evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
However, total Medicare payments to RNHCIs are subject to limits established in sections 1821(c)(2) (A) or (B) of the Act. In the event that the Medicare program reduces payments to RNHCIs based on t hese limits, RNHCIs may also bill beneficiaries an amount equal to any such reduction.  130.4 - Coverage of RNHCI Items Furnished in the Home  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Prior to the passage of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003, the Medicare programs RNHCI benefit was limited to inpatient services provided in an RNHCI facility.  The MMA revised sections 1821(a) and 1861 of the Social Security Act to extend coverage to RNHCI items and services that are provided in a beneficiarys home and that are comparable to items and services provided by a home health agency that is not an RNHCI.  Beneficiaries elect the RNHCI benefit if they are conscientiously opposed to accepting most medical treatment, since accepting such services would be inconsistent with their sincere religious beliefs.  The Medicare home health benefit provides skilled nursing, physical therapy, occupational therapy, speech language pathology and home health aide services to eligible beneficiaries under a physicians plan of care.  The home health benefit also provides medical supplies, a covered osteoporosis drug and durable medical equipment (DME) while under a plan of care (see chapter 7).   Medicare covers specified durable medical equipment and intermittent RNHCI nursing visits provided in the home to RNHCI beneficiaries.  These services comprise the RNHCI home benefit.  The remainder of the services covered under the Medicare home health benefit are medical in nature and must be provided under the order of a physician.  As such, these services conflict with RNHCI beneficiaries conscientious opposition to medical care.
(Medicare Benefit Policy Manual)
The RNHCI home benefit must exclude the same services that are excluded from the home health benefit, which include: drugs and biologicals; transportation; services that would not be covered as inpatient services; housekeeping services; services covered under the End Stage Renal Disease program; prosthetic devices; and medical social services provided to family members.  These exclusions are defined at 42 CFR 409.49.  Additionally, the RNHCI home benefit excludes the items or services provided by any HHA that is not an RNHCI; or any supplier, independent RNHCI nurse or aide that is work ing directly for a beneficiary rather than under arrangements with the RNHCI.   Medicare requires a brief letter of intent from the provider in order to determine the number of RNHCIs that will be implementing the home service benefit.
(Medicare Benefit Policy Manual)
In the case where an  RNHCI chooses to provide home services then only care on an intermittent basis, which is provided to an eligible beneficiary who is confined to their home for health reasons, will be covered under the home benefit.  The home benefit is not to be confused with hospice care, which may involve more frequent visits and can involve institutional services.  If for some reason the home serviced patient requires more than intermittent service, then institutional services may be required.  However, the patient would need to meet the criteria for admission to a RNHCI, or the patient would require another institutional setting not necessarily covered by Medicare.  Similar to the inpatient RNHCI benefit, the physician role in certifying and ordering the home benefit is replaced with the use of the RNHCI utilization review committee to review the need for care and plan for initial and continued care in the home setting.  The home benefit will also require a prompt review of admission to the home service, since the patien t must be fully eligible (have a health condition that keeps them confined to the home (42CFR409.42(a), have health needs that can be met with intermittent care, and have a valid election) before billable services can be rendered and Medicare payment reque sted.  Additionally the utilization review committee is responsible for review and approval of care plans and orders for DME items, and review of the need for the continuation of services.  As in the original RNHCI benefit, Medicare will only pay for nonme dical services in the home, but not for those religious items or services provided by the RNHCI.  Medicare covers these items and services for dates of service from January 1, 2005 through December 30, 2006.   Total Medicare payments under this benefit for each calendar year during this period are limited to $700,000.  130.4.1 - Coverage and Payment of Durable Medical Equipment Under the RNHCI Home Benefit  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Medicare covers a defined list of nonmedical DME items for RNHCI home services that are comparable to items used in the inpatient RNHCI setting and could be provided by an HHA.  The DME items include canes, crutches, walkers, commodes, a standard wheelchai r, hospital beds, bedpans, and urinals.  Those
(Medicare Benefit Policy Manual)
RNHCI setting and could be provided by an HHA.  The DME items include canes, crutches, walkers, commodes, a standard wheelchai r, hospital beds, bedpans, and urinals.  Those RNHCIs offering home services may order these items without a physician order and without compromising the beneficiary election for RNHCI care.  The need for each item of DME ordered must be supported by the RNHCI patients plan of care for the home setting and the RNHCI nurses notes for home services.  It must be noted that the benefit is applicable only to what we shall refer to as nonmedical DME items and does not include any of the related services provi ded by RNHCI staff members.
