evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Occurring During Concurrent Stays  04/04/2005 3452 R573CP  06/03/2005 Clarifying Manual Instructions for Coding and Payment for Drug Administration Under the Hospital Outpatient Prospective Payment System (OPPS)  06/01/2005 3848 R566CP  05/20/2005 Clarifying Manual Instructions for Coding and Payment for Drug Administration Under the Hospital Outpatient Prospective Payment System (OPPS)  06/01/2005 3848 R557CP  05/06/2005 Clarifying Manual Instructions for Coding and Payment for Drug Administration Under the Hospital Outpatient Prospective Payment System (OPPS)  06/01/2005 3848 R530CP  04/22/2005 Billing Requirements for Physician Services Rendered in Method II Critical Access Hospitals (CAHs)  07/05/2005 3800 Rev #  Issue Date  Subject  Impl Date  CR#  R496CP  03/04/2005 Billing for Blood and Blood Products Under the Hospital Outpatient Prospective Payment System (OPPS)  07/05/2005 3681 R483CP  02/25/2005 Hospital Partial Hospitalization Services Billing Requirements  10/04/2004 3297 R477CP  02/18/2005 New Case -Mix Adjusted End Stage Renal Disease (ESRD) Composite Payment Rates and New Composite Rate Exceptions Window for Pediatric ESRD Facilities  04/04/2005 3720 R465CP  02/04/2005 Billing Requirements for Physician Services in Method II Critical Access Hospitals (CAHs)  07/05/2005 3559 R442CP  01/21/2005 Hospital Outpatient Prospective Payment System (OPPS): Use of Modifiers - 52, -73 and -74 for Reduced or Discontinued Services  02/22/2005 3507 R407CP  12/17/2004 Hospital Billing for Repetitive Services  01/03/2005 3633 R404CP  12/17/2004 January 2005 Update of the Hospital Outpatient Prospective Payment System (OPPS): Changes to Coding and Payment for Drug Administration  01/03/2005 3610 R403CP  12/17/2004 January 2005 Update of the Hospital Outpatient Prospective Payment System (OPPS): Billing for Devices that do not have Transitional Pass -Through Status, and that are not Classified as New Technology Ambulatory Payment Classification (APC) Groups  01/03/2005 3606 R379CP  11/26/2004 Low Osmolar Contrast Material/Laboratory Tests/Payment for Inpatient Services Furnished by a Critical Access Hospital
(Medicare Claims Processing Manual)
as New Technology Ambulatory Payment Classification (APC) Groups  01/03/2005 3606 R379CP  11/26/2004 Low Osmolar Contrast Material/Laboratory Tests/Payment for Inpatient Services Furnished by a Critical Access Hospital (CAH)  04/04/2005 3439 R370CP  11/19/2004 New Case -Mix Adjusted End Stage Renal Disease (ESRD) Composite 04/04/2005 3572 Rev #  Issue Date  Subject  Impl Date  CR#  Payment Rates and New Composite Rates and New Composite Rate Exceptions Window for Pediatric ESRD Facilities  R351CP  10/29/2004 Editing of Hospitals and Skilled Nursing Facilities Part B Inpatient Services (Full Replacement of Change Request 3366)  01/03/2005 3531 R336CP  10/29/2004 Indian Health Service (IHS) or Tribal Hospitals including Critical Access Hospitals (CAH) Payment Methodology for Inpatient Social Admissions and Outpatient Services Occurring During Concurrent Stays  04/04/2005 3452 R301CP  09/17/2004 Editing Of Hospital And Skilled Nursing Facility Part B Inpatient Services  01/03/2005 3366 R270CP  08/03/2004 Update to the Frequency of Billing  01/03/2005 3382 R262CP  07/30/2004 Bonus Payment to Physicians That Render Services in a CAH in a Designated Physician Scarcity Area  01/03/2005 3262 R251CP  07/23/2004 Editing Of Hospital And Skilled Nursing Facility Part B Inpatient Services  01/03/2005 3366 R243CP  07/23/2004 Patient Status Code and Reason for Patient Visit for the Hospital Outpatient Prospective Payment System (OPPS)  