evekhm/cms_iom_500 huggingface dataset:
(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 code 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 -packag ed 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 for 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 procedure 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 multiple 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 Rural Sole Community  Hospitals  (Rev. 12369, Issued: 1 1-17-23; Effective: 01 -01-2023; Implementation: 01- 03-2023)   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 t he 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)  Effective 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 yea r 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)  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)
(Medicare Claims Processing Manual)
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 ar e 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 adjust ed to cost).  The reduction also does not apply to hospital outpatient services paid through other fee schedules or other mechanisms.  Examples of these exceptions 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., clinical laboratory services and durable medical equipment).  The specific services to which this policy applies can be identified by OPPS status indicator.  CMS will identify the status indicators of the HCPCS codes to which the reduction applies each year in the change request that announces changes to the OPPS for  the forthcoming calendar year.  Also, the status indicators for the services (identified by HCPCS codes) to which the reduction applies can be found in the OPPS final rule for the year of interest under Hospital Outpatient Regulations and Notices at www.cms.hhs.gov/HospitalOutpatientPPS/ .  The services excluded from the payment reduction may change each year if the method of calculating payment under the OPPS changes.   10.6.2.3 - Contractor Responsibilities  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)
(Medicare Claims Processing Manual)
10.6.2.3 - Contractor Responsibilities  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  CMS claims processing software will automatically reduce payment to Subsection (d) hospitals when those hospitals that fail to meet the quality reporting requirements bill for services to which the reduced update applies.  However, contractors must updat e the Outpatient Provider Specific File (OPSF) quality reporting field when CMS furnishes the list of hospitals to which the payment reduction applies.  The FISS auto- populates the Hospital Quality Indicator field of the OPSF field with a 1 for all hospitals.  Once CMS has issued the list of hospitals failing to meet the requirements, Medicare contractors must remove the 1 in the Hospital Quality Indicator field for each Subsection (d) hospital that fails to meet the quality reporting requirements.  Con tractors make no changes to the 1 indicator for hospitals that are not Subsection (d) hospitals providing OPPS services or for hospitals that are Subsection (d) hospitals providing OPPS services that are not listed as failing the requirements.   CMS sends Medicare contractors the file of hospitals to which the reduction applies for a given calendar year by a Joint Signature Memorandum/Technical Direction Letter as soon as the list is available.  This will be sent as soon as possible, expected to be on or about December 1 of each year preceding the calendar year to which the payment reduction applies.  Should a Subsection (d) hospital later be determined to have met the criteria after dissemination of this list, CMS will change the hospitals status .  CMS will notify Medicare contractors of the change in status and contractors must update the OPSF as needed and must mass adjust paid claims.
(Medicare Claims Processing Manual)
For new hospitals, Medicare contractors must provide information to the Quality Contractor to be specified by CMS as soon as possible so that the Quality Contractor can enter the provider information into the Program Resource System and follow through with ensuring provider participation with the requirements for quality data reporting, if applicable.  CMS will notify Medicare contractors of how to contact the Quality Contractor each year in the annual OPPS update change request.  This allows the Quality Contractor the opportunity to contact new facilities as early as possible in the calendar year to inform them of the hospital outpatient quality reporting requirements.  As soon as possible, Medicare contractors must provide the following information on newl y participating hospitals to the Quality Contractor to be specified by CMS:    State code;   Provider name;   Provider ID numbe;   Medicare accept dat;e   Contact name (if available); and   Telephone number.   10.6.2.4 - Application of the Payment Reduction Factor in Calculation of the Reduced Payment and Reduced Copayment  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  For services to which the payment adjustment applies, CMS calculates a payment reduction factor that is used in the OPPS Pricer to adjust the payments for hospitals that fail to meet the reporting requirements.  