evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The CWF:    rejects a DME MAC claim that contain DMEPOS HCPCS codes when the DME MAC claim has a date of service that falls within the inpatient stay;   considers an inpatient stay to include all days prior to the date of discharge;    processes a DME MAC claim that contain DMEPOS HCPCS codes when the DME MAC claim has the same from date equal to the date of inpatient discharge;    validates for a crossover service on a DME MAC claim for an inpatient beneficiary based on the from date only of the DME MAC claim;    identifies a DME MAC claim for maintenance and servicing by the MS modifier; and   allows payment for a DME MAC claim for maintenance and servicing of capped rental items when a claim contains the MS modifier.   The CWF approves to pay maintenance and servicing claims regardless of whether the beneficiary is in an institutional setting or in the home environment.   The changes in the general policy apply to all items of DMEPOS paid by the DME MACs, however, changes in anniversary date billing apply only to capped rental DME.   In cases where the anniversary date falls at the end of the month (for example January 31) and a subsequent month does not have a day with the same date (for example, February), the DME MAC uses the final date in the calendar month (for example, February 28).   EXAMPLE 1:   A beneficiary rents a wheelchair beginning on January 1.  The DME MAC determines that the wheelchair is medically necessary and that the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair.  The beneficiary enters a covered a hospital on February 15 and is discharged on April 5.   In this example, Medicare pays for the entire month of February, because the patient was in the home for part of the month.  However, the DME MAC denies the claim for March, because the patient was in a covered hospital stay for the entire month.
(Medicare Claims Processing Manual)
Because the anniversary date (from date) of the monthly bill was April 1, and the patient was still in the covered hospital stay on that date, the DME supplier must not submit another claim until April 5 (the date of discharge).  April 5 becomes the new anniversary date (from date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1 st of the month for the remainder of the capped rental period.  The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date.   EXAMPLE 2:   A beneficiary receives oxygen on January 1.  On February 28, the patient enters a hospital and is discharged on March 15.   In this example, the DME MAC denies a claim dated March 1.  The supplier submits a new claim dated March 15, which would then become the anniversary date for billing purposes.  The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date.   EXAMPLE 3:   A beneficiary rents a hospital bed beginning on January 1.  On March 15, the patient enters a hospital and is discharged on March 25.   In this example, the DME MAC pays for the entire month of March.   EXAMPLE 4:  A beneficiary rents a wheelchair beginning December 15.  On January 1, the patient enters a hospital and is discharged on January 31.   In this example, the DME MAC denies the claim dated January 15.  The supplier submits a new claim dated January 31, which becomes the anniversary date for billing purposes.  The supplier should annotate the claim to indicate that the patient was in a hospital on the first claim with the new anniversary date.  The February claim would be dated February 28 because there is no 31st day in February.   211 - SNF Consolidated Billing and DME Provided by DMEPOS Suppliers  (Rev. 222, Issued: 07- 02-04) (Effective/Implementation: Not Applicable)
(Medicare Claims Processing Manual)
211 - SNF Consolidated Billing and DME Provided by DMEPOS Suppliers  (Rev. 222, Issued: 07- 02-04) (Effective/Implementation: Not Applicable)  211.1 - General Information  (Rev. 222, Issued: 07- 02-04) (Effective/Implementation:  Not Applicable)  The Social Security Act (1861(n)) specifies that a hospital or a skilled nursing facility (SNF) cannot be considered a patients home for purposes of the DME benefit.  (This restriction of coverage to only those items that are furnished for use in the patients home does not apply to coverage under the separate Part B benefits for Prosthetics, Orthotics, and Supplies, which are payable without regard to the particular setting in which they are furnished.)  When DME is furnished for use in a SNF during a covered Part A stay , the DME MACs shall not make separate payment for DME, since the DME is already included in the payment that the SNF receives for the covered stay itself.  When DME is furnished for use in a SNF during a noncovered stay (SNF benefits exhausted, no qualifying 3- day hospital stay, etc.), the DME MACs still shall not make separate payment for DME, as explained above, Part Bs DME benefit does not cover DME items that are furnished for use in S NFs.  Even if a patient already rents or owns a piece of DME in their home, the SNF cannot require the patient to bring their own rented or purchased DME with them into the SNF.  211.2 - Partial Month Stays For Capped Rental Equipment  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)