(Medicare Benefit Policy Manual)
The RNHCI shall establish a payment arrangement with one or more DME suppliers to obtain any of the items on the DME list (below) they may require for a beneficiary.  The supplier will provide the items and related instructions  on use to the beneficiary/family/care giver.  The RNHCI will submit claims for these DME items to the RNHCI specialty FI.   The RNHCI must stress to suppliers that DME claims are not to be submitted to the DMERC because this will cause the beneficiarys election for RNHCI care to be revoked.   DME Items and HCPCS Codes for use by RNHCI Home Service Units Canes   E0100 Cane, includes canes of all materials, adjustable or fixed, with tip   E0105 Cane, quad or three prong, includes canes of all materials, adjus table or fixed with tip  Crutches   E0112 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips   E0113 Crutch underarm, wood, adjustable or fixed, pair, with pad, tip and handgrip  E0114 Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips   E0116 Crutch underarm, other than wood, adjustable or fixed, with pad, tip and handgrip   Walkers   E0130 Walker, rigid (pickup), adjustable or fixed height   E0135 Walker, folding (pickup), adjustable or fixed height   E0141 Walker, rigid, wheeled, adjustable or fixed height   E0143 Walker, folding, wheeled, adjustable or fixed height   Commodes   E0163 Commode chair, stationary, with fixed arms   E0167 Pail or pan for use with commode chair   Wheelchairs   K0001 Standard wheelchair   Hospital Beds & Accessories   E0250 Hospital bed, fixed height, with any type side rails, with mattress   E0255 Hospital bed, variable height, hi- lo, with any type side rails, with mattress   E0260 Hospital bed, semi- electric (head and foot adjustment), with any type side rails, with mattress
(Medicare Benefit Policy Manual)
E0255 Hospital bed, variable height, hi- lo, with any type side rails, with mattress   E0260 Hospital bed, semi- electric (head and foot adjustment), with any type side rails, with mattress   E0275 Bed pan, standard, metal or plastic  E0276 Bed pan, fracture, metal or plastic  E0290 Hospital bed, fixed height, without side rails, with mattress   E0292 Hospital bed, variable height, hi- lo, without side rails, with mattress   E0325 Urinal; male, jug -type, any material   E0326 Urinal; female, jug -type, any material   Payment to RNHCIs for these specified DME items will be made based on the DME fee schedule.  Coinsurance applies to these items.  Deductible does not apply to these items.  130.4.2 - Coverage and Payment of Home Visits Under the RNHCI Home Benefit  (Rev. 45, Issued:  02-10-06; Effective:  05-11-06;Implementation:  05-11-06)  Medicare covers intermittent RNHCI nursing visits provided in the home to RNHCI beneficiaries.  The RNHCI nursing personnel may be skilled in ministering to a beneficiarys religious needs (not covered by Medicare), but do not have the training or nursing skill sets required of credentialed/licensed health care professionals (e.g., registered nurse).  While RNHCI nurses may provide tender loving care, they are focused primarily on religious healing and meeting basic beneficiary needs for assistance with activities of daily living (e.g., bathing, toileting, dressing , ambulation), as part of creating a milieu for religious healing.  The care provided by an RNHCI nurse is not at the level of either a registered nurse or a licensed practical nurse.  The physical care provided by an RNHCI nurse is at a level that could b e considered as supportive, but decidedly not skilled as defined by the Medicare program.   For purposes of payment for RNHCI nursing services in the home, the following services are comparable to the services of HHAs that are not RNHCIs (e.g., the RNHCI nurse and the home health aide share the following basic tasks):
