evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Beginning January 1, 2006, hospitals should not report CPT codes 99217- 99220 or 99234- 99236 for observation services.  In addition, the following HCPCS codes were discontinued as of January 1, 2006:  G0244 (Observation care by facility to patient), G0263 ( Direct Admission with congestive heart failure, chest pain or asthma), and G0264 (Assessment other than congestive heart failure, chest pain, or asthma).   The three discontinued G -codes and the CPT codes that were no longer recognized were replaced by two new G -codes to be used by hospitals to report all observation services, whether separately payable or packaged, and direct referral for observation care, w hether separately payable or packaged:    G0378-  Hospital observation service, per hour; and   G0379-  Direct admission of patient for hospital observation care.   The I/OCE determines whether observation services billed as units of G0378 are separately payable under APC 0339 (Observation) or whether payment for observation services will be packaged into the payment for other services provided by the hospital in the same encounter.  Therefore, hospitals should bill HCPCS code G0378 when observation services are ordered and provided to any patient regardless of the patients condition. The units of service should equal the number of hours the patient receives observati on services.   Hospitals should report G0379 when observation services are the result of a direct referral for observation care without an associated emergency room visit, hospital outpatient clinic visit, critical care service, or hospital outpatient surgical procedure (status indicator T procedure) on the day of initiation of observation services.  H ospitals should only report HCPCS code G0379 when a patient is referred directly for observation care after being seen by a physician in the community (see 290.4.2 below)
(Medicare Claims Processing Manual)
2. Observation Time   a. Observation time must be documented in the medical record.   b. Hospital billing for observation services begins at the clock time documented in the patients medical record, which coincides with the time that observation services are initiated in accordance with a physicians order for observation services.   c. A beneficiary's time receiving observation services (and hospital billing) ends when all clinical or medical interventions have been completed, including follow -up care furnished by hospital staff and physicians that may take place after a physician has  ordered the patient be released or admitted as an inpatient.  d. The number of units reported with HCPCS code G0378 must equal or exceed 8 hours.  3. Additional Hospital Services   a. The claim for observation services must include one of the following services in addition to the reported observation services.  The additional services listed below must have a line item date of service on the same day or the day before the date reported for observation:    An emergency department visit (APC 0609, 0613, 0614, 0615, 0616) or   A clinic visit (APC 0604, 0605, 0606, 0607, 0608); or   Critical care (APC 0617); or   Direct referral for observation care reported with HCPCS code G0379 (APC 0604); must be reported on the same date of service as the date reported for observation services.   b. No procedure with a T status indicator can be reported on the same day or day before observation care is provided.  4. Physician Evaluation  a. The beneficiary must be in the care of a physician during the period of observation, as documented in the medical record by outpatient registration, discharge, and other appropriate progress notes that are timed, written, and signed by the physician.  b. The medical record must include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care.   Only observation services that are billed on a 13X bill type may be considered for a separate APC payment.
(Medicare Claims Processing Manual)
Only observation services that are billed on a 13X bill type may be considered for a separate APC payment.   Hospitals should bill all of the other services associated with the observation care, including direct referral for observation, hospital clinic visits, emergency room visits, critical care services, and T status procedures, on the same claim so that the claims processing logic may appropriately determine the payment status (either packaged or separately payable) of HCPCS codes G0378 and G0379.  If a bill for observation care does not meet all of the requirements listed above, then payment for the observation care will be packaged into payments for other separately payable services provided to the beneficiary in the same encounter.   290.5 - Billing and Payment for Observation Services Furnished on or After January 1, 2008 (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  290.5.1 - Billing and Payment for Observation Services Furnished Between January 1, 2008 and December 31, 2015  (Rev. 3425, Issued: 12- 18-15, Effective: 01 -01-16, Implementation: 01- 04-16)
(Medicare Claims Processing Manual)
