evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
The payment rates under the FS for ground ambulance transports (both the fee schedule base rates and the mileage amounts) are increased for services furnished during the period July 1, 2004 through December 31, 2006 as well as July 1, 2008 through December  31, 2010.  For ground ambulance transport services furnished where the POP is urban, the rates are increased by 1 percent for claims with dates of service July 1, 2004 through December 31, 2006 in accordance with Section 414 of the Medicare Modernization Act (MMA) of 2003 and by 2 percent for claims with dates of service July 1, 2008 through December 31, 2010 in accordance with Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 and Sections 3105(a) and 10311(a) of the Patient Protection and Affordable Care Act (ACA) of 2010.  For ground ambulance transport services furnished where the POP is rural, the rates are increased by 2 percent for claims with dates of service July 1, 2004 through December 31, 2006 in accordance with S ection 414 of the Medicare Modernization Act (MMA) of 2003  and by 3 percent for claims with dates of service July 1, 2008 through December 31, 2010 in accordance with Section 146(a) of the Medicare Improvements for Patients and Providers Act of 2008 and Sections 3105(a) and 10311(a) of the Patient Protection and Affordable Care Act (ACA) of 2010.  Subsequently, section 106 (a) of the Medicare and Medicaid Extenders Act of 2010 (MMEA) again amended section 1834 (1) (12) (A) of the Act to extend the payment increases for an additional year, through December 31, 2011.  These amounts are incorporated into the fee schedule amounts that appear in the Ambulance FS file maintained by CMS and downloaded by CMS contractors.  There is no calculation to be done by the MAC in order to implement this provision.  The following chart summarizes the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 payment changes for ground ambulance services that became effective on July 1, 2004 as well as the Medicare Improvement for Patients and Provide rs Act (MIPPA) of 2008 changes that became effective July 1, 2008 and were extended by the Patient Protection and Affordable Care Act of 2010 and the Medicare and Medicaid Extenders Act of 2010 (MMEA).  Summary Chart of Additional Payments for Ground Ambulance Services Provided by MMA, MIPPA and MMEA
(Medicare Claims Processing Manual)
Service  Effective Dates  Payment Increase*  All rural miles  7/1/04 - 12/31/06  2% All rural miles  7/1/08 - 12/31/11  3% Rural miles 51+  7/1/04 - 12/31/08  25% **  All urban miles  7/1/04 - 12/31/06  1% All urban miles  7/1/08 - 12/31/11  2% Service  Effective Dates  Payment Increase*  Urban miles 51+  7/1/04 - 12/31/08  25% **  All rural base rates  7/1/04 - 12/31/06  2% All rural base rates  7/1/08 - 12/31/11  3% Rural base rates (lowest quartile)  7/1/04 - 12/31/11  22.6 %**  All urban base rates  7/1/04 - 12/31/06  1% All urban base rates  7/1/08 - 12/31/11  2% All base rates (regional fee schedule blend)  7/1/04 - 12/31/09  Floor   NOTES:  *  All payments are percentage increases and all are cumulative.   **Contractor systems perform this calculation.  All other increases are incorporated into the CMS Medicare Ambulance FS file.   B. Air Ambulance Services   1. Base Rates   Each type of air ambulance service has a base rate.  There is no conversion factor (CF) applicable to air ambulance services.   2. Geographic Adjustment Factor (GAF)   The GAF, as described above for ground ambulance services, is also used for air ambulance services.  However, for air ambulance services, the applicable GPCI is applied to 50 percent of each of the base rates (fixed and rotary wing).   3. Mileage   The FS for air ambulance services provides a separate payment for mileage.   4. Adjustment for Services Furnished in Rural Areas   The payment rates for air ambulance services where the POP is in a rural area are greater than in an urban area.  For air ambulance services (fixed or rotary wing), the rural adjustment is an increase of 50 percent to the unadjusted FS amount, e.g., the applicable air service base rate multiplied by the GAF plus the mileage amount or, in other words, 1.5 times both the applicable air service base rate and the total mileage amount.