(Medicare Benefit Policy Manual)
 Assist with activities of daily living which include: ambulation, bed to chair transfer, and assist with range of motion exercises; bathing, shampoo, nail care and dressing; feeding and nutr ition; and toileting;   Light housekeeping, incident to visit    Documenting visit   By comparison the home health aide will routinely perform additional medically oriented services (e.g., observation and reporting of existing medical conditions, taking and reporting vital signs, and using basic infection control procedures).   Due to the uniqueness of RNHCI nursing in the Medicare program, Medicare pays for RNHCI nursing visits at a percentage of the HHAs low utilization payment adjustment (LUPA) rate for hom e health aides.  Only a visit by an RNHCI nurse to a home will be considered as billable to Medicare.  A visit is defined as an episode in which an RNHCI nurse will render physical care to an RHNCI beneficiary in the home setting.  The visit is a single bi llable unit that is not influenced by the number of involved caregivers or the duration of the episode.  The difference in skill levels and the incorporation of RNHCI religious activity (noncovered by Medicare) into a visit, resulted in a payment rate that  is 80% of the home health aide rate adjusted by metropolitan service area (MSA) wage index rate for the involved RNHCI.   RNHCI nursing visits are paid using the LUPA system even in situations where the involved patient would not be classified as low utili zation.  The HHAs have moved to PPS, which is constructed on the medical model and therefore inappropriate for RNHCI use.  The same labor/non -labor portions applied in the HHA PPS will be used for calculating the RNHCI nursing visit payments.   Example of LUPA Payment:  An RNHCI in Baltimore, MD, provides twelve RNHCI nursing visits over the course of a 30 day period.   1.  Home Health Aide Visit (National standardized rate for 2005)  $44.76  2.  RNHCI Nurse Visit (.80 * $ 44.76)  35.81  3.  Calculate the labor portion of the Standardized       Budget Neutral Per -Visit Payment Amount for
(Medicare Benefit Policy Manual)
2.  RNHCI Nurse Visit (.80 * $ 44.76)  35.81  3.  Calculate the labor portion of the Standardized       Budget Neutral Per -Visit Payment Amount for       1 RNHCI nurse visit....(.76775 * $.35.81)  27.49  4.  Apply wage index factor for Baltimore, MD..(.9907 * $ 27.49)  27.23  5.  Calculate t he non- labor portion of the      Standardized Budget Neutral Per -Visit Payment      Amount for 1 RNHCI nurse visit.(.23225 * $ 35.81)  8.32  6.  Subtotal Low Utilization Payment Adjustment  (LUPA) wage for 1 RNHCI nurse visit..($ 27.49 + $ 8.32)  $35.55  7.  Total -  Calculate total Low Utilization Payment      Adjustment (LUPA) for 12 RNHCI nurse visits      provided during the 30 -day episode    (12 * $ 35.55)  $426.60  Step 1.  Take the HHA aide visit base rate ($ 44. 76) for the involved year (2005), from the HHA update published annually each November in the Federal Register.  Step 2.  To calculate the RNHCI nurse visit base rate, multiply the HHA base rate ($ 44.76) by the allowed percentage for an RNHCI nurse visit (.80%) to allow for religious activity and reduced physical care skill level = ($ 35.81)   Step 3. To calculate the labor portion of the Standardized Budget Neutral Per -Visit Payment Amount for 1 RNHCI nurse visit, multiply the fixed allowance .76775 by the RNHCI nurse visit r ate ($ 35.81) = ($ 27.49)   Step 4. Apply the wage index for the involved MSA from the HHA update published annually each November in the Federal Register (Baltimore, MD = .9907) multiplied by the labor portion of the RNHCI nurse visit ($ 27.49) = ($27.23).
