- 27-11, Effective: 08-28-11, Implementation: 08-28-11)   New HCPCS modifiers were developed to facilitate implementation of various policies that apply to certain competitive bidding items. The KG, KK, KU, KW, and KY modifiers are pricing modifiers that suppliers must use to identify when the same supply or accessory HCPC S code is furnished in multiple competitive bidding product categories. For example, HCPCS code E0981 (Wheelchair Accessory, Seat Upholstery, Replacement Only, Each) is found in both the standard and complex rehabilitative power wheelchair competitive bidd ing product categories. Contract suppliers for the standard power wheelchair product category shall submit E0981 claims using the KG modifier, whereas contract suppliers for the complex rehabilitative power wheelchair product category shall use the KK modifier. All suppliers, including grandfathered suppliers, shall submit claims for competitive bid items using the aforementioned competitive bidding modifiers. The KG and KK modifiers are used in Round I of the competitive bidding program and the KU and KW m odifiers are reserved for future program use.   50.4 - Claims Jurisdiction and Billing Procedures for Traveling Beneficiaries  (Rev. 1544, Issued: 06- 26-08, Effective: 07-01-08, Implementation: 07-07-08)  Claims for non- mail order competitively bid items fur nished to beneficiaries who maintain a permanent residence in a CBA, but who are traveling outside of their CB when they obtain the item, must be submitted with a KT modifier to indicate a traveling beneficiary.  Claims for competitively bid items furnis hed to beneficiaries who obtain the item outside of their CBA that do not have a KT modifier shall be denied.  Jurisdiction for these claims remains with DME MAC with jurisdiction for the beneficiary based on the beneficiarys permanent residence. Claims  for mail order competitively bid items that have a KT modifier shall be denied.
(Medicare Claims Processing Manual)
50.5 - Claims for DMEPOS Items Furnished to a Beneficiary by a Skilled Nursing Facility (SNF) or Nursing Facility (NF)  (Rev. 1544, Issued: 06- 26-08, Effective: 07-01-08, Im plementation: 07 -07-08)  For purposes of claims adjudication under DMEPOS Competitive Bidding, beneficiaries who maintain a permanent residence in a CBA and, while a resident of a SNF or NF outside of a CBA, obtain a competitively bid item from that SNF or  NF are treated as traveling beneficiaries when their permanent address is within a CBA. As a result, the SNF or NF shall submit a KT modifier on any claims for competitively bid items furnished to beneficiaries, under these circumstances.   A claim must include a place of service 31 to indicate that the beneficiary resides in a SNF or 32 to indicate that the beneficiary resides in a NF, as applicable.  See 20.5.2 for the policies applicable to SNFs and NFs that furnish competitively bid items under D MEPOS Competitive Bidding Program.   50.6 - Billing for Mail Order Items (Rev. 1544, Issued: 06- 26-08, Effective: 07- 01-08, Implementation: 07- 07-08)
(Medicare Claims Processing Manual)
50.6 - Billing for Mail Order Items (Rev. 1544, Issued: 06- 26-08, Effective: 07- 01-08, Implementation: 07- 07-08)  The KL modifier has been established for use in submitting claims for mail order DMEPOS items (e.g., dia betic supplies). Beneficiaries who maintain a permanent residence in CBAs for which there is a competitive bidding program for mail order diabetic supplies may choose to obtain their diabetic supplies through mail order or at a storefront.  A beneficiary w ho resides in a CBA and chooses to obtain their diabetic supplies through mail order must obtain these supplies from a contract supplier for mail order diabetic supplies for the CBA where they maintain a permanent residence.  Claims for mail order diabetic supplies furnished to beneficiaries who maintain a permanent residence in a CBA must be billed with the modifier KL.  If the beneficiary chooses to obtain their diabetic supplies at a storefront, DMEPOS competitive bidding rules do not apply and these c laims will be processed under the normal guidelines for supply claims.  See 20.5.3 for additional information on mail -order contract suppliers of diabetic supplies.  50.7 - Claims Submitted for Physicians and Treating Practitioners Who Furnish Competitive ly Bid Items (Rev. 1544, Issued: 06- 26-08, Effective: 07- 01-08, Implementation: 07- 07-08)  Under DMEPOS Competitive Bidding, physicians and treating practitioners may furnish certain competitively bid items without submitting a bid and being awarded a cont ract.  This exception requires that the items be furnished by the physician or treating practitioner to his or her own patients as part of his or her professional service.   The professional service must be furnished on the same date as the date that the DME item is initially furnished.  In addition, physicians and treating practitioners must submit their office visit claim on the same day that they submit the DME claim to ensure timely and accurate claims processing.  Physicians and treating practitioners  who provide DME items in their offices shall continue to be paid even though they are not a contract supplier for the items.  See 20.6 for additional information.
(Medicare Claims Processing Manual)
Physicians and treating practitioners that are located in a CBA must submit the KV modif ier on claims for competitively bid items and related accessories that are furnished in accordance with this exception to receive payment for these items for the CBA where the beneficiary maintains a permanent residence.  Physician and treating practitioner submitted competitive bidding claims that do not have an accompanying office visit will be denied.  Physicians and treating practitioners located outside a CBA who furnish DME competitively bid items and/or related accessories as part of a professional s ervice to traveling beneficiaries who maintain a permanent residence in a CBA must also affix the KV modifier to claims submitted for these items.   50.8 - Billing for Oxygen and Oxygen Equipment  (Rev. 1544, Issued: 06- 26-08, Effective: 07- 01-08, Implementation: 07 -07-08)  Noncontract suppliers of oxygen and oxygen equipment may elect to become grandfathered suppliers and continue furnishing these items and services to beneficiaries after the start of the DMEPOS Competitive Bidding Program, if th e beneficiary agrees to the arrangement.  This grandfathering process only applies to suppliers that began furnishing oxygen and oxygen equipment to beneficiaries in a CBA prior to the implementation of the competitive bidding program for that area and cho ose to continue to furnish the grandfathered oxygen and oxygen equipment to these same beneficiaries in the CBA after the start of the DMEPOS Competitive Bidding Program.  See 20.6 for additional information on payments to noncontract suppliers.