(Medicare Claims Processing Manual)
A. General Rule  For capped rental DME items where the DME supplier submits a monthly bill, the date of delivery (the from date) on the first claim must be the from, or anniversary date, on all subsequent claims for the item.  For example, if the first claim for a wh eelchair is dated September 15, all subsequent bills must be dated on the 15th of the following months (October 15, November 15, etc.).   The following instructions discuss DME payment when the DME is furnished during a month in which the beneficiary spends part of the month in a SNF, and part of the month in his or her own home.  In accordance with DME payment policy, Medicare will make separate payment for a full month for DME items in such situations, provided the beneficiary was in the home on the from date or anniversary date defined above.   B. Policy   If a beneficiary using DME is at home on the from or anniversary date, Medicare will make payment for DME for the entire month, even if the from date is the date of discharge from the SNF.   If a beneficiary using DME is in a covered Part A stay in a SNF for a full month, Medicare will not make payment for DME for that month.   For capped rental items, if the covered Part A SNF stay overlaps the from or anniversary date of the Certificate of Medical Necessity (CMN), and the beneficiary is not in the covered Part A SNF stay for the entire month, the date of discharge becomes the new anniversary date for subsequent claims.  In this situation, the supplier must submit a new claim with the date of discharge as the new anniversary date upon the beneficiarys release from the SNF.  Suppliers should annotate claims, to indicate tha t the patient was in a SNF, resulting in the need to establish a new anniversary date.   NOTES:  The  DME MACs must continue to make payment for maintenance and servicing of capped rental items regardless of whether the beneficiary is in a covered Part A SNF stay on the date of service of the maintenance and servicing claim.
(Medicare Claims Processing Manual)
NOTES:  The  DME MACs must continue to make payment for maintenance and servicing of capped rental items regardless of whether the beneficiary is in a covered Part A SNF stay on the date of service of the maintenance and servicing claim.   The DME MACs must make payment for DME on the date of discharge from a covered Part A SNF stay.  Claims must edit based on the from date of the claim and not the through date of the claim.   EXAMPLE 1:   A beneficiary rents a wheelchair beginning on January 1.  The DME MAC determines that the wheelchair is medically necessary and that the beneficiary meets all coverage criteria, and so begins to make payment on the wheelchair.  The beneficiary enters a covered Part A stay in a SNF on February 15 and is discharged on April 5.  In this example, Medicare will make payment for the entire month of February, because the patient was in the home for part of the month.  However, the DME MAC will deny the claim for March, because the patient was in a covered Part A stay in the SNF for the entire month.  Because the anniversary date (from date) of the monthly bill was April 1, and the patient was still in the covered Part A stay in a SNF on that date, the DME supplier must not submit another claim until April 5 (the date of discharge).  April 5 becomes t he new anniversary date (from date) for billing purposes, so the supplier would now bill on the 5th of the month rather than the 1st of the month for the remainder of the capped rental period.  The supplier should annotate the claim to indicate that the patient was in a SNF on the first claim with the new anniversary date.   EXAMPLE 2:   A beneficiary receives oxygen on January 1.  On February 28, the patient enters a covered Part A stay in a SNF and is discharged on March 15.   In this example, the DME MAC would deny a claim dated March 1.  The supplier would submit a new claim dated March 15, which would then become the anniversary date for billing purposes.  The supplier should annotate the claim to indicate that the patient wa s in a covered Part A stay in a SNF on the first claim with the new anniversary date.   EXAMPLE 3:
(Medicare Claims Processing Manual)