(Medicare Benefit Policy Manual)
Step 5. To calculate the non -labor portion of the Standardized Budget Neutral Per -Visit Payment Amount for 1 RNHCI nurse visit, multiply the fixed allowance .23225 by the RNHCI nurse visit rate ($ 35.81) = ($ 8.32)   Step 6. To calculate the LUPA rate for  1 RNHCI nurse visit add the products from Step 4 ($27.49) and Step 5 ($ 8.32) = ($ 35.55)   Step 7. To calculate the LUPA payment for RNHCI nurse visits to one beneficiary in a 30 day period, multiply the product of Step 6 ($ 35.55) by the number of visits  (12) = ($ 426.60)
(Medicare Benefit Policy Manual)
Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R10892BP  08/06/2021 Internet Only Manual Updates to Publication (Pub.) 100- 02 to Implement Updates to Policy and Correct Errors and Omissions (Inpatient Rehabilitation Facility (IRF)  11/08/2021  12353  R234BP  03/10/2017 Clarification of Admission Order and Medical Review Requirements  06/12/2017  9979 R232BP  12/22/2016 January 2017 Update of the Hospital Outpatient Prospective Payment Sy stem (OPPS)  01/03/2017  9930 R179BP  01/14/2014 Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius  01/07/2014  8458 R176BP  12/13/2013 Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo  vs. Sebelius  Rescinded and replaced by Transmittal 179  01/07/2014  8458 R119BP  01/05/2010 Coverage of Inpatient Rehabilitation Services  01/04/2010  6699 R112BP  10/23/2009 Coverage of Inpatient Rehabilitation Services  Rescinded and replaced by Transmittal 119 01/04/2010  6699 R45BP  02/10/2006 Revisions to Instructions for Contractors Other Than the Religious Nonmedical Health Care Institution (RNHCI) Specialty Contractor Regardin g Claims for Beneficiaries with RNHCI Elections  05/11/2006  4218 R25BP  11/05/2004 Implementation of Coverage of Religious Nonmedical Health Care Institution (RNHCI) Items and Services Furnished in the Home, MMA section 706. 04/04/2005  3529 R1BP  10/01/2003 Introduction to the Benefit Policy Manual  N/A N/A Back to top of Chapter
(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 15  Covered Medical and Other Health Services   Table of Contents  (Rev.  12448; Issued:  01-11-24)
(Medicare Benefit Policy Manual)
Transmittals for Chapter 15  10 - Supplementary Medical Insurance (SMI) Provisions 20 - When Part B Expenses Are Incurred  20.1 - Physician Expense for Surgery, Childbirth, and Treatment for Infertility  20.2 - Physician Expense for Allergy Treatment  20.3 - Artificial Limbs, Braces, and Other Custom Made Items Ordered But Not Furnished  30 - Physician Services  30.1 - Provider- Based Physician Services  30.2 - Teaching Physician Services  30.3 - Interns and Residents  30.4 - Optometrists Services  30.5 - Chiropractors Services  30.6 - Indian Health Service (IHS) Physician and Nonphysician Services  30.6.1 - Payment for Medicare Part B Services Furnished by Certain IHS Hospitals and Clinics  40 - Effect of Beneficiary Agreements Not to Use Medicare Coverage  40.1 - Private Contracts Between Beneficiaries and Physicians/Practitioners  40.2 - General Rules of Private Contracts  40.3 - Effective Date of the Opt -Out Provision 40.4 - Definition of Physician/Practitioner  40.5 - When a Physician or Practitioner Opts Out of Medicare  40.6 - When Payment May be Made to a Beneficiary for Service of an Opt -Out Physician/Practitioner  40.7 - Definition of a Private Contract  40.8 - Requirements