01/03/2005 2800 R239CP  07/23/2004 Update to the Frequency of Billing  01/03/2005 3382 R231CP  07/23/2004 Indian Health Service (IHS) or Tribal Critical Access Hospital (CAH) Payment Methodology for Inpatient and Outpatient Services  01/03/2005 3235 R180CP  05/14/2004 Hospital Partial Hospitalization Services Billing Requirements  N/A 3297 Rev #  Issue Date  Subject  Impl Date  CR#  R167CP  04/30/2004 Discontinued Use of Revenue Code 0910 10/04/2004 3194 R156CP  04/30/2004 Payment Procedure for Maryland Hospitals Under the Jurisdiction of the Health Services Cost Review Commission  10/04/2004 3200
(Medicare Claims Processing Manual)
04/30/2004 Discontinued Use of Revenue Code 0910 10/04/2004 3194 R156CP  04/30/2004 Payment Procedure for Maryland Hospitals Under the Jurisdiction of the Health Services Cost Review Commission  10/04/2004 3200 R152CP  04/30/2004 Inclusion of Core -Based Statistical Area (CBSA) Data Elements to the Provider Specific Files  10/04/2004 3272 R132CP  03/30/2004 April 2004 Update of the Hospital Outpatient Prospective Payment System  04/05/2004 3154 R103CP  02/20/2004 Optional Method for Outpatient Services: Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional Services  07/01/2004 3114 R089CP  02/06/2004 The Elimination of the 90- Day Grace Period for HCPCS Codes  07/06/2004 3093 R063CP  01/16/2004 Special Rules for Critical Access Hospital (CAH) Outpatient Billing  04/05/2004 3051 R053CP  12/22/2003 Outpatient Code Editors  01/05/2004 3021 R046CP  12/19/2003 Outpatient Code Editors  01/05/2004 3021 R045CP  12/19/2003 Outpatient Provider Specific File  01/20/2004 2994 R041CP  12/08/2003 Special Rules for Critical Access Hospital Outpatient Billing  01/05/2004 2990 R036CP  11/28/2003 Add revenue code 068x  01/01/2004 2995 R026CP  11/04/2003 Lung Volume Reduction Surgery  01/05/2004 2688 R001CP  10/01/2003 Initial Publication of Manual  NA NA Back to top of Chapter
Article - Billing and Coding: Hospital Outpatient Drugs and Biologicals Under the Outpatient Prospective Payment System (OPPS) (A55913)
CMS National Coverage PolicyCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 17, 90.2 Drugs, Biologicals, and RadiopharmaceuticalsCMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 17, 90.3 Hospital Outpatient Payment Under OPPS for New, Unclassified Drugs and Biologicals After FDA Approval But Before Assignment of a Product-Specific Drug or Biological HCPCS CodeArticle TextPalmetto GBA A/B MAC for JM and JJ has identified a pattern of incorrect billing of Part A hospital claims for unclassified drugs and biologicals under OPPS using HCPCS code C9399. Based on data analysis there have been numerous claims submitted listing C9399 for unclassified drugs and biologicals that do not meet the definition of a new drug or biological. Only new FDA approved drugs and biologicals, on or after January 1, 2004, that have not yet been assigned a specific HCPCS code are to be billed with the C9399 HCPCS code.C-codes are for new drugs and biologicals and are generally replaced or expire after a year. After the year, if a drug or biological does not have an established or valid HCPCS code, then it should be billed with a NOC code.NOC codes are for Unclassified drugs or Not Otherwise Classified drugs (J3490) and biologics (J3590).Drugs and biologicals appropriately billed using C9399 are separately payable and are priced by Palmetto GBA using Average Wholesale Price (AWP) and CMS pricing methodology. NOC coded drugs and biologics (J3490 and J3590) are not separately paid and are considered inclusive of both the acquisition cost and the associated pharmacy overhead or nuclear medicine handling cost.
