evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Inpatient routine services in a hospital generally are those services included by the provider in a daily service charge --sometimes referred to as the "Room and B oard" charge. They include the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customa rily made to Medicare Part A.  Many nursing services provided by the floor nurse (such as IV infusions and injections, blood administration, and nebulizer treatments, etc.) may or may not have a separate charge established depending upon the classification  of an item or service as routine or ancillary among providers of the same class in the same State.  Some providers customary charging practice has established separate charges for these services following the PRM -1 instructions, however, in order for a providers customary charging practice to be recognized it must be consistently followed for all patients and this must not result in an inequitable apportionment of cost to the program.  If the PRM -1 instructions have not been followed, a provider cannot bill these services as separate charges.  Additionally, it is important that the charges for service rendered and documentation meet the definition of the HCPCS in order to separately bill.  240.1 - Editing Of  Hospital Part B Inpatient Services: Reasonable and Necessary Part A Hospital Inpatient Denials  (Rev.  4394, Issued: 09- 13-19, Effective: 10- 01-13, Implementation: 10- 15-19) When inpatient services are denied as not medically necessary or a provider submitt ed medical necessity denial utilizing occurrence span code M1, and the services are furnished by a participating hospital, Medicare pays under Part B for physician services and the non- physician medical and other health services provided in Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10.1, Reasonable and Necessary Part A Hospital Inpatient Claim Denials.  A hospital may also be paid for Part B inpatient services if it determines under Medicare's utilization review requirements that a benefi ciary should have received hospital outpatient rather than hospital inpatient services, and the beneficiary has already been discharged from the hospital (commonly referred to as hospital self -audit). If the hospital already submitted a claim to Medicare f or payment under Part A, the hospital would be required to adjust
(Medicare Claims Processing Manual)
services, and the beneficiary has already been discharged from the hospital (commonly referred to as hospital self -audit). If the hospital already submitted a claim to Medicare f or payment under Part A, the hospital would be required to adjust its Part A claim (to make the provider liable) prior to submitting a claim for payment of Part B inpatient services. Whether or not the hospital had submitted a claim to Part A for payment, we require the hospital to submit a Part A claim indicating that the provider is liable under section 1879 of the Act for the cost of the Part A services.  The hospital could then submit an inpatient claim for payment under Part B for all services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as a hospital inpatient, except where those services specifically require an outpatient status.  A hospital part B inpatient services claim billed when a reasonable and necessary part A hospital inpatient was denied must be billed with:   A condition code W2 attesting that this is a rebilling and no appeal is in process,   A/B REBILLING in the treatment authorization field, and   The original, denied inpatient claim (CCN/DCN/ICN) number.  NOTE:  Providers submitting an 837I are instructed to place the appropriate Prior Authorization code above into Loop 2300 REF02 (REF01 = G1) as follows: REF*G1*A/B REBILLING~ For DDE or paper Claims, "A/B Rebilling" will be added in FL 63. NOTE:  Providers submit ting an 837I are instructed to place the DCN in the Billing Notes loop 2300/NTE in the format: NTE*ADD*ABREBILL12345678901234~ For DDE or paper Claims, Providers are instructed to use the word "ABREBILL" plus the denied inpatient DCN/CCN/ICN shall be added to the Remarks Field (form locator #80) on the claim using the following format: "ABREBILL12345678901234". (The numeric string (12345678901234) is meant to represent original claim DCN/ICN numbers from the inpatient denial.) Not Allowed Revenue Codes  The claims processing system shall set edits to prevent
(Medicare Claims Processing Manual)
(The numeric string (12345678901234) is meant to represent original claim DCN/ICN numbers from the inpatient denial.) Not Allowed Revenue Codes  The claims processing system shall set edits to prevent payment on Type of Bill 012x for claims containing the revenue codes listed in the table below.  010x  011x  012x  013x  014x  015x  016x  017x  018x  019x  020x  021x  022x  023x  029x  0390  0399  045x  050x  051x  052x  054x  055x  056x  057x  058x  059x  060x  0630  0631  0632  0633  0637  064x  065x  066x  067x  068x  072x  0762  082x  083x  084x  085x  088x  089x  0905  0906  0907  0912  0913  093x  0941  0943  0944  0945  0946  0947  0948  095x  0960  0961  0962  0963  0964*  0969  097x  098x  099x  100x  210x  310x
(Medicare Claims Processing Manual)