EXAMPLE 3:   A beneficiary rents a hospital bed beginning on January 1.  On March 15, the patient enters a covered Part A stay in a SNF and is discharged on March 25.  In this example, the DME MAC will make payment for the entire month of March.   NOTE:  The changes in the general policy in this instruction apply to all items of DME paid by the DME MACs.  However, changes in anniversary date billing requirements only apply to capped rental DME.  212 - Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers  (Rev.  2977, Issued; 06- 20-14, Effective: 09 -23-14; ICD- 10: Upon Implementation of ICD- 10, Implementation: 09 -23-14; ICD -10: Upon Implementation of ICD -10)  Section 1842 (b)(6)(F) of the Social Security Act requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician.  Consequently, Medicare makes payment for all such items and services to a single home health agency (HHA) overseeing that plan.  The law states payment will be made to the HHA without regard as to whether or not the item or service was furnished by the agency, by others under arrangement to the HHA, or when any other contracting or consulting arrangements exist with the primary HHA, or otherwise.  Payment for all items is included in the home health prospective payment system (HH PPS) episode payment the HHA receives.   Nonroutine medical supplies are among the types of services that are subject to the home health consolidated billing provision.  Medicare periodically publishes Recurring Update Notifications that contain updated lists of nonroutine supply codes that must be included in home health consolidated billing.  These services may not be billed separately by a DMEPOS supplier when a Medicare beneficiary is in a HH PPS episode of care.   Durable Medical Equipment (DME), including prosthetics, orthotics and oxygen, is exempt from home health consolidated billing by law.  For detailed information regarding home health consolidated billing, DMEPOS suppliers should refer to chapter 10, section 20 of this manual.
(Medicare Claims Processing Manual)
213- Billing for Home IVIG Items and Services  (Rev. 12437, Issued: 12- 28-23, Effective: 01 -01-24, Implementation: 01- 02-24)  Effective January 1, 2024, Medicare makes a separate bundled payment for home intravenous immune globulin (IVIG) items and services to DME suppliers. This payment amount covers the cost of nursing services and supplies including an infusion set and tubing, for the provision of IVIG administration in  the home by a DME supplier.    The items and services payment is made per visit for days on which the IVIG is administered by a nurse in the patients home. The patient must have a diagnosis of Primary Immune Deficiency Disease (PIDD) as indicated in the Intravenous Immune Globulin Poli cy Article (A5209). Payment for home IVIG items and services is only made when the patient is receiving one of the IVIG products listed on the Local Coverage Determination (LCD) for Intravenous Immune Globulin (L33610).   A single payment will be made for the items and services provided on the calendar day when such items and services are furnished in the home. The HCPCS (Q2052) Services, Supplies, and Accessories used in the Home for the Administration of Intravenous Immune Globulin) will be billed separately from, or on the same claim as, the J -code for the IVIG product. The Q -code should be billed as a separ ate claim line on the same claim for the same place of service as the J-code for the IVIG. In cases where the IVIG  product is mailed or delivered to the patient prior to administration, the date of service for the administration of the IVIG (the Q -code) may be no more than 30 calendar days after the date of service on the IVIG product claim line. No more than one Q -code should be billed per claim line per date of service.
(Medicare Claims Processing Manual)
If a provider is billing for multiple administrations of IVIG on a single claim, then the supplier would bill the Q -code for each date of service on a separate claim line, which would be payable per visit (that is, each time the IVIG is administered). Ther e may be situations in which multiple units of IVIG are shipped to the patient and billed on a single J code claim line followed by more than one Q -code administration claim line, each with the date of service on which the IVIG was administered. However, only one unit of service (Q -code) shall be paid per infusion date of service.   Providers should report visit length in 15- minute increments (15 minutes=1 unit) ) when billing for IVIG (Q2052) . See the table below for the rounding of units.    Rounding of Time Units   Unit Time  1 <23 minutes  2 = 23 minutes to <38 minutes  3 = 38 minutes to <53 minutes  4 = 53 minutes to <68 minutes  5 = 68 minutes to <83 minutes  6 = 83 minutes to <98 minutes  7 = 98 minutes to <113 minutes  8 = 113 minutes to <128 minutes  9 = 128 minutes to <143 minutes  10 = 143 minutes to <158 minutes    A submitted claim for home IVIG items and services is subject to a Common Working File (CWF) edit in the event that an IVIG J -code is not found on the same claim as the IVIG items and services payment code (Q -code), or in claims history in the previous 30 days. If a J -code is not found on the same claim as the Q -code, the claims processing system will recycle the Q -code claim for the IVIG items and services associated with the administration of the IVIG product (J -code), until a claim containing the J -code for IVIG product is received in the CWF. The home IVIG items and services claim will recycle three times (with a 30 -day look back period) for a total of 15 business days. After 15 business days, if no J -code claim is found in claims history, the Q -code cla im will be denied.
