evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The following services are excluded from comprehensive APC packaging:   ambulance services   brachytherapy sources (status indicator U)   diagnostic and mammography screenings   physical therapy, speech -language pathology and occupational therapy services reported on a separate facility claim for recurring services    pass-through drugs, biologicals, and devices (status indic ators G or H)   preventive services defined in 42 CFR410.2  self-administered drugs (SADs) -  drugs that are usually self -administered and do not function as supplies in the provision of the comprehensive service   services assigned to OPPS status indicator F ( certain CRNA services, Hepatitis B vaccines and corneal tissue acquisition)   services assigned to OPPS status indicator L (influenza and pneumococcal pneumonia vaccines)   certain Part B inpatient services  Ancillary Part B inpatient services payable under P art B when the primary J1 service for the claim is not a payable Medicare Part B inpatient service(for example, exhausted Medicare Part A benefits, beneficiaries with Part B only)   services assigned to a New Technology APC.    For the remainder of the PHE for  COVID -19,  o Over -the-counter (OTC) COVID -19 tests  o New COVID -19 treatments that meet the following criteria:  1) The treatment must be a drug or biological product (which could include a blood product) authorized to treat COVID -19, as indicated in section I. Criteria for Issuance of Authorization of the letter of authorization for the drug or biological product, or the drug or biological product must be approved by the FDA for treating COVID -19  2) The emergency use authorization (EUA) for the drug or biologica l product (which could include a blood product) must authorize the use of the product in the outpatient setting or not limit its use to the inpatient setting, or the product must be approved by the FDA to treat COVID -19 disease and not limit its use to the  inpatient setting.
(Medicare Claims Processing Manual)
The single payment for a comprehensive claim is based on the rate associated with either the J1 service or the specific combination of J2 services. When multiple J1 services are reported on the same claim, the single payment is based on the rate associated with the highest ranking J1 service. When certain pairs of J1 services (or in certain cases a J1 service and an add -on code) are reported on the same claim, the claim is eligible for a complexity adjustment, which provides a single payment for the claim based on the rate of the next higher comprehensive APC within the same clinical family. When a J1 service and a J2 service are reported on the same claim, the single payment is based on the rate associated with the J1 service, and the combination of the J1 and J2 services on the claim does not make the claim eligible for a complexity adjustment. Note that complexity adjustments will not be applied to discontinued services (reported with mod - 73 or - 74).    10.2.4 - Reporting for Certain  Outpatient Department Services (That Are Similar to Therapy Services) (Non -Therapy Outpatient Department Services) and Are Adjunctive to Comprehensive APC Procedures  (Rev. 10541; Issued: 12-31-20; Effective: 01-01-21; Implementation: 01-04-21)  This la nguage was originally published in the October 2016 Update of the Outpatient Perspective Payment System (OPPS) (Transmittal R3602CP). We are updating this language based on the removal of the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4) relat ed to functional reporting for therapy services.
(Medicare Claims Processing Manual)
Non-therapy outpatient department services are services such as physical therapy, occupational therapy, and speech -language pathology provided during the perioperative period (of a Comprehensive APC (C -APC ) procedure) without a certified therapy plan of care. These are not therapy services as described in section 1834(k) of the Act, regardless of whether the services are delivered by therapists or other non- therapist health care workers. Therapy services ar e those provided by therapists under a plan of care in accordance  with section 1835(a)(2)(C) and section 1835(a)(2)(D) of the Act and are paid for under section 1834(k) of the Act, subject to annual therapy caps as applicable (78 FR 74867 and 79 FR 66800), until they were repealed by Bipartisan Budget Act of 2018, effective January 1, 2018. Because these services are outpatient department services and not therapy services, the requirement for functional reporting under the regulations at 42 CFR 410.59(a)(4)  and 42 CFR 410.60(a)(4) does not apply. The functional reporting requirements were applicable until January 1, 2019 at which time the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4) were removed (83 FR 41786 and 83 FR 59452).   The comprehensive  APC payment policy packages payment for adjunctive items, services, and procedures into the most costly primary procedures under the OPPS at the claim level. When non- therapy outpatient department services are included on the same claim as a C -APC procedure (status indicator (SI) = J1) (see 80 FR 70326) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), these services are considered adjunctive to the primary procedure. Payment for non- therapy outpatient de partment services is included as a packaged part of the payment for the C -APC procedure.