Article - Billing and Coding: Hospital Outpatient Drugs and Biologicals Under the Outpatient Prospective Payment System (OPPS) (A55913)
The CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 17, 90.2 provides the following instructions regarding hospital outpatient billing of Drugs and Biologicals:Hospitals should report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used.HCPCS code C9399, Unclassified drug or biological, is for new drugs and biologicals that are approved by FDA on or after January 1, 2004, for which a specific HCPCS code has not been assigned.Inappropriatelyusing C9399 when a NOC code (J3490 or J3590) should be used is a billing error and may result in a claims payment error or overpayment. CMS has tasked all A/B MACs, including Palmetto GBA, to assist with reducing the national claims payment error rate.The following are examples of drugs inappropriately billed using C9399 that should have been billed using J3490, J3590 or the specific assigned J HCPCS codes:Sugammadex- J3490-Unclassified drugDiltiazem HCL- J3490  Unclassified drugPropofol - J3490  Unclassified drugHospitals are encouraged to provide or improve quality assurance oversight of OPPS claims for drugs and biologicals in order to use the most current HCPCS code for the drug and/or biological on the claim submitted. On the CMS Medicare Coverage Database there is alisting of HCPCS codes specific for drugs:2020 Table of DrugsHospital OPPS claims for drugs and biologicals should be billed with the appropriate HCPCS codes under revenue code 0636 (whether they are separately payable or packaged). This is consistent with the National Uniform Billing Committee (NUBC) billing guidelines, providing CMS and Palmetto GBA A/B MAC with the most complete and detailed information for accurate rate setting and claims payment.Hospital OPPS claims for Self Administered Drugs (SAD), that are listed and posted on the Palmetto GBA A/B MAC JM and JJ websites, should be billed with the appropriate HCPCS code.
Article - Billing and Coding: Hospital Outpatient Drugs and Biologicals Under the Outpatient Prospective Payment System (OPPS) (A55913)
Hospital OPPS claims for Self Administered Drugs (SAD), that are listed and posted on the Palmetto GBA A/B MAC JM and JJ websites, should be billed with the appropriate HCPCS code.Palmetto GBA has identified a pattern of incorrect billing for the total quantity administered and billed for unclassified drugs and biologicals under OPPS using C9399. Some providers have billed each unit dose of the drug or biological on separate claim lines. The quantity of a C9399 drug or biological administered should be billed on 1 claim line for 1 unit dose for the date of service given. The total dose quantity administered needs to be indicatedin the remarks field (Field Locator 80) on the UB-04 (CMS 1450 form) or the equivalent 5010 electronic claims field.The CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 17, 90.3 instructs, that on the claim, providers must report:the National Drug Code (NDC),total quantity of the drug that was administered, expressed in the unit of measure applicable to the drug or biological, andthe date the drug was administered.
Article - Billing and Coding: JW and JZ Modifier Billing Guidelines (A55932)
CMS National Coverage PolicyN/AArticle TextThis article addresses the required use of the JW and JZ modifier to indicate drug wastage. CMS and Noridian encourage physicians, hospitals and other providers and suppliers to administer drugs and biologicals to patients in such a way that these are used most efficiently, in a clinically appropriate manner (IOM100-4 Chapter 17, Sections 40-40.1).When a physician, hospital or other provider or supplier must discard the remainder of a single-use vial or other single-use package after administering a dose/quantity of the drug or biological to a Medicare patient, the program provides payment for the discarded drug or biological amount as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label.The following serves to clarify billing guidelines and provide examples of proper billing with a single-dose vial and discarded drug billing:Providers and hospitals are reminded to ensure amounts of drugs administered to patients are accurately reported in terms of the dosage specified in the long descriptor for the applicable HCPCS codes. This is because the short descriptors are limited to 28 characters so they do not always capture the complete description of the drug.When submitting Medicare claims, units of service (UOS) should be reported in multiples of the dosage included in the long HCPCS code descriptor. If the dosage given is not a multiple of the number provided in the HCPCS code description, the provider shall round up to the nearest whole number in order to express the number as a multiple.If the provider must discard the remainder of a single-use vial or other package after administering the prescribed dosage of any given drug, Medicare may cover the amount of the drug discarded along with the amount administered. The following elements must be followed in order for the discarded amount to be covered.The vial must be a single-use vial. Multi-use vials are not subject to payment for any discarded amounts of the drug.Any amount of drug billed as wastage from a single-dose vial, must actually be discarded and may not be used for another patient regardless of whether or not that other patient has Medicare.