b. The medical record must include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care.   Criteria 1 and 3 related to observation care beginning and ending time and physician evaluation apply regardless of whether the hospital believes that the criteria will be met for payment of the extended encounter through extended assessment and management  composite payment.  Only visits, critical care and observation services that are billed on a 13X bill type may be considered for a composite APC payment.  Non-repetitive services provided on the same day as either direct referral for observation care or observation services must be reported on the same claim because the OCE claim -by-claim logic cannot function properly unless all services related to the episode of observation care, including hospital clinic visits, emergency department visits, critical care services, and T status procedures, are reported on the same claim.  Additional guidance can be found in chapter 1, section 50.2.2 of this manual.  If a claim for services provided during an extended assessment and management encounter including observation care does not meet all of the requirements listed above, then the usual APC logic will apply to separately payable items and services on the claim ; the special logic for direct admission will apply, and payment for the observation care will be packaged into payments for other separately payable services provided to the beneficiary in the same encounter.   290.5.2 - Billing and Payment for Direct Referral for Observation Care Furnished Beginning January 1, 2008  (Rev. 3425, Issued: 12- 18-15, Effective: 01 -01-16, Implementation: 01- 04-16)
(Medicare Claims Processing Manual)
Observation services are reported using HCPCS code G0378 (Hospital observation service, per hour).  Beginning January 1, 2008, HCPCS code G0378 for hourly observation services is assigned status indicator N, signifying that its payment is always packaged.  No separate payment is made for observation services reported with HCPCS code G0378, and APC 0339 is deleted as of January 1, 2008.  In most circumstances, observation services are supportive and ancillary to the other services provided to a patient.  Beg inning January 1, 2016, in certain circumstances when observation services are billed in conjunction with a clinic visit, Type A emergency department visit (Level 1 through 5), Type B emergency department visit (Level 1 through 5), critical care services, or a direct referral as an integral part of a patients extended encounter of care, comprehensive payment may be made for all services on the claim including, the entire extended care encounter through comprehensive APC 8011 (Comprehensive Observation Services) when certain criteria are met. For information about comprehensive APCs, see 10.2.3 (Comprehensive APCs) of this chapter.   There is no limitation on diagnosis for payment of APC 8011; however, comprehensive APC payment will not be made when observation services are reported in association with a surgical procedure (T status procedure) or the hours of observation care reported are less than 8.  The I/OCE evaluates every claim received to determine if payment through a comprehensive  APC is appropriate.  If payment through a comprehensive  APC is inappropriate, the I/OCE, in conjunction with the Pricer, determines the appropriate status indicator, APC, and payment for every code on a claim.   All of the following requirements must be met in order for a hospital to receive a comprehensive APC payment through the Comprehensive Observation Services APC (APC 8011):   1.  Observation Time   a. Observation time must be documented in the medical record.   b. Hospital billing for observation services begins at the clock time documented in the patients medical record, which coincides with the time that observation services are initiated in accordance with a physicians order for observation services.
(Medicare Claims Processing Manual)
b. The medical record must include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care.   Criteria 1 and 3 related to observation care beginning and ending time and physician evaluation apply regardless of whether the hospital believes that the criteria will be met for payment of the extended encounter through the Comprehensive Observation Services APC (APC 8011).  Only visits, critical care and observation services that are billed on a 13X bill type may be considered for a comprehensive APC payment through the Comprehensive Observation Services APC (APC 8011).  Non-repetitive services provided on the same day as either direct referral for observation care or observation services must be reported on the same claim because the OCE claim -by-claim logic cannot function properly unless all services related to the episode of observation care, including hospital clinic visits, emergency department visits, critical care services, and T status procedures, are reported on the same claim.  Additional guidance can be found in chapter 1, section 50.2.2 of this manual.  If a claim for services provided during an extended assessment and management encounter including observation care does not meet all of the requirements listed above, then the usual APC logic will apply to separately payable items and services on the claim; the special logic for direct admission will apply, and payment for the observation care will be packaged into payments for other separately payable services provided to the beneficiary in the same encounter.   290.6 - Services Not Covered as Observation Services  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  Hospitals must not bill beneficiaries directly for reasonable and necessary observation services for which the OPPS packages payment for observation as part of the payment for the separately payable items and services on the claim.  Hospitals should not confuse packaged payment with non- coverage or nonpayment.  See the Medicare Benefit Policy Manual, Pub 100- 02, chapter 6, section 20.6 for further explanation of non- covered services and notification of the beneficiary in relation to observation care.      300 - Medical Nutrition Therapy (MNT) Services  ((Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)