(Medicare Claims Processing Manual)
Effective for claims received on or after October 1, 2016 with dates of service on or after January 1, 2015, providers may report non -therapy outpatient department s ervices (that are similar to therapy services) that are adjunctive to a C -APC procedure (SI = J1) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), in one of two ways:   1. Without using the therapy CPT c odes and instead reporting these non -therapy services with Revenue Code 0940 (Other Therapeutic Services); or  2. Reporting non- therapy outpatient department services that are adjunctive to J1 or J2 services with the appropriate occurrence codes, CPT codes , modifiers, and revenue codes.   10.3 - Calculation of APC Payment Rates 10.3 - Calculation of APC Payment Rates (Rev. 1445, Issued:  02- 08-08; Effective:  01- 01-08; Implementation:  03 -10-08)  The OPPS national unadjusted payment rates for APCs other than drugs and biologicals are calculated as the products of the scaled relative weight for the APC and the OPPS conversion factor.  Hospital specific payments for these APCs are derived after application of applicable adjustment factors (e.g., multiple surger y reduction, rural sole community adjustment, etc.) and the post reclassification wage index that applies to the hospital to which payment is being made.  Payment rates for separately paid drugs and biologicals are generally established based on a percenta ge of the average sales price of the drug or biological.   An APCs scaled relative weight is generally calculated based on the median cost (operating and capital) of all of the services included in the APC group.  Median costs are developed from a database  of the most currently available hospital outpatient claims using the most recently filed cost report data.   The following is a simplified description of the process used to calculate the OPPS payment rates for services for which the rate is based on the median cost.    Hospital -specific, department -specific cost -to-charge ratios are used to convert billed charges to costs for each HCPCS code;
(Medicare Claims Processing Manual)
 Hospital -specific, department -specific cost -to-charge ratios are used to convert billed charges to costs for each HCPCS code;    For most APCs, single procedure bills (claims that contain only one separately paid procedure code) for all of the  procedures within a particular APC are used to calculate the median costs on which APC payment weights are based to ensure that the median captures the full cost of the procedure when it is the only service furnished. The costs on the bill are summed to a dd the costs of any packaged services into the procedure with which the packaged services are packaged.  Composite  APCs are an exception to this statement since the payment for them is calculated only from multiple procedure claims that meet the criteria f or composite APC payment;    60 percent of the total cost is wage neutralized and the set of claims for each APC is trimmed at +/ - 3 standard deviations from the geometric mean;    A median cost is calculated for each APC, using the claims for the procedures that meet the criteria for being assigned to that APC and the array of costs determined from those claims.  In some cases, a subset of single procedure bills that meet specified criteria are used to calculate the median cost for the APC.  For example, CMS uses only claims with correct device codes, no token charges for devices, no interrupted procedures, and without no cost or full credit devices to set the median cost for device -dependent APCs.  Similarly, the median costs for composite APCs are calcul ated using only claims that meet the criteria for the composite APC.    Median costs are converted to relative weights by dividing each APCs median cost by the median cost for the Level 3 Hospital Clinic Visit APC.    Relative weights are scaled for budget neutrality.    Scaled weights are converted to payment rates using a conversion factor which takes into account pass-through payments to be made in the coming year, changes to the wage index (see section 10.8.1), the cost of outlier payments (see section 10.7)  and the annual market basket update factor.
(Medicare Claims Processing Manual)
CMS issues a proposed rule with a 60 day comment period in the summer of the year before the year in which the proposed payment rates would be applicable.  There is a 60 day comment period, after which CMS issu es a final rule with comment period to announce the forthcoming years payment policies and rates.  The CMS OPPS Webpage at http://www.cms.hhs.gov/HospitalOutpatientPPS/  is the best source for both rules and the supporting files.   10.4 - Packaging  (Rev. 3941; Issued: 12- 22-17; Effective: 01-  01-18; Implementation: 01 -02-18)  Under the OPPS, packaged services are items and services that are considered to be an integral part of another service that  is paid under the OPPS.  No separate payment is made for packaged services, because the cost of these items and services is included in the APC payment for the service of which they are an integral part.  For example, routine supplies, anesthesia, recover y room use, and most drugs are considered to be an integral part of a surgical procedure so payment for these items is packaged into the APC payment for the surgical procedure.  A. Packaging for Claims Resulting in APC Payments   If a claim contains servic es that result in an APC payment but also contains packaged services, separate payment for the packaged services is not made since payment is included in the APC.  However, charges related to the packaged services are used for outlier and Transitional Corr idor Payments (TOPs) as well as for future rate setting.  Therefore, it is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT and/or CMS instructions and correct coding principles, and all charges for all servi ces they furnish, whether payment for the services is made separately paid or is packaged.   B. Packaging for Claims Resulting in No APC Payments    If the claim contains only services payable under cost reimbursement, such as corneal tissue, and services that would be packaged services if an APC were payable, then the packaged services are not separately payable.  In addition, these charges for the packaged services are not used to calculate TOPs.