(Medicare Claims Processing Manual)
The basis for a rural adjustment for air ambulance services is determined in the same manner as for ground services.  That is, whether the POP is within a rural ZIP Code as described above for ground services.  20.1.5  - ZIP Code Determines Fee Schedule Amounts  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06- 20-16)  The POP determines the basis for payment under the FS, and the POP is reported by its 5- digit ZIP Code.  Thus, the ZIP Code of the POP determines both the applicable GPCI and whether a rural adjustment applies.  If the ambulance transport required a second or subsequent leg, then the ZIP Code of the POP of the second or subsequent leg determines both the applicable GPCI for such leg and whether a rural adjustment applies to such leg.  Accordingly, the ZIP Code of the POP must be reported on every claim to determine both the correct GPCI and, if applicable, any rural adjustment.  Part B contractors must report the POP ZIP Code, at the line item level, to CWF when they report all other ambulance claim information. CWF must report the POP ZIP Code to the national claims history file, along with the rest of the ambulance claims record.   A.  No ZIP Code   In areas without an apparent ZIP Code, it is the providers/suppliers responsibility to confirm that the POP does not have a ZIP Code that has been assigned by the USPS.  If the provider/supplier has made a good- faith effort to confirm that no ZIP Code for the POP exists, it may use the ZIP Code nearest to the POP.  Providers and suppliers should document their confirmation with the USPS, or other authoritative source, that the POP does not have an assigned ZIP Code and annotate the claim to indicate that a surrogate ZIP Code has been used (e.g., Surrogate ZIP Code; POP in No -ZIP).  Providers and suppliers should maintain this documentation and provide it to their contractor upon request.   Contractors must request additional documentation from providers/suppliers when a claim submitted using a surrogate ZIP Code does not contain sufficient information to determine that the ZIP Code does not exist for the POP.  They must investigate and repor t any claims submitted with an inappropriate and/or falsified surrogate ZIP Code.
(Medicare Claims Processing Manual)
If the ZIP Code entered on the claim is not in the CMS -supplied ZIP Code File, manually verify the ZIP Code to identify a potential coding error on the claim or a new ZIP Code established by the U.S. Postal Service (USPS).  ZIP Code information may be found at the USPS Web site at http://www.usps.com/ , or other commercially available sources of ZIP Code information may be consulted.   If this process validates the ZIP Code, the claim may be processed.  All such ZIP Codes are to be considered urban ZIP Codes until CMS determines that the code should be designated as rural, unless the contractor exercises its discretion to designate the Z IP Code as rural.  (See Section  20.1.5.B   New ZIP Codes)    If this process does not validate the ZIP Code, the claim must be rejected as unprocessable.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two   Group Code: CO  CARC: 16  RARC: N53  MSN: N/A  B.  New ZIP Codes   New ZIP Codes are considered urban until CMS determines that the ZIP Code is located in a rural area.  Thus, until a ZIP Code is added to the Medicare ZIP Code file with a rural designation, it will be considered an urban ZIP Code.  However, despite the de fault designation of new ZIP Codes as urban, contractors have discretion to determine that a new ZIP Code is rural until designated otherwise.  If the contractor designates a new ZIP Code as rural, and CMS later changes the designation to urban, then the c ontractor, as well as any provider or supplier paid for mileage or for air services with a rural adjustment, will be held harmless for this adjustment.   Providers and suppliers should annotate claims using a new ZIP Code with a remark to that effect.  Providers and suppliers should maintain documentation of the new ZIP Code and provide it to their contractor upon request.   If the provider or supplier believes that a new ZIP Code that the contractor has designated as urban should be designated as rural (under the standard established by the Medicare FS regulation), it may request an adjustment from the A/B MAC (A) or appeal the determination with the A/B/MAC (B), as applicable, in accordance with standard procedures.