(Medicare Claims Processing Manual)
Suppliers must ensure that an eligible J -code (as indicated on L33610) associated with the visit is billed with the visit or no more than 30 days prior to the visit. Visits are denied if an eligible J -code for the visit is not billed. Claims reporting mult iple visits on the same line item date of service will be returned as unprocessable.  220 - Appeals  (Rev. 1, 10- 01-03)  See chapter 29 for a description of the appeals process.   230 - DME MAC Systems (Rev. 629, Issued:  07- 29-05; Effective:  01 -01-06; Implementation:  01 -03-06)  The VMS shall allow the DME MACs  the flexibility to report CMN edits as medical review or claims processing workload.    300 - New Systems Requirements  (Rev. 166, 4- 30-04)  The DME MAC systems have the capability to turn off the remit switch when sending a remittance notice is not appropriate (e.g. when the beneficiary has submitted a claim).  Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R12437CP  12/28/2023 Implementation of the New Home Intravenous Immune Globulin (IVIG) Items and Services Payment  01/02/2024  13217  R12423CP  12/20/2023 Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92  01/02/2024  13222  R12379CP  11/22/2023 Implementation of New Benefit Category for Lymphedema Compression Treatment Items  01/02/2024  13286 R12359CP  11/09/2023 Implementation of New Benefit Category for Lymphedema Compression Treatment Items - Rescinded and replaced by transmittal  12379  01/02/2024  13286  09/14/2023 Implementation of the New Home Intravenous Immune Globulin (IVIG) Items and Services Payment - Rescinded and replaced by transmittal -12437  01/02/2024  13217  07/28/2023 Implementation of New Benefit Category for Lymphedema Compression Treatment Items - SENSITIVE CONTROVERSIAL - Rescinded and replaced by transmitta l 12359/ NO LONGER SENSITIVE   01/02/2024  13286
(Medicare Claims Processing Manual)
07/28/2023 Implementation of New Benefit Category for Lymphedema Compression Treatment Items - SENSITIVE CONTROVERSIAL - Rescinded and replaced by transmitta l 12359/ NO LONGER SENSITIVE   01/02/2024  13286  07/21/2023 Implementation of the New Home Intravenous Immune Globulin (IVIG) Items and Services Payment - SENSITIVE CONTROVERSIAL - Rescinded and replaced by transmittal  12252  01/02/2024  13217 R12013CP  05/02/2023 Inflation Reduction Act Section 11407: Limitations on Monthly Coinsurance and Adjustments to Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment (DME)  IMPLEMENTATION  07/03/2023  13014 R11917CP  03/21/2023 Inflation Reduction Act Section 11407: Limitations on Monthly Coinsurance and Adjustments to Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment (DME)  IMPLEMENTATION - Rescinded and replaced by transmittal 12013  07/03/2023  13014 Rev #  Issue Date  Subject  Impl Date  CR#  R11834CP  02/02/2023 Inflation Reduction Act Section 11407: Limitations on Monthly Coinsurance and Adjustments to Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment (DME)  IMPLEMENTATION
(Medicare Claims Processing Manual)