CMS calculates this factor by dividing the OPPS conversion factor that incorporates the reduced update factor by the OPPS conversion factor that incorporates the full update factor for the applicable calendar year.   This ratio is applied to the full national unadjusted payment amount for a service s ubject to the payment reduction in order to calculate the reduced payment amount.  Similarly, this ratio is applied to the full national unadjusted copayment for an applicable service to calculate the reduced copayment that may be collected from the beneficiary by the hospital.  The payment reducti on factor will be included in the annual OPPS update change request and may also be found in the applicable OPPS final rule, which can be found at www.cms.hhs.gov/HospitalOutpatientPPS/  under Hospital Outpatient Regulations and Notices.   10.6.3 - Payment Adjustment for Certain Cancer Hospitals  (Rev. 2453, Issued: 04- 26-12, Effective: 01 -01-12, Implementation: 05- 29 -12)
(Medicare Claims Processing Manual)
A rural emergency hospital (REH), as defined in  419.91, is an entity that operates for the purpose of providing emergency department services, observation care, and other outpatient medical and health services specified by the Secretary in which the annual per patient average length of stay does not exceed 24 hours. The time calculation for determining the length of stay of a patient receiving REH services begins with the registration, check -in or triage of the patient (whichever occurs first) and ends wi th the discharge of the patient from the REH. The discharge occurs when the physician or other appropriate clinician has signed the discharge order, or at the time the outpatient service is completed and documented in the medical record. The entity must not provide inpatient services, except those furnished in a unit that is a distinct part licensed as a skilled nursing facility to furnish post -hospital extended care services.    Rural emergency hospital services, as defined in  419.91, are all covered outpatient department (OPD) services, as defined in section 1833(t)(1)(B) of the Act, excluding services described in section 1833(t)(1)(B)(ii), furnished by an REH that would be paid under the OPPS when provided in a hospital paid under the OPPS for outpatient services, provided that such services are furnished consistent with the conditions of participation at 42 C.F.R.  485.510 -  485.544.  A. Payment for REH Services  Beginning January 1, 2023, a REH that provides a REH service will receive a Medicare payment for the service that is equal to the amount of payment that would otherwise apply under section 1833(t) of the Act for the equivalent covered OPD service, increase d by 5 percent to reflect the higher costs incurred by such hospitals. The beneficiary co-
(Medicare Claims Processing Manual)
1 The information described in Section 10.6.4 of this Manual is based on proposed policies to implement payment for REHs, published as a rider to the CY2023 OPPS proposed rule. All policies are subject to change pending the publication of the final policies  concerning this new provider type, including associated REH payment policies, in the CY2023 OPPS Final Rule, CMS- 1772- FC. If there are changes to these proposed policies made in response to public comments in the final rule, CMS will update this section accordingly.  payment for the service is calculated the same way as it is calculated under section 1833(t)(8) of the Act for the equivalent covered OPD service, excluding the 5 percent payment increase.   EXAMPLE:  1. Service/Rate x 0.05 = Increase Amount for REH Services  $100.00/Rate x 0.05 = $5.00  Increase Amount for REH Services
(Medicare Claims Processing Manual)
EXAMPLE:  1. Service/Rate x 0.05 = Increase Amount for REH Services  $100.00/Rate x 0.05 = $5.00  Increase Amount for REH Services    2. Service/Rate + Increase Amount for REH Services = Allowed Amount   $100.00 + $5.00 = $105.00 Allowed Amount    3. Service/Rate x 0.20 = Coinsurance   $100.00 * 0.20 = $20.00 Coinsurance    Claims for REH services are paid based on OPPS prospective rates and are adjudicated based on OPPS payment policies and rules.  Services performed by an REH that do not meet the definition of an REH service (i.e. certain outpatient services that may be provided on an outpatient basis by OPPS hospitals but are not paid under the OPPS) are paid at the same rate as the service would be paid if performed at an OPPS hospital and paid based on the applicable fee schedule outside of the OPPS.  