(Medicare Claims Processing Manual)
When processing a claim with a POP ZIP Code that is not on the Medicare ZIP Code file, contractors must search the USPS Web site at http://www.usps.com/ , other governmental Web sites, and commercial Web sites, to validate the new ZIP Code.  (The Census Bureau Web site located at http://www.census.gov/  contains a list of valid ZIP Codes.)  If the ZIP Code cannot be validated using the USPS Web site or other authoritative source such as the Census Bureau Web site, reject the claim as unprocessable.   C.  Inaccurate ZIP Codes   If providers and suppliers knowingly and willfully report a surrogate ZIP Code because they do not know the proper ZIP Code, they may be engaging in abusive and/or potentially fraudulent billing.  Furthermore, a provider or supplier that specifies a surrogate rural ZIP Code on a claim when not appropriate to do so for the purpose of receiving a higher payment than would have been paid otherwise, may be committing abuse and/or potential fraud.   D.  Claims Outside of the U.S.  The following policy applies to claims outside of the U.S.:    Ground transports with pickup and drop off points within Canada or Mexico will be paid at the fee associated with the U.S. ZIP Code that is closest to the POP;    For water transport from the territorial waters of the U.S., the fee associated with the U.S. port of entry ZIP Code will be paid;    Ground transports with pickup within Canada or Mexico to the U.S. will be paid at the fee associated with the U.S. ZIP Code at the point of entry; and    Fees associated with the U.S. border port of entry ZIP Codes will be paid for air transport from areas outside the U.S. to the U.S. for covered claims.  As discussed more fully below, CMS will provide contractors with a file of ZIP Codes that will map to the appropriate geographic location and, where appropriate, with a rural designation identified with the letter R or B.  Urban ZIP Codes are identified with a blank in this position.   20.1.5.1 - CMS Supplied National ZIP Code File and National Ambulance Fee Schedule File  (Rev. 2703, Issued: 05- 10-13, Effective: 10 -01-13, Implementation: 10- 07-13)
(Medicare Claims Processing Manual)
CMS will provide each contractor with two files:  a national ZIP Code file and a national Ambulance FS file.   A. The national ZIP5 Code file is a file of 5 -digit USPS ZIP Codes that will map each ZIP Code to the appropriate FS locality.  Every 2 months, CMS obtains an updated listing of ZIP Codes from the USPS.  On the basis of the updated USPS file, CMS updates the Medicare ZIP Code file and makes it available to contractors.   The following is a record layout of the ZIP5 file effective January 1, 2009   ZIP5 CODE to LOCALITY RECORD LAYOUT   Field Name  Position  Format  COBOL Description  State  1-2 X(02)  Alpha State Code  ZIP Code  3-7 X(05)  Postal ZIP Code  A/B MAC (B)  8-12 X(05)  A/B MAC (B)  Number  Pricing Locality  13-14 X(02)  Pricing Locality  Rural Indicator  15 X(01)  Effective 1/1/07  Blank = urban, R=rural, B=super rural  Field Name  Position  Format  COBOL Description  Beneficiary Lab CB Locality  16-17 X(02)  Lab competitive bid locality; Z1= CBA1  Z2= CBA2  Z9= Not a demonstration locality  Rural Indicator 2  18 X(01)  What was effective 12/1/06 Blank=urban, R=rural, B=super rural  Filler  19-20 X(02)   Plus Four Flag  21 X(01)  0 = no +4 extension  1 = +4 extension  Filler  22-75 X(54)   Year/Quarter  76-80 X(05)  YYYYQ   NOTE:   Effective October 1, 2007, claims for ambulance services will continue to be submitted and priced using 5- digit ZIP Codes.  Contractors will not need to make use of the ZIP9 file for ambulance claims.   Beginning in 2009, contractors shall maintain separate ZIP Code files for each year which will be updated on a quarterly basis. Claims shall be processed using the correct ZIP Code file based on the date of service submitted on the claim.  A ZIP Code located in a rural area will be identified with either a letter R or a letter B.  Some ZIP Codes will be designated as rural due to the Rural Urban Commuting Area (RUCA) Score even though the ZIP Code may be located, in whole or in part, wit hin an MSA or Core Based Statistical Area (CBSA).