of a Private Contract  40.9 - Requirements of the Opt-Out Affidavit  40.10 - Failure to Properly Opt Out  40.11 - Failure to Maintain Opt- Out 40.12 - Actions to Take in Cases of Failure to Maintain Opt- Out 40.13 - Physician/Practitioner Who Has Never Enrolled in Medicare  40.14 - Nonparticipating Physicians or Practitioners Who Opt Out of Medicare  40.15 - Excluded Physicians and Practitioners  40.16 - Relationship Between Opt- Out and Medicare Participation Agreements  40.17 - Participating Physicians and Practitioners  40.18 - Physicians or Practitioners Who Choose to Opt Out of Medicare  40.19 - Opt -Out Relationship to Noncovered Services  40.20 - Maintaining Information on Opt-Out Physicians  40.21 - Informing Medicare Managed Care Plans of the Identity of the Opt-Out Physicians or Practitioners  40.22 -  Informing the National Supplier Clearinghouse (NSC) of the Identity of the Opt -Out Physicians or Practitioners  40.23 -  Organizations That Furnish Physician or Practitioner Services  40.24 -  The Difference Between Advance Beneficiary Notices (ABN) and Private Contracts  40.25
(Medicare Benefit Policy Manual)
(NSC) of the Identity of the Opt -Out Physicians or Practitioners  40.23 -  Organizations That Furnish Physician or Practitioner Services  40.24 -  The Difference Between Advance Beneficiary Notices (ABN) and Private Contracts  40.25 -  Private Contracting Rules When Medicare is the Secondary Payer  40.26 -  Registration and Identification of Physicians or Practitioners Who Opt Out  40.27 -  System Identification  40.28 -  Emergency and Urgent Care Situations  40.29 -  Definition of Emergency and Urgent Care Situations  40.30 -  Denial of Payment to Employers of Opt -Out Physicians and Practitioners  40.31 -  Denial of Payment to Beneficiaries and Others  40.32 -  Payment for Medically Necessary Services Ordered or Prescribed by an Opt -out physician or Practitioner  40.33 -  Mandatory Claims Submission  40.34 -  Cancellation of Opt -Out 40.35 -  Early Termination of Opt -Out 40.36 -  Appeals  40.37 -  Application to the Medicare Advantage Program  40.38 -  Claims Denial Notices to Opt- Out Physicians and Practitioners  40.39 -  Claims Denial Notices to Beneficiaries  50 - Drugs and Biologicals  50.1 -  Definition of Drug or Biological  50.2 -  Determining Self -Administration of Drug or Biological  50.3 -  Incident -to Requirements  50.4 -  Reasonableness and Necessity  50.4.1 -  Approved Use of Drug  50.4.2 -  Unlabeled Use of Drug  50.4.3 -  Examples of Not Reasonable and Necessary  50.4.4 -  Payment for Antigens and Immunizations  50.4.4.1 -  Antigens  50.4.4.2 -  Immunizations  50.4.5 -  Off Lable Use of Anti -Cancer Drugs and Biologicals  50.4.5.1 -  Process for Amending the List of Compendia for Determination of Medically -Accepted Indications for Off -Label Uses of Drugs and Biologicals in an Anti-Cancer Chemotherapeutic Regimen  50.4.6 -  Less Than Effective Drug  50.4.7 -  Denial of Medicare Payment for Compounded Drugs Produced in Violation of Federal Food, Drug, and Cosmetic Act  50.4.8 -  Process for Amending the List of Compendia for Determination of Medically-Accepted Indications for Off -Label Uses of Drugs and Biologicals in an Anti -Cancer Chemotherapeutic Regimen  50.5 -  Self-Administered Drugs and Biologicals  50.5.1 -
(Medicare Benefit Policy Manual)