* In the case of Revenue Code 0964, this is used by hospitals that have a CRNA exception.   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 Three.    Group Code: PR CARC: 96  RARC: M28  MSN: 21.21  CWF shall edit to ensure that DSMT services are not billed on a 012x claim.   Hospitals are required to report HCPCS codes that identify the services rendered.  240.2 - Editing Of Hospital Part B Inpatient Services:  Other Circumstances in Which Pa yment Cannot Be Made under Part A  (Rev. 4394, Issued: 09- 13-19, Effective: 10-01-13, Implementation: 10-15-19)  When Medicare pays under Part B for the limited set of non -physician medical and other health services provided in Pub. 100-02, Medicare Benefit Policy Manual, chapter 6, 10.2 (that is, when furnished by a participating hospital to an inpatient of the hospital who is not entitled to benefits under Part A, has exhausted his or her Part A benefits, or receives services not covered under Part A), the contractor shall set revenue code edits to prevent payment on Type of Bill 012x for claims containing the revenue codes listed in the table below with exceptions as noted.  For the exceptions noted, contractors shall ensure that only the exceptions ident ified are allowed to process with the revenue code.  Not Allowed Revenue Codes
(Medicare Claims Processing Manual)
010x  011x  012x  013x  014x  015x  016x  017x  018x  019x  020x  021x  022x  023x  0250  0251  0252  0253  0256  0257  0258  0259  0261  0269  0270  0273  0277  0279  028x  029x  0360  0362  0367  0369  0370  0374  0379  038x  039x  041x  045x  0470  0472  0479  049x  050x  051x  052x  053x  0541  0542  0543  0544  0546  0547  0548  0549  055x  056x  057x  058x  059x  060x  0620  0623  0624  0630  0631  0632  0633  0637  064x  065x  066x  067x  068x  069x  072x  0760  0762  079X  081x  082x  083x  084x  085x  088x  090x  091x  093x  0940  0941  0942*  0943  0944  0945  0946  0947  0948  0949  095x  0960  0961  0962  0964*  0969  097x  098x  099x  100x  210x  310x           * In the case of Revenue Code 0964, this is used by hospitals that have a CRNA exception.   * In the case of Revenue Code 0942, this is used by rural hospitals for kidney disease education (KDE) services.  The actual geographic location, core based statisti cal area (CBSA) is used to identify facilities located in rural areas. In addition, KDE services are covered when claims are received from section 401 hospitals.  Additionally, models may allow this Revenue Code.  The contractor shall use the following rem ittance advice messages and associated codes when rejecting/denying claims under this policy. This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR  CARC: 96  RARC: M28  MSN: 21.21   Hospitals are required to report HCPCS codes that identify the services rendered.
(Medicare Claims Processing Manual)
Group Code: PR  CARC: 96  RARC: M28  MSN: 21.21   Hospitals are required to report HCPCS codes that identify the services rendered.   240.3 - Implantable Prosthetic Devices  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)  Under 42 CFR 419.2(b)(11), implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of these devices, are paid under the OPPS, and are therefore packaged with the surgical  implantation procedure unless the device has pass -through payment status.  This payment provision applies when such a device is billed as a Part B outpatient service, or as a Part B inpatient service when the inpatient admission is determined not reasonable and necessary and the b eneficiary should have been treated as a hospital outpatient (see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 6, 10.1).  In these circumstances, hospitals should submit the usual HCPCS code for Part B payment of the device.
(Medicare Claims Processing Manual)
In the other circumst ances in which a beneficiary does not have Part A coverage of inpatient services on the date that such a device is implanted (that is, when furnished by a participating hospital to an inpatient who is not entitled to benefits under Part A, has exhausted hi s or her Part A benefits, or receives services not covered under Part A), hospitals paid under the OPPS should report HCPCS code, C9899, Implanted Prosthetic Device, Payable Only for Inpatients who do not Have Inpatient Coverage, that is effective for serv ices furnished on or after January 1, 2009.  This code allows an alternative Part B inpatient payment methodology for the device as discussed in this section, and may be reported only on claims with TOB 12X when the prosthetic device is implanted on a day on which the beneficiary does not have coverage under Part A because he or she is not entitled to Part A benefits, has exhausted his or her Part A benefits, or receives services not covered under Part A.  The line containing this new code will be rejected if it is reported on a claim that is not a TOB 12X or if it is reported with a line item date of service on which the beneficiary has coverage of inpatient hospital services.  By reporting C9899, the hospital is reporting that the item is eligible  for sepa rate OPPS payment because the primary procedure is not a payable Part B inpatient service under Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10.2 (Other Circumstances in Which Payment Cannot Be Made under Part A).