(Medicare Claims Processing Manual)
AB designation indicates that the ZIP Code is in a rural county (or RUCA area) that is comprised by the lowest quartile by population of all such rural areas arrayed by population density.  Effective for claims with dates of service between July 1, 2004 and December 31, 2010, contractors must apply a bonus amount to be determined by CMS to the base rate portion of the payment under the FS for ground ambulance services with a POP B ZIP Code.  This amount is in addition to the rural bonus amount applied t o ground mileage for ground transports originating in a rural POP ZIP Code.   Each calendar quarter beginning October 2007, CMS will upload updated ZIP5 and ZIP9 ZIP Code files to the Direct Connect (formerly the Network Data Mover).  Contractors shall make use of the ZIP5 file for ambulance claims and the ZIP9 file as appropriate p er IOM Pub. 100- 04, Medicare Claims Processing Manual, chapter 1 - General Billing Requirements , section 10.1.1 -  Payment Jurisdiction Among A/B MACs (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services and the additional information found in Transmittal 1193, Change Request 5208, issued March 9, 2007.  The updated files will be available for downloading on approximately November 15th for the January 1 release, approximate ly February 15th for the April 1 release, approximately May 15th for the July 1 release, and approximately August 15th for the October 1 release.  Contractors are responsible for retrieving the ZIP Code files upon notification and must implement the following procedure for retrieving the files:   1. Upon quarterly Change Requests communicating the availability of updated ZIP Code files, go to the Direct Connect and search for the files.  Confirm that the release number (last 5 digits) corresponds to the upcoming calendar quarter.  If the release number (last 5 digits) does not correspond to the upcoming calendar quarter, notify CMS.   2. After confirming that the ZIP Code files on the Direct Connect corresponds to the next calendar quarter, download the files and incorporate the files into your testing regime for the upcoming model release.
(Medicare Claims Processing Manual)
2. After confirming that the ZIP Code files on the Direct Connect corresponds to the next calendar quarter, download the files and incorporate the files into your testing regime for the upcoming model release.   The names of the files will be in the following format:    MU00.AAA2390.ZIP5.LOCALITY.Vyyyyr and MU00.AAA2390.ZIP9.LOCALITY.Vyyyyr where yyyy equals the calendar year and r equals the release number with January =1, April =2, July =3, and October =4. So, for example, the names of the file updates for October 2007 are MU00.AAA2390.ZIP5.LOCALITY.V20074 and MU00.AAA2390.ZIP9.LOCALITY.V20074.  The release number for this file is 20074, release 4 for the year 2007.   When the updated files are loaded to the Direct Connect, they will overlay the previous ZIP Code files.   NOTE:   Even the most recently updated ZIP Code files will not contain ZIP Codes established by the USPS after CMS compiles the files.  Therefore, for ZIP Codes reported on claims that are not on the most recent ZIP Code files, follow the instructions for new ZI P Codes in 20.1.5(B).  B. CMS will also provide contractors with a national Ambulance FS file that will contain payment amounts for the applicable HCPCS codes.  The file will include FS payment amounts by locality for all FS localities.  The FS file will be available via the CMS M ainframe Telecommunications System.  Contractors are responsible for retrieving this file when it becomes available.  The full FS amount will be included in this file.  CMS will notify contractors of updates to the FS and when the updated files will be a vailable for retrieval.  CMS will send a full-replacement file for annual updates and for any other updates that may occur.   The following is a record layout of the Ambulance Fee Schedule file:
(Medicare Claims Processing Manual)
The following is a record layout of the Ambulance Fee Schedule file:   AMBULANCE FEE SCHEDULE FILE RECORD DESCRIPTION Field Name  Position  Format  Description  HCPCS  1-5 X(5)  Level 2 HCPCs code number for the service.  A/B MAC (B)  Number  6-10 X(5)  Contractor Number  Locality Code  11-12 X(2)  Identification of Pricing Locality  RVU  13-18 9(4)V2  Relative Value Units set a numeric value for ambulance services relative to the value of a base level ambulance service.  GPCI (PE)  19-22 9V3  The GPCI for the practice expense portion of the Medicare physician fee schedule is used to adjust payment to account for regional differences.  Base Rate  23-29 9(5)V2  A nationally uniform base amount used to calculate each HCPCS payment amount.   Urban Rate  30-36 9(5)V2  Urban Ground/Air mileage rate.  Rural  Rate  37-43 9(5)V2  Rural Ground/Air mileage rate.  Current Year  44-47 x(4)  4 digit current effective year.  Current Quarter  48-48 x(1) 1 digit  current effective quarter: 1=January, 2=April, 3=July, 4 =October.  Current Date  49-56 x(8) Current Effective Start Date.  Filler  57-80 X(26)  Future use     20.1.6 - Contractor Determination of Fee Schedule Amounts  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09)  The FS amount is determined by the FS locality, based on the POP of the ZIP Code.  Use the ZIP Code of the POP to electronically crosswalk to the appropriate FS amount.  All ZIP Codes on the ZIP Code file are urban unless identified as rural by the letter R or the letter B.  Contractors determine the FS amount as follows:    If an urban ZIP Code is reported with a ground or air HCPCS code, the contractors determine the amount for the service by using the FS amount for the urban base rate.  To determine the amount for mileage, multiply the number of reported miles by the urban mileage rate.