for Determination of Medically-Accepted Indications for Off -Label Uses of Drugs and Biologicals in an Anti -Cancer Chemotherapeutic Regimen  50.5 -  Self-Administered Drugs and Biologicals  50.5.1 -  Immunosuppressive Drugs  50.5.2 -  Erythropoietin (EPO)  50.5.2.1 -  Requirements for Medicare Coverage for EPO  50.5.2.2 -  Medicare Coverage of Epoetin Alfa (Procrit) for Preoperative Use  50.5.3 -  Oral Anti -Cancer Drugs  50.5.4 -  Oral Anti -Nausea (Anti -Emetic) Drugs  50.5.5 -  Hemophilia Clotting Factors  50.6 -  Coverage of Intravenous Immune Globulin for Treatment of Primary Immune Deficiency Diseases in the Home  60 - Services and Supplies  Furnished Incident To a Physician's/NPP's Professional Service  60.1 -  Incident To Physicians Professional Services  60.2 -  Services of Nonphysician Personnel Furnished Incident To Physicians Services  60.3 -  Incident To PhysiciansServices in Clinic  60.4 -  Services Incident to a Physicians Service to Homebound Patients Under General Physician Supervision 60.4.1 -  Definition of Homebound Patient Under the Medicare Home Health (HH) Benefit  70 - Sleep Disorder Clinics  80 - Requirements for Diagnostic X -Ray, Diagnostic Laboratory, and Other Diagnostic Tests  80.1 -  Clinical Laboratory Services  80.1.1 -  Certification Changes  80.1.2 -  A/B MAC (B)  Contacts With Independent Clinical Laboratories  80.1.3 -  Independent Laboratory Service to a Patient in the Patients Home or an Institution 80.2 -  Psychological and Neuropsychological Tests  80.3 -  Audiology Services  80.3.1 -  Definition of Qualified Audiologist  80.4 -  Coverage of Portable X -Ray Services Not Under the Direct Supervision of a Physician 80.4.1 -  Diagnostic X -Ray Tests  80.4.2 -  Applicability of Health and Safety Standards  80.4.3 -  Scope of Portable X -Ray Benefit  80.4.4 -  Exclusions From Coverage as Portable X -Ray Services  80.4.5 -  Electrocardiograms  80.5 -  Bone Mass Measurements (BMMs)  80.5.1 -  Background  80.5.2 -  Authority 80.5.3
(Medicare Benefit Policy Manual)
From Coverage as Portable X -Ray Services  80.4.5 -  Electrocardiograms  80.5 -  Bone Mass Measurements (BMMs)  80.5.1 -  Background  80.5.2 -  Authority 80.5.3 -  Definition  80.5.4 -  Conditions for Coverage  80.5.5 -  Frequency Standards  80.5.6 -  Beneficiaries Who May be Covered  80.5.7 -  Noncovered BMMs  80.5.8 -  Claims Processing  80.5.9 -  National Coverage Determinations (NCDs)  80.6 -  Requirements for Ordering and Following Orders for Diagnostic Tests  80.6.1 -  Definitions  80.6.2 -  Interpreting Physician Determines a Different Diagnostic Test is Appropriate  80.6.3 -  Rules for Testing Facility to Furnish Additional Tests  80.6.4 -  Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests  80.6.5 -  Surgical/Cytopathology Exception 90 - X-Ray, Radium, and Radioactive Isotope Therapy  100 -  Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations  110 -  Durable Medical Equipment -  General  110.1 -  Definition of Durable Medical Equipment  110.2 -  Repairs, Maintenance, Replacement, and Delivery  110.3 -  Coverage of Supplies and Accessories  110.4 -  Miscellaneous Issues Included in the Coverage of Equipment  110.5 -  Incurred Expense Dates for Durable Medical Equipment  110.6 -  Determining Months for Which Periodic Payments May Be Made for Equipment Used in an Institution  110.7 -  No Payment for Purchased Equipment Delivered Outside the United States or Before Beneficiarys Coverage Began