(Medicare Claims Processing Manual)
If the claim contains only services payable under a fee sched ule, such as clinical diagnostic laboratory tests, and also contains services that would be packaged services if an APC were payable, the packaged services are not separately payable. In addition, the charges are not used to calculate TOPs.   If a claim con tains services payable under cost reimbursement, services payable under a fee schedule, and services that would be packaged services if an APC were payable, the packaged services are not separately payable. In addition, the charges are not used to calculat e TOPs payments.   C. Packaging Types Under the OPPS   1. Unconditionally packaged services are services for which separate payment is never made because the payment for the service is always packaged into the payment for other services.  Unconditionally packaged services are identified in the OPPS Addendum B with status indictor of N. See the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/ for the most recent Addendum B (HCPCS codes with status indicators).  In general, the charges for unconditionally packaged services are used to calculate outlier and TOPS payments when they appear on a claim with a service that is separately paid under the OPPS because the packaged service is consi dered to be part of the package of services for which payment is being made through the APC payment for the separately paid service.   2. STV- packaged services are services for which separate payment is made only if there is no service with status indicator  S, T, or V reported on the same claim.  If a claim includes a service that is assigned status indicator S, T, or V reported on the same claim as the STV- packaged service, the payment for the STV-packaged service is packaged into the payment for the service(s) with status indicator S, T, V and no separate payment is made for the STV -packaged service.  STV -packaged services are assigned status indicator Q1. See the OPPS Webpage at http://www.cms. hhs.gov/HospitalOutpatientPPS/ for identification of STV -packaged codes.
(Medicare Claims Processing Manual)
for identification of STV -packaged codes.   3. T- packaged services are services for which separate payment is made only if there is no service with status indicator T reported on the same claim.  When there is a claim that inc ludes a service that is assigned status indicator T reported on the same claim as the T -packaged service, the payment for the T- packaged service is packaged into the payment for the service(s) with status indicator T and no separate payment is made for the T- packaged service.  T -packaged services are assigned status indicator Q2. See the OPPS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/  for identification of T- packaged codes.   4. A service that is assigned to a composite APC is a major component of a single episode of care.  The hospital receives one payment through a composite APC for multiple major separately identifiable services.  Services mapped to composite APCs are assigned st atus indicator Q3.  See the discussion of composite APCs in section 10.2.1.  5. Q4 services are assigned to laboratory HCPCS codes that appear on the Clinical Laboratory Fee Schedule (CLFS).  Status indicator Q4 designates packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator J1, J2, S, T, V, Q1, Q2, or Q3. When a Q4 service is not  billed on the same claim as another separately payable service then the IOCE automatically changes their status indicator to A and separate payment is made at the CLFS payment rate.   6. J1 services are assigned to comprehensive APCs.  Payment for all adjunctive services reported on the same claim as a J1 service is packaged into payment for the primary J1 service. See the discussion of comprehensive APCs in section 10.2.3.  7. J2 services are assigned to comprehensive APCs when a specific combination of services are reported on the claim.  Payment for all adjunctive services reported on the same claim as a J2 service is packaged into payment for the J2 service when certain conditions are met.  See the discussion of comprehensive APCs in section 10.2.3.
(Medicare Claims Processing Manual)
10.4.1 - Combinations of Packaged Services of Different Types That are Furnished on the Same Claim  (Rev. 3685, Issued: 12- 22-16, Effective: 01- 01-17, Implementation: 01- 03-17)  Where a claim contains multiple codes that are STV -packaged codes and does not contain a procedure with status indicator S, T, or V on the same claim, separate payment is made for the STV -packaged co de that is assigned to the highest paid APC and payment for the other STV -packaged codes on the claim is packaged into the payment for the highest paid STV -packaged code.   Where a claim contains multiple codes that are T -packaged codes and does not contain a procedure with status indicator T on the same claim, separate payment is made for the T -packaged code assigned to the highest paid APC and payment for the other T -packaged codes on the claim is packaged into the payment for the highest paid T -packaged code.   Where a claim contains a combination of STV -packaged and T -packaged codes and does not contain a procedure with status indicator S, T, or V, separate payment is made for the STV -packaged or T -packaged code with the highest payment rate and payment fo r the other STV -packaged and T -packaged codes is packaged into the payment for the highest paid STV -packaged or T -packaged procedure.   Where a claim contains a combination of STV -packaged and T -packaged codes and codes that could be paid through composite APCs, payment for the STV -packaged and/or T -packaged services is packaged into separate payment for the composite APC.   10.5 - Discounting (Rev. 1445, Issued:  02- 08-08; Effective:  01- 01-08; Implementation:  03 -10-08)   Fifty percent of the full OPPS amount is paid if a procedure for which anesthesia is planned is discontinued after the patient is prepared and taken to the room where the procedure is to be performed but before anesthesia is provided.   Fifty percent of the full OPPS amount is paid if a proce dure for which anesthesia is not planned is discontinued after the patient is prepared and taken to the room where the procedure is to be performed.   Multiple surgical procedures furnished during the same operative session are discounted.    The full amount is paid for the surgical procedure with the highest weight;