NO LONGER SENSITIVE - Rescinded and replaced by transmittal 11917  07/03/2023  13014 R11429CP  05/23/2022 Revisions to National Coverage Determination (NCD) 240.2 (Home Use of Oxygen) and 240.2.2 (Home Oxygen Use for Cluster Headache)  01/03/2023  12607 R11414CP  05/12/2022 Claims Processing Manual Update -  Pub. 100.04 for Elimination of Certificates of Medical Necessity (CMNs) and Durable Medical Equipment Forms (DIFs)  06/13/2022  12734 R11263CP  02/10/2022 Revisions to National Coverage Determination (NCD) 240.2 (Home Use of Oxygen) and 240.2.2 (Home Oxygen Use for Cluster Headache) - Rescinded and replaced by transmittal 11429 06/14/2022  12607 R10840CP  06/11/2021 Updates to the Internet Only Publication 100-04, Chapter 1, Section 10.1 and Chapter 20, Section 10 07/12/2021  12310 R10236CP  07/31/2020 Update to the IOM Publication (Pub) 100- 04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (URLs) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the HIPAA Eligibility Transaction System (HETS)  08/31/2020  11857
(Medicare Claims Processing Manual)
12/20/2019 Manual Update to Publication (Pub.) 100- 04, Chapter 20, to Revise the Subsection 10 -  Where to Bill Durable Medical Equipment, Prosthetics, Orthotics, and Supplies 03/23/2020  11554 Rev #  Issue Date  Subject  Impl Date  CR#  (DMEPOS) and Parenteral and Enteral Nutrition (PEN) Items and Services  R4202CP  01/18/2019 Update to Pub. 100- 04 Chapters 8, 20, and 24 to Provide Language -Only Changes for the New Medicare Card Project  02/19/2019  10964 R4112CP  11/01/2018 Temporary Transitional Payment for Home Infusion Therapy Services for CYs 2019 and 2020 01/07/2019  10836 R4052CP  05/17/2018 Removal of KH Modifier from Capped Rental Claims  10/01/2018  10422 R4037CP  04/27/2018 Removal of KH Modifier from Capped Rental Claims -  Rescinded and replaced by transmittal 4052  10/01/2018  10422 R4027CP  04/27/2018 Inexpensive or Routinely Purchased Durable Medical Equipment (DME) Payment Classification for Speech Generating Devices (SGD) and Accessories
(Medicare Claims Processing Manual)
10/01/2018  10604 R4001CP  03/16/2018 Internet Only Manual Updates to Pub. 100-01, 100- 02 and 100- 04 to Correct Errors and Omissions (SNF) (2018)  06/19/2018  10512 R3895CP  10/27/2017 Revised and New Modifiers for Oxygen Flow Rate  04/02/2018  10158 R3824CP  08/02/2017 July Quarterly Update for 2017 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule  07/03/2017  10071 R3801CP  06/28/2017 Extension of the Transition to the Fully Adjusted Durable Medical Equipment, Prosthetics, Orthotics and Supplies Payment Rates under Section 16007 of the 21st Century Cures Act  07/03/2017  9968 Rev #  Issue Date  Subject  Impl Date  CR#  R3730CP  03/03/2017 Payment for Oxygen Volume Adjustments and Portable Oxygen Equipment  04/03/2017  9848 R3716CP  02/10/2017 Extension of the Transition to the Fully Adjusted Durable Medical Equipment, Prosthetics, Orthotics and Supplies Payment Rates under Section 16007 of the 21st Century Cures Act  Rescinded and replaced by transmittal 3801 07/03/2017  9968 R3713CP  02/03/2017 Extension of Payment Change for Group 3 Complex Rehabilitative Power Wheelchairs Accessories and Seat and Back Cushions under Section 16005 of the 21st Century Cures Act  07/03/2017  9966 R3679CP  12/16/2016 Payment for Oxygen Volume Adjustments and Portable Oxygen Equipment -  Rescinded and replaced by Transmittal 3730  04/03/2017  9848 R3649CP  11/10/2016 Payment for Oxygen Volume Adjustments and Portable Oxygen Equipment  Rescinded and replaced by Transmittal 3679 04/03/2017  9848 R3593CP  08/17/2016 Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP): Additional Instructions for the Implementation of Round 2 Recompete of the DMEPOS CBP and National Mail Order (NMO) Recompete  10/03/2016  9579 R3565CP  07/20/2016 Durable Medical Equipment, Prosthetics,