(Medicare Claims Processing Manual)
If C9899 is a separately pa yable Part B inpatient service, the contractor shall determine the payment amount as follows.  If the device has pass through status under the OPPS, the contractor shall establish the payment amount for the device at the product of the charge for the device and the hospital specific cost to charge ratio.  Where the device does not have pass through status under the OPPS, the contractor shall establish the payment amount for the device at the amount for a comparable device in the DMEPOS fee schedule where th ere is such an amount.  Payment under the DMEPOS fee schedule is made at the lesser of charges or the fee schedule amount and therefore if there is a fee for the specific item on the DMEPOS fee schedule, the payment amount for the item will be set at the l esser of the actual charges or the DMEPOS fee schedule amount.  Where the item does not have pass through payment status and where there is no amount for a comparable device in the DMEPOS fee schedule, the contractor shall establish a payment amount that i s specific to the particular implanted prosthetic device for the applicable calendar year.  This amount (less applicable unpaid deductible and coinsurance) will be paid for that specific device for services furnished in the applicable calendar year unless the actual charge for the item is less than the established amount). Where the actual charge is less than the established amount, the contractor will pay the actual charge for the item (less applicable unpaid deductible and coinsurance).   In setting a cont ractor established payment rate for the specific device, the contractor takes into account the cost information available at the time the payment rate is established.  This information may include, but is not limited to, the amount of device cost that woul d be removed from an applicable APC payment for implantation of the device if the provider received a device without cost or a full credit for the cost of the device.
(Medicare Claims Processing Manual)
If the contractor chooses to use this amount, see www.cms.hhs.gov/HospitalOutpatientPPS/  for the amount of reduction to the APC payment that would apply in these cases.  From the OPPS webpage, select Device, Radiolabeled Product, and Procedure Edits from the list on the left side of the page.  Open the file Procedure to Device edits to determine the HCPCS code that best describes the procedure in which the device would be used.  Then identify the APC to which that procedure code maps from the most recent Addenda B on the OPPS webpage and open the file FB/FC Modifier Procedures and Devices .  Select the applicable years file of APCs subject to full and partial credit reductions (for example: CY 2008 APCs Subject to Full and Partial Credit Reduction Policy).  Select the Full offset reduction amount that pertains to the APC that is most a pplicable to the device described by C9899.  It would be reasonable to set this amount as payment for the device.  For example, if C9899 is reporting insertion of a single chamber pacemaker (C1786 or equivalent narrative description on the claim in remarks) the file of procedure to device edits shows that a single chamber pacemaker is the dominant device for APC 0090 (APC  0089 is for insertion of both pacemaker and electrodes and therefore would not apply if electrodes are not also billed).  The table of offset reduction amounts for CY 2008 shows that the estimated cost of a single chamber pacemaker for APC 0090 is $4881.77.  It would therefore be reasonable for the contractor/MAC to set the payment rate for a single chamber pacemaker to $4881.77. I n this case the coinsurance would be $936.75 (20 percent of $4881.77, which is less than the inpatient deductible).
(Medicare Claims Processing Manual)
The beneficiary coinsurance is 20 percent of the payment amount for the device (i.e. the pass through payment amount, the DMEPOS fee schedule amount, the contractor established amount, or the actual charge if less than the DMEPOS fee schedule amount or the contractor established amount for the specific device), not to exceed the Medicare inpatient deductible that is applicable to the year in which the implanted prosthetic device is furnished.  When a hospital that is not paid under the OPPS furnishes an implantable prosthetic device other than dental), which replaces all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such a device, to an inpatient who has coverage under Part B but does not have Part A coverage, and the primary procedure is not a payable Part B inpatient service under Pub. 100-02, Medicare Be nefit Policy Manual, chapter 6, 10.2 (Other Circumstances in Which Payment Cannot Be Made under Part A), payment for the implantable prosthetic device is made under the payment mechanism that applies to other hospital outpatient services (e.g., reasonab le cost, all inclusive rate, waiver).   240.4 - Indian Health Service/Tribal Hospital Inpatient Social Admissions  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)
(Medicare Claims Processing Manual)
240.4 - Indian Health Service/Tribal Hospital Inpatient Social Admissions  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)  There may be situations when an American Indian/Alaskan Native (A I/AN) beneficiary is admitted to an IHS/Tribal facility for social reasons. These social admissions are for patient and family convenience and are not billable to Medicare.  There are also occasions where IHS/Tribal hospitals elect to admit patients prior to a scheduled day of surgery, or place a patient in a room after an inpatient discharge. These services are also considered to be social admissions as well.  For patients in a social admission status requiring outpatient services at another facility, Medi care disallows payment for inpatient Part B ancillary services, Type of Bill (TOB) 12X during a social admission stay when there is another bill from a different facility for an outpatient service, TOB 13X or 72X. The Common Working File (CWF) returns an A/B crossover edit and creates an unsolicited response (IUR) in this situation.  The CWF also creates an IUR when a line item date of service on TOB 12X is equal to or one day following the discharge date on TOB 11X for the same provider.   The CWF bypasses both of these edits when the beneficiary is not entitled to Medicare Part A at the time the services on TOB 12X are rendered.    240.5 - Payment of Part B Services in the Payment Window for Outpatient Services Treated as Inpatient Services When Payment Canno t Be Made Under Part A  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)