Article - Billing and Coding: JW and JZ Modifier Billing Guidelines (A55932)
Please clearly document in the patient's medical record the actual dose administered in addition to the exact amount wasted and the total amount of the vial is labeled to contain. This kind of detailed documentation helps benefit your practice by justifying your billing in the event a medical review should occur.Medicare requires discarded drugs be reported with the JW modifier on a separate line, the total number of discarded units reported should not include amounts of the drug also included on the administered line due to the rounding up of units.Please remember to verify the milligrams administered to the patient and then convert to the proper units for billing.Due to single-use vial type, the provider may bill for the amount administered as well as the amount appropriately discarded. The discarded amount is reported with the JW modifier. The JW modifier is only applied to the amount of the drug or biological that is discarded. A situation in which the JW modifier is not permitted is when the actual dose of the drug or biological administered is less than the billing unit. (See "Medicare Claims Processing Manual," Chapter 17, Section 40). As an example, if one billing unit for a drug is equal to 10mg of the drug in a single-use vial, and a 7mg dose is administered to a patient resulting in 3mg remaining drug being discarded, then the 7mg dose is billed using one UOS that represents 10mg on a single line item. The single line item would be processed for payment of the total 10mg of the drug administered and discarded. Billing another unit on a separate line item with the JW modifier for the discarded 3mg of the drug is not permitted because it would result in an overpayment. Therefore, when the billing unit is equal or greater than the total actual dose and the amount discarded, the use of the JW modifier is not permitted.Effective July 1, 2023, Medicare requires the JZ modifier on all claim for single-dose containers where there are no discarded amounts.To submit claims for a waste-required claim, submit two complete claim lines.Claim line #1:HCPCS code for drug givenNo modifierNumber of units given to the patientCalculated submitted price for ONLY the amount of drug givenClaim line #2:HCPCS code for drug wastedJW modifier to indicate wasteNumber of units wastedCalculated submitted price for ONLY the amount of drug wasted
Article - Billing and Coding: JW and JZ Modifier Billing Guidelines (A55932)
Claim line #2:HCPCS code for drug wastedJW modifier to indicate wasteNumber of units wastedCalculated submitted price for ONLY the amount of drug wastedTo submit claims for a non-discarded claim, submit one complete claim line.HCPCS code for drug givenJZ modifier to indicate no wasteNumber of units given to the patientCalculate submitted price for the amount givenSources:CR 9603-JW Modifier: Drug amount discarded/not administered to any patientInternet Only Manual (IOM) 100-4-Claims Processing Manual; Chapter 17-Drugs and Biologicals; Sections 40-40.1Discarded Drugs and Biologicals - JW Modifier and JZ Modifier Policy Frequently Asked Questions (cms.gov)
Article - Billing and Coding: Diagnostic Colonoscopy (A55937)
CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33671 (Diagnostic Colonoscopy). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Medical record documentation (office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the colonoscopy procedure. The procedure results/report and any associated pathology report must be included in the patient's medical record.If the provider of the colonoscopy is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of procedure results/report and pathology report along with copies of the ordering/referring physician's order for the procedure.The patients medical record should contain documentation to support an incomplete procedure.