(Medicare Claims Processing Manual)
 Multiple surgical procedures furnished during the same operative session are discounted.    The full amount is paid for the surgical procedure with the highest weight;    Fifty percent is paid for any other surgical procedure(s) performed at the same time;     Similar discounting occurs now under the physician fee schedule and the payment system for ASCs;    When multi ple surgical procedures are performed during the same operative session, beneficiary coinsurance is discounted in proportion to the APC payment.  10.6 - Payment Adjustments  (Rev. 1445, Issued:  02-08-08; Effective:  01-01- 08; Implementation:  03 -10-08)  Payments are adjusted to reflect geographic differences in labor- related costs.  In addition, beginning January 1, 2006, rural sole community hospitals (SCHs) receive a 7.1 percent increase in payments for most services, with certain exceptions, including separately paid drugs and biologicals.  This adjustment is authorized under section 1833(t)(13)(B) of the Act, and implemented in accordance with section 419.43(g) of the regulations.  The adjustment is automatically applied in Pricer.   The Secretary may also establish other adjustments or special adjustments for certain classes of hospitals.   10.6.1 - Payment Adjustment for Certain Rural Hospitals  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)   Beginning January 1, 2006, rural sole community hospitals (SCHs), including essential access community hospitals (EACHs), receive a 7.1 percent increase in payments for most services, with certain exceptions.  Services which are excepted from the increase in payments include, but are not limited to, separately paid drugs and biologicals and items paid at charges adjusted to cost.  This adjustment is authorized under Section 1833(t)(13)(B) of the Act, and implemented in accordance with Section 419.43(g) of the regulations.  The adjustment is automatically applied in Pricer.   10.6.2 - Payment Adjustment for Failure to Meet the Hospital Outpatient Quality Reporting Requirements  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)
(Medicare Claims Processing Manual)
10.6.2 - Payment Adjustment for Failure to Meet the Hospital Outpatient Quality Reporting Requirements  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)   Effect ive for services furnished on or after January 1, 2009, Section 1833(t)(17)(A) of the Act requires that Subsection (d) hospitals that have failed to meet the specified hospital outpatient quality reporting requirements for the relevant calendar year will  receive payment under the OPPS that reflects a 2 percentage point reduction of the annual OPPS update factor.  See www.qualitynet.org for information on complying with the reporting requirements and standards that must be met to receive the full update.   10.6.2.1 - Hospitals to Which the Payment Reduction Applies  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)
(Medicare Claims Processing Manual)
The reduction applies only to hospitals that are identified as Subsection (d) hospitals.  Subsection (d) hospitals have the same definition for hospitals paid under the OPPS as for hospitals paid under the IPPS.  Specifically, Subsection (d) hospitals are defined under Section 1886(d)(1)(B) of the Act as hospitals that are located in the 50 states or the District of Columbia other than those categories of hospitals or hospital units that are specifically excluded from the IPPS, including psychiatric, rehabilitation, long- term care, childrens and cancer hospitals or hospital units.  In other words, the provision does not apply to hospitals and hospital units excluded from the IPPS or to hospitals located in Maryland, Puerto Rico or the U.S. territories.  Hospitals that are not required to submit quality data (i.e., those that are not Subsection (d) hospitals) will receive the full OPPS update.  Similarly, the reduced update will not apply to Subpart (d) hospitals that are not paid under the OPPS (e.g., Indian Health Service hospitals).  10.6.2.2 - Services to which the Payment Reduction Applies  (Rev. 1657, Issued: 12- 31-08, Effective: 01-01-09, Implementation: 01-05-09)    The reduction to the annual update factor for failure to meet the quality reporting requirements applies to most, but not all, services paid under the OPPS.  The reduction of payments does not apply to services paid under the OPPS if the payment amounts are not calculated using the conversion factor to which the annual update factor applies (e.g., drugs and biologicals paid based on the average sales price (ASP) methodology, new technology services paid at a fixed amount, and services paid at charges adjusted to cost).  The reduction also does not apply to hospital outpatient services paid through other fee schedules or other mechanisms.  Examples of these excepti ons are services paid under the physician fee schedule (e.g., physical therapy and diagnostic and screening mammography), services paid at reasonable cost (e.g., influenza and pneumococcal vaccines), and services paid under other fee schedules (e.g., clini cal laboratory services and durable medical equipment).