(Medicare Claims Processing Manual)
See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals) an d Pub 100- 04, Medicare Claims Processing Manual, Chapter 4,  10.12 (Payment Window for Outpatient Services Treated as Inpatient Services) regarding  services bundled into the original Part A claim under the 3 -day (1 -day for non -IPPS hospitals) payment window prior to the inpatient admission, that may be billed to Part B when Part A payment cannot be made.  Hospitals should use the following type of bi ll to report these services:    13X TOB (85X for a CAH) - Hospital outpatient services included in the payment window for outpatient services treated as inpatient services    14X TOB - Laboratory tests that are paid under the clinical laboratory fee schedule (see chapter 16, 40.3 of this manual), and included in the payment window for outpatient services treated as inpatient services   240.6 - Submitting Provider -Liable No- Pay Part A Claims  and Beneficiary Liability  (Rev. 2877, Issued: 02- 07-14, Effective: 10- 01-13, Implementation: 04- 07-14)  When Part A payment cannot be made for a hospital inpatient admission and the hospital, not the beneficiary, is liable under section 1879 of the Act for the cost of the Part A items and services, the hospital must submit a provider -liable no pay Part A claim (110 TOB) (see chapter 3 40.2.2,  Charges to Beneficiaries for Part A Services of this manual) .  Submission of this claim cancels  any claim that may have already been submitted by the hospital for payment under Part A.  When a Medicare review contractor denies a Part A claim for medical necessity, the claims system converts the originally submitted 11X claim to a 110 TOB on behalf of the hospital.
(Medicare Claims Processing Manual)
When the hospital and not the beneficiary is liable for the cost of the Part A services (pursuant to the limitation on liability provision in Section 1879 of the Social Security Act), the beneficiary is not responsible for paying the deduc tible and coinsurance charges related to the denied Part A claim and the beneficiarys Medicare utilization record is not charged for the services and items furnished.  The hospital must refund any payments (including coinsurance and deductible) made by the beneficiary or third party for a denied Part A claim when the provider is held financially liable for that denial (see section 1879(b) of the Act; 42 CFR  411.402; and chapter 30  30.1.2, Beneficiary Determined to Be Without Liability and 30.2.2, P rovider/Practitioner/Supplier is Determined to Be Liable of this manual).    Medicare beneficiaries are liable for their usual Part B financial liability for services covered under Part B when Part A payment cannot be made, including Part B copayments for e ach payable Part B inpatient or Part B outpatient service.  The beneficiary is also liable for the cost of services not covered under Part B.   250 - Special Rules for Critical Access Hospital Outpatient Billing  (Rev. 1111, Issued: 11- 09-06, Effective: 04- 01-07, Implementation: 04- 02-07)  For cost reporting periods beginning before October 1, 2000, a CAH will be paid for outpatient services under the method in 250.1.  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  This provision was implemented with respect to cost reporting periods starting on or after October 1, 2001.
(Medicare Claims Processing Manual)
For cost reporting period beginning on or afte r October 1, 2001, the CAH will be paid under the method in item 1 below unless it elects to be paid under the method in 250.1 of this manual.  If a CAH elects payment under the elective method (cost -based facility payment plus fee schedule for professional services) for a cost reporting period, that election is effective for the entire cost reporting period to which it applies.  If the CAH wishes to make a new election or change a previous election, that election should be made in writing, made on an annual basis and delivered to the appropriate A/B MAC (A), at least 30 days in advance of the beginning of the affected cost reporting period.  All outpatient CAH services, other than pneumococcal pneumonia vaccines, influenza vaccines, administratio n of the vaccines, screening mammograms, and clinical diagnostic laboratory tests are subject to Part B deductible and coinsurance.  Regardless of the payment method applicable for a period, payment for outpatient CAH services is not subject to the followi ng payment principles:    Lesser of cost or charges,    Reasonable compensation equivalent (RCE) limits,    Any type of reduction to operating or capital costs under 42 CFR 413.124 or 413.30(j)(7) , or    Blended payment rates for ASC -type, radiology, and other diagnostic services.  See 250.4 below regarding payment for screening mammography services.   250.1 - Standard Method - Cost -Based Facility Services, With Billing of A/B MAC (B) for Professional Services (Rev. 2581, Issued: 11- 02-12, Effective: 04- 01-13, Implementation: 04- 01-13)   Effective for cost reporting periods beginning on or after January 1, 2004, payment for outpatient CAH services under this method will be made for the lesser of: 1) 80 percent of 101 percent of the reasonable cost of the CAH in furnishing those services, or 2) 101 percent of the reasonable cost of the CAH in furnishing those s ervices, less applicable Part B deductible and coinsurance amounts.