Article - Billing and Coding: Endometrial Hyperplasia Treatment with Intrauterine Device (Hormone-Eluting) (A55951)
CMS National Coverage PolicyN/AArticle Text
Article - Billing and Coding: Endometrial Hyperplasia Treatment with Intrauterine Device (Hormone-Eluting) (A55951)
The endometrium may develop endometrial hyperplasia (EH), which includes non-neoplastic entities (disordered proliferative endometrium, benign hyperplasia, simple and complex hyperplasias without atypia) characterized by a proliferation of endometrial glands, and endometrial intraepithelial neoplasms (EIN), and all atypical complex hyperplasia characterized by neoplastic features but without invasion. EH frequently results from chronic estrogen stimulation unopposed by the counterbalancing effects of progesterone. The majority of women with EH will present with abnormal uterine bleeding. Management treatment options of EH include surveillance, progestin therapy, or hysterectomy. All management strategies should be accompanied by removal of the source of unopposed estrogen, as this is the main etiology of endometrial neoplasia.This article addresses the management of EH with an insertion of a progestin-containing intrauterine device (IUD) with the delivery of progestins over five years, as an accepted method of treatment in patients with abnormal uterine bleeding who are unable to tolerate oral megestrol or develop high-risk complications of oral megestrol, who are not reasonable surgical candidates or who wish to preserve fertility. Women who are at a high risk of surgical complications due to medical comorbidities or surgical history should be evaluated and counseled regarding whether surgery or progestin therapy is the preferable option.Per ACOG Committee Opinions, for most women with atypical EH/EIN who are postmenopausal, hysterectomy rather than progestin therapy is recommended.WPS GHA has determined that the use of a progestin-containing IUD with the delivery of progestins over five years, may be approved for use in the Medicare beneficiary who presents with endometrial hyperplasia without atypia.Per Medicare regulations, contraceptive devices or medications are not allowed for payment. For this reason the service, 58300, insertion of IUD has an "N" status in the Medicare Physician Fee Schedule, which means the service cannot be covered when billed to Medicare.
Article - Billing and Coding: Endometrial Hyperplasia Treatment with Intrauterine Device (Hormone-Eluting) (A55951)
Since the CPT code for IUD insertion will be auto-denied, providers should bill this service using CPT code 58999, the appropriate diagnoses listed in this article and the product description "hormone IUD for endometrial hyperplasia" in Item 19 of the CMS-1500 form or the electronic equivalent.Coverage for this method of treatment must be reasonable and necessary for the diagnosis, or treatment of illness, or to improve the functioning of the patients clinical condition, the standard of medical practice regarding the effectiveness of the IUD for the diagnosis and condition and meet all other applicable Medicare statutory and regulatory requirements.The patients medical record must clearly document the specific clinical circumstances supporting the medical necessity for services included within this Article.
Article - Billing and Coding: Endometrial Hyperplasia Treatment with Intrauterine Device (Hormone-Eluting) (A55951)
Evaluation to include abnormal uterine bleeding,Evaluation should not be performed without complaint of post-menopausal bleeding,Evidence of transvaginal ultrasound on file with documented stripe greater than 4mm.Pathology biopsy report:Simple/benign hyperplasia: a progesterone IUD is a reasonable treatment option.A Copper IUD is not a reasonable treatment option.EIN/complex EH: documentation supports patient is a poor surgical candidate. Current nonsurgical management options are limited to hormonal therapy.This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
42 CFR § 410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Institute
htmlGlobal site tag (gtag.js) - Google AnalyticsGoogle tag (gtag.js)42 CFR  410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. | Electronic Code of Federal Regulations (e-CFR) | US Law | LII / Legal Information Instituteschema.org metadata/schema.orgAPI urlinclude adcodemobile: vignettes and page-leveladsense/adsense/include adcodePlease help us improve our site!No thank youSkip to main contentCornell LawSchoolSearchCornellToggle navigationPlease helpus improve our site!Support Us!SearchAboutLIIWho We AreWhat We DoWho Pays For ThisContact UsGet thelawConstitutionSupreme CourtU.S. CodeCFRFederal RulesFederal Rules of Appellate ProcedureFederal Rules of Civil ProcedureFederal Rules of Criminal ProcedureFederal Rules of EvidenceFederal Rules of Bankruptcy ProcedureU.C.C.Law by jurisdictionState lawUniform lawsFederal lawWorld lawLawyer directoryLegal encyclopediaBusiness lawConstitutional lawCriminal lawFamily lawEmployment lawMoney and FinancesMore...Help outGiveSponsorAdvertiseCreatePromoteJoin Lawyer DirectoryLIIElectronic Code of Federal Regulations (e-CFR)Title 42Public HealthCHAPTER IVCENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICESSUBCHAPTER BMEDICARE PROGRAMPART 410SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITSSubpart BMedical and Other Health Services 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.42 CFR  410.32 - Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.CFRTable of Popular Namesprev|next'text' content area