(Medicare Claims Processing Manual)
The MNT benefit is a completely separate benefit from the diabetes self -management training (DSMT) benefit. CMS had originally planned to limit how much of both benefits a beneficiary might receive in the same time period. However, the national coverage determination, published May 1, 2002, allows a beneficiary to receive the full amount of both benefits in the same period. Therefore, a beneficiary can receive the full 10 hours of initial DSMT and the full 3 hours of MNT. However, providers are not allowed to bill for both DSMT and MNT on the same date of service for the same beneficiary.    300.1 - General Conditions and Limitations on Coverage  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  A. General Conditions of Coverage   The following are the general conditions of coverage:    A physician must make a referral and indicate a diagnosis of diabetes or renal disease. Physician is defined in 1861(r)(l) of the Act.    The number of hours covered in an episode of care may not be exceeded unless a second referral is received from the physician;    Services may be provided either on an individual or group basis without restrictions and;    For a beneficiary with a diagnosis of diabetes, DSMT and MNT services can be provided within the same time period, and the maximum number of hours allowed under each benefit are covered. The only exception is that DSMT and MNT may not be provided on the same day to the same beneficiary. For a beneficiary with a diagnosis of diabetes who has received DSMT and is also diagnosed with renal disease in the same episode of care, the beneficiary may receive MNT services based on a change in medical condition, di agnosis, or treatment as stated in 42 CFR 410.132(b)(5).   B. Limitations on Coverage   The following limitations apply:    MNT services are not covered for beneficiaries receiving maintenance dialysis for which payment is made under section 1881 of the Act.   A beneficiary may not receive MNT and DSMT on the same day.   300.2 - Referrals for MNT Services  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)
(Medicare Claims Processing Manual)
C. A/B MAC (A)  Special Billing Instructions   MNT Services can be billed to A/B MACs (A) when performed in an outpatient hospital setting.  The Hospital outpatient departments can bill for the MNT services through the A/B MAC (A) if the nutritionists or registered dietitians reassign their benefits to  the hospital.  If the hospitals do not get the reassignments the nutritionists and the registered dietitians will have to bill the Medicare A/B MAC (B) under their own provider number or the hospital will have to bill the Medicare A/B MAC (B).   NOTE:   Nutritionists and registered dietitians must obtain a Medicare provider number before they can reassign their benefits.   The only applicable bill types are 13X, 23X, 32X, and 85X.      300.5.1 - Rural Health Centers (RHCs)/Federally Qualified Health Centers (FQHCs) Special Billing Instructions  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  Detailed billing instructions for MNT services provided in Rural Health Clinics and Federally Qualified Health Centers can be found in Chapter 9, section 182 of this manual.   300.6 - Common Working File (CWF) Edits  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  The Common Working File (CWF) edit will allow 3 hours of therapy for MNT in the initial calendar year. The edit will allow more than 3 hours of therapy if there is a change in the beneficiarys medical condition, diagnosis, or treatment regimen and this change must be documented in the beneficiarys medical record. Two new G codes have been created for use when a beneficiary receives a second referral in a calendar year that allows the beneficiary to receive more than 3 hours of therapy. Another edit will a llow 2 hours of follow up MNT with another referral in subsequent years.   Advance Beneficiary Notice (ABN)
(Medicare Claims Processing Manual)
Group Code: CO  CARC: 96  RARC: N386  MSN: 16.10Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl  Date  CR#  R12421CP  12/21/2023 January 2024 Update of the Hospital Outpatient Prospective Payment System (OPPS)   01/02/2024 13488  R12423CP   12/20/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024 13222  R12369CP  11/17/2023 Implementation of Rural Emergency Hospital (REH) Provider Type   01/03/2023    12820  R12321CP  10/18/2023 Implementation of Rural Emergency Hospital (REH) Provider Type - Rescinded and replaced by Transmittal 12369  01/03/2023 12820   07/13/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92-  SENSITIVE/CONTROVERSIAL  Rescinded and replaced by Transmittal 12423 01/02/2024 13222  R11941CP  04/05/2023 Correction to Manual for Outlier Calculations 05/05/2023 13142  R11937CP  03/31/2023 April 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS)   04/03/2023 13136  R11900CP  03/13/2023 Implementation of Rural Emergency Hospital (REH) Provider Type -- Rescinded and replaced by Transmittal 12321  01/03/2023 12820  R11897CP  03/10/2023 April 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS) - Rescinded and replaced by Transmittal 11 937 04/03/2023 13136  R11801CP  01/20/203 January 2023 Update of the Hospital Outpatient Prospective  Payment System (OPPS)