(Medicare Claims Processing Manual)
 If a rural ZIP Code is reported with a ground HCPCS code, the contractor determines the amount for the service by using the FS amount for the rural base rate.  To determine the amount for mileage, contractors must use the following formula:   o For services furnished on or after July 1, 2004, for rural miles 1- 17, the rate equals 1.5 times the rural ground mileage rate per mile. Therefore, multiply 1.5 times the rural mileage rate amount on the FS to derive the appropriate FS rate per mile;  o For services furnished during the period July 1, 2004 through December 31, 2008, for all ground miles greater than 50 (i.e., miles 51+), the FS rate equals 1.25 times the applicable mileage rate (urban or rural). Therefore, multiply 1.25 times the urban or rural, as appropriate, mileage rate amount on the FS  to derive the appropriate FS rate per mile.    If a rural ZIP Code is reported with an air HCPCS code, the contractor determines the FS amount for the service by using the FS amount for rural air base rate.  To determine the amount allowable for the mileage, multiply the number of loaded miles by the r ural air mileage rate.   20.2 - Payment for Mileage Charges  (Rev. 1696; Issued:  03- 06-09; Effective/Implementation Date:  04 -06-09) B3-5116.3, PM AB -00-131  Charges for mileage must be based on loaded mileage only, e.g., from the pickup of a patient to his/her arrival at destination.  It is presumed that all unloaded mileage costs are taken into account when a supplier establishes his basic charge for ambulanc e services and his rate for loaded mileage.  Suppliers should be notified that separate charges for unloaded mileage will be denied.   Instructions on billing mileage are found in 30.    20.3 - Air Ambulance  (Rev. 3380, Issued: 10- 23-15, Effective: 01 -01-16, Implementation: 01- 04-16)
(Medicare Claims Processing Manual)
Instructions on billing mileage are found in 30.    20.3 - Air Ambulance  (Rev. 3380, Issued: 10- 23-15, Effective: 01 -01-16, Implementation: 01- 04-16)  Refer to IOM Pub. 100- 02, Medicare Benefit Policy Manual, chapter 10 -  Ambulance Services, section 10.4  Air Ambulance Services, and section 30.1.2  Definitions of Air Ambulance Services for additional information on the coverage and definitions of air ambulance services.  Under certain circumstances, transportation by airplane or helicopter may qualify as covered ambulance services.  If the conditions of coverage are met, payment may be made for the air ambulance services .  Air ambulance services are paid at different rates according to two air ambulance categories:    AIR ambulance service, conventional air services, transport, one way, fixed wing (FW) (HCPCS code A0430)    AIR ambulance service, conventional air services, transport, one way, rotary wing  (RW) (HCPCS code A0431)   Covered air ambulance mileage services are paid when the appropriate HCPCS code is reported on the claim:   HCPCS code A0435 identifies FIXED WING AIR MILEAGE    HCPCS code A0436 identifies ROTARY WING AIR MILEAGE   Effective for claims with dates of service on or after January 1, 2011, air mileage must be reported in fractional numbers of loaded statute miles flown.  Contractors must ensure that the appropriate air transport code is used with the appropriate mileage code.   Air ambulance services may be paid only for ambulance services to a hospital.  Other destinations e.g., skilled nursing facility, a physicians office, or a patients home may not be paid air ambulance.  The destination is identified by the use of an appropriate modifier as defined in Section 30(A) of this chapter.   Claims for air transports may account for all mileage from the point of pickup, including where applicable:  ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing.  Additional air mileage may be allowe d by the contractor in situations where additional mileage is incurred, due to circumstances beyond the pilots control.  These circumstances include, but are not limited to, the following:    Military base and other restricted zones, air -defense zones, and similar FAA restrictions and prohibitions;    Hazardous weather; or