(Medicare Claims Processing Manual)
If a noncontract supplier does not want to continue furnishing oxygen and oxygen equipment to its existing customers/beneficiaries, the beneficiaries must use a contract supplier to obtain the oxygen and oxygen equipment.  Ordinarily, the title to the oxygen equipment would transfer to the beneficiary after rental payments have been made for 36 months of continuous use.  However, Medicare allows for a minimum of 10 months of payments to be made to a contract supplier for oxygen and oxygen equipment furnished to a beneficiary who changes suppliers under the DMEPOS Competitive Bidding Program because the current supplier chose not to become a grandfathered supplier.  Therefore, under the DMEPOS Competitive Bidding Program, up to 45 continuous payments could be made fo r the oxygen and oxygen equipment.  The beneficiary is liable for co -payments for all paid oxygen and oxygen equipment claims.  50.9 - Billing for Capped Rental DME Items  (Rev. 1544, Issued: 06- 26-08, Effective: 07- 01-08, Implementation: 07- 07-08)
(Medicare Claims Processing Manual)
50.9 - Billing for Capped Rental DME Items  (Rev. 1544, Issued: 06- 26-08, Effective: 07- 01-08, Implementation: 07- 07-08)  Noncont ract suppliers of capped rental DME equipment may elect to become grandfathered suppliers and continue furnishing equipment to their existing beneficiaries after the start of the DMEPOS Competitive Bidding Program, if the beneficiary agrees to the arrang ement. This grandfathering process only applies to suppliers that began furnishing the capped rental DME item to beneficiaries in a CBA prior to the implementation of the competitive bidding program for that area and choose to continue to furnish the grandfathered item to these same beneficiaries in the CBA after the start of the DMEPOS Competitive Bidding Program.  See 20.6 for additional information on payments to noncontract suppliers.  If a noncontract supplier does not want to continue furnishing capp ed rental DME to its existing customers/beneficiaries after the start of the DMEPOS Competitive Bidding Program, the beneficiary must use a contract supplier to obtain the item. Ordinarily, the title to the capped rental DME item would transfer to the bene ficiary after rental payments have been made for 13 months of continuous use.  However, for beneficiaries that switch from a noncontract supplier to a contract supplier, the 13 month capped rental period starts over again. In this case, Medicare allows for  a minimum of 13 months of rental payments to be made to a contract supplier because their current supplier chose not to become a grandfathered supplier.  Therefore, under DMEPOS Competitive Bidding Program, when a beneficiary switches from a noncontract s upplier to a contract supplier, up to 25 continuous payments could be made for the capped rental DME item.  The beneficiary is liable for co -payments for all paid capped rental DME equipment claims.  50.9.1 - Certificates of Medical Necessity (CMN) and Cap ped Rental Billing  (Rev. 1544, Issued: 06- 26-08, Effective: 07- 01-08, Implementation: 07- 07-08)
(Medicare Claims Processing Manual)
50.9.1 - Certificates of Medical Necessity (CMN) and Cap ped Rental Billing  (Rev. 1544, Issued: 06- 26-08, Effective: 07- 01-08, Implementation: 07- 07-08)  Suppliers are not required to obtain a new Certificate of Medical Necessity (CMN) for situations in which a beneficiary who was receiving a capped rental item prior to the implementation of DMEPOS Competitive Bidding goes to a new supplier after the implementation of the DMEPOS Competitive Bidding Program (e.g., the previous supplier decides not to become a grandfathered supplier), unless the beneficiarys medic al necessity for the item has changed.  Notwithstanding this situation, the new supplier shall bill using the appropriate modifiers for their first rental month (KH), the second and third rental months (KI), and all subsequent rental months (KJ).  50.10 - Claims Submitted for Hospitals Who Furnish Competitively Bid Items  (Rev. 2231, Issued: 05- 27-11, Effective: 08- 28-11, Implementation: 08- 28-11)  Under DMEPOS Competitive Bidding, hospitals may furnish certain types of competitively bid DME to their patients on the date of discharge without submitting a bid and being awarded a contract.  The DME items that a hospital may furnish as part of the exception are limited to: crutches, canes, walkers, folding manual wheelchairs, blood glucose monitors, and i nfusion pumps.  Payment for items furnished under this exception will be made based on the single payment amount for the item for the CBA where the beneficiary resides.  Separate payment is not made for walkers and related accessories furnished by a hospit al on the date of admission because payment for these items is included in the Part A payment for inpatient facility services.  Refer to Pub. 100- 04, the Medicare Claims Processing Manual, Chapter 1, 10.1.1.1  for instructions for submitting claims.   50.11 - Claims Submitted for Medicare Beneficiaries Previously Enrolled in a Medicare Advantage Plan  (Rev. 2231, Issued: 05- 27-11, Effective: 08- 28-11, Implementation: 08- 28-11)