(Medicare Claims Processing Manual)
01/03/2023 13031  Rev #  Issue Date  Subject  Impl  Date  CR#  R11737CP  12/08/2022 January 2023 Update of the Hospital Outpatient Prospective Payment System (OPPS)  - Rescinded and replaced by transmittal 11801 01/03/2023 13031  R11729CP  12/06/2022 Implementation of Rural Emergency Hospital (REH) Provider Type - Rescinded and replaced by transmittal  11900 01/03/2023 12820       R11685CP  11/09/2022 Billing for Hospital Part B Inpatient Services  12/12/2022 11685   07/28/2022 Implementation of Rural Emergency Hospital (REH) Provider Type SENSITIVE/CONTROVERSIAL   Rescinded and replaced by transmittal 11729  01/03/2023 12820  R11504CP   07/21/2022 Modification of Existing Common Working File (CWF) Editing for Preventive Services   01/03/2023 12792  R11457CP  06/15/2022 July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  07/05/2022 12761  R11435CP  05/26/2022 July 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  -Rescinded and Replaced by Transmittal #11457 07/05/2022 12761  R11426CP   05/20/2022 An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilit ation (ICR) Conditions of Coverage
(Medicare Claims Processing Manual)
07/05/2022 12613  R11396CP  05/04/2022 Update to Chapters 3, 4, 27 and 37 of Publication (Pub.) 100 -04 Medicare 10/03/2022 12715  Rev #  Issue Date  Subject  Impl  Date  CR#  Claims Processing Manual to Remove Reference to the Term "OSCAR"  R11272CP  02/18/2022 An Omnibus CR Covering: (1) Removal of Two National Coverage Determination (NCDs), (2) Updates to the Medical Nutrition Therapy (MNT) Policy, and (3) Updates to the Pulmonary Rehabilitation (PR), Cardiac Rehabilitation (CR), and Intensive Cardiac Rehabilit ation (ICR) Conditions of Coverage  -Rescinded and Replaced by Transmittal #11426  07/05/2022 12613  R11305CP  03/24/2022 April 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  04/04/2022 12666  R11150CP  12/10/2021 January 2022 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/03/2021 12552  R10869CP  07/14/2021 Updates to Chapter 4, Section 10.11.9 -  Methodology for Calculation of the Cost-to-Charge Ratio [CCR] for Community Mental Health Centers [CMHCs] in the Medicare Claims Processing Manual  08/13/2021 12332 R10541CP  12/31/2020 January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/04/2021 12120 R4513CP  02/04/2020 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)   01/06/2020 11605 R4494CP  01/15/2020 January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) - No Longer Sensitive Rescinded and Replaced by Transmittal #4513 01/06/2020 11605
(Medicare Claims Processing Manual)
12/20/2019 January 2020 Update of the Hospital Outpatient Prospective Payment 01/06/2020 11605 Rev #  Issue Date  Subject  Impl  Date  CR#  System (OPPS) - Sensitive/Controversial  Rescinded and Replaced by Transmittal # 4494  R4394CP  09/13/2019 Billing for Hospital Part B Inpatient Services  10/15/2019 11413 R4390CP   09/06/2019 Fiscal Year (FY) 2020 Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital (LTCH) PPS Changes   10/07/2019 11361 R4391CP  09/06/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model  07/01/2019 10971 R4337CP    07/18/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4391  07/01/2019 10971 R4308CP  05/16/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and Replaced by Transmittal 4337  07/01/2019 10971 R4295CP  05/03/2019 Update to the Internet Only Manual (IOM) Publication (Pub.) 100- 04, Chapter 4  08/27/2019 11274 R4308CP  05/16/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model  07/01/2019 10971
(Medicare Claims Processing Manual)
R4259CP  03/22/2019 Billing for Hospital Part B Inpatient Services  06/21/2019    11181 R4257CP  03/14/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD 07/01/2019 10971 Rev #  Issue Date  Subject  Impl  Date  CR#  TCOC) Model - Rescinded and replaced by Transmittal 4308 R4255CP  03/15/2019 April 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)  04/01/2019 11216 R4233CP  02/08/2019 Update to Publication (Pub.) 100- 04 Chapters 4 and 17 to Provide Language -Only Changes for the New Medicare Card Project  03/12/2019 11084 R4230CP  02/01/2019 Implementation of the Medicare Performance Adjustment (MPA) for the Maryland Total Cost of Care (MD TCOC) Model - Rescinded and replaced by Transmittal 4257 07/01/2019 10971 R4204CP  01/17/2019 January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/07/2019 11099 R4186CP  12/31/2018 January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS) - Rescinded and replaced by Transmittal 4204 01/07/2019 11099 R4157CP  11/02/2018 Hospital and Critical Access Hospital (CAH) Swing -Bed Manual Revisions and Shared Systems Changes  04/01/2019 10962 R3941CP  12/22/2017 January 2018 Update of the Hospital Outpatient Prospective Payment System (OPPS)  01/02/2018 10417 R3795CP  06/17/2017 Updates in the Fiscal Intermediary Shared System (FISS) Inpatient and Outpatient Provider Specific Files (PSF)  10/02/2017 10165 R3750CP  04/17/2017 New Fields in the Fiscal Intermediary Shared System (FISS) Inpatient and Outpatient Provider Specific Files (PSF)  07/03/2017 9926 Rev #  Issue Date  Subject  Impl  Date  CR#  R3739CP  03/17/2017 Billing for Advance Care Planning (ACP) Claims  06/19/2017 10000 R3685CP  12/22/2016 January 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)