Such services are not considered REH services and do not receive the additional 5 percent payment that REH services receive. Ambulance services furnished by an entity owned and operated by a rural emergency hospital are paid under the ambulance fee schedule as described at section 1834(l) of the Act. Post -hospital extended care services furnished by a rural emergency hospital that has a unit that is a distinct part licensed as a skilled nursing facility are paid under the skilled nursing facility prospective payment system des cribed at section 1888(e) of the Act. B. Monthly REH Facility Payment  In addition to payment for individual claims, section 1834(x)(2) of the Act requires REHs to be paid a monthly facility payment.  The monthly facility payment for every REH is the same. There is no adjustment to the facility payment because of the size of the REH or amount of revenue generated by the REH.  For 2024 and subsequent years, this payment will be updated annually by the hospital market basket percentage increase.    10.7 - Outliers  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)    10.7.1 - Outlier Adjustments  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)
(Medicare Claims Processing Manual)
10.7.1 - Outlier Adjustments  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    The OPPS incorporates an outlier adjustment to ensure that outpatient services with variable and potentially significant costs do not pose excessive financial risk to providers.  Section 419.43(f) of the Code of Federal Regulations excludes drugs, biologicals and items and services paid at charges adjusted to cost from outlier payments.  The OPPS determines eligibility for outliers using either a multiple threshold, w hich is the product of a multiplier and the APC payment rate, or a combination of a multiple and fixed -dollar threshold.  A service or group of services becomes eligible for outlier payments when the cost of the service or group of services estimated using  the hospitals most recent overall cost -to-charge ratio (CCR) separately exceeds each relevant threshold.  For community mental health centers (CMHCs), CMS determines whether billed partial hospitalization or intensive outpatient  services are eligible for outlier payments using a multiple threshold specific to CMHCs.  The outlier payment is a percentage of the difference between the cost estimate and the multiple threshold.  The CMS OPPS Web site at www.cms.hhs.gov/HospitalOutpatientPPS/  under Annual Policy Files includes a table depicting the specific hospital and CMHC outlier thresholds and the payment percentages in place for each year of the OPPS.    Beginning in CY 2000, CMS determined outlier payments on a claim basis.  CMS determined a claims eligibility to receive outlier payments using a multiple threshold.  A claim was eligible for outlier payments when the total estimate of charges reduced to cost for the entire claim exceeded a multiple of the total claim APC payment amount.  As provided in Section 1833(t)(5)(D), CMS used each hospitals overall CCR rather than a CCR for each department within the hospital.  CMS continues to use an overall hospital CCR specific to ancillary cost centers to estimate costs from charges for outlier payments.
(Medicare Claims Processing Manual)
List of Data Elements for FISS Extract  Provider #  Medicare beneficiary identifier  Document Control Number (DCN)  Type of Bill  Original Paid Date  Statement From Date  Statement To Date  Original Reimbursement Amount (claims page 10)  Revised Reimbursement Amount (claim page 10)  Difference between these amounts  Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1)  Difference between these amounts  Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2)  Difference between these amounts  Original Outlier Amount (Value Code 17)  Revised Outlier Amount (Value Code 17)  Difference between these amounts  Original DSH Amount (Value Code 18)  Revised DSH Amount (Value Code 18)  Difference between these amounts  Original IME Amount (Value Code 19)  Revised IME Amount (Value Code 19)  List of Data Elements for FISS Extract  Difference between these amounts  Original New Tech Add -on (Value Code 77)  Revised New Tech Add -on (Value Code 77)  Difference between these amounts  Original Device Reductions (Value Code D4)  Revised Device Reductions (Value Code D4)  Difference between these amounts  Original Hospital Portion (claim page 14)  Revised Hospital Portion (claim page 14)  Difference between these amounts  Original Federal Portion  (claim page 14)  Revised Federal Portion  (claim page 14)  Difference between these amounts  Original C TOT PAY (claim page 14)  Revised C TOT PAY (claim page 14)  Difference between these amounts  Original C FSP (claim page 14)  Revised C FSP (claim page 14)  Difference between these amounts  Original C OUTLIER (claim page 14)  Revised C OUTLIER (claim page 14)  Difference between these amounts  Original C DSH ADJ (claim page 14)  Revised C DSH ADJ (claim page 14)  Difference between these amounts  Original C IME ADJ (claim page 14)  Revised C IME ADJ (claim page 14)  Difference between these amounts  Original Pricer Amount  Revised Pricer Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14) Revised PPS Return Code (claim page 14)  DRG
(Medicare Claims Processing Manual)
Amount  Difference between these amounts  Original PPS Payment (claim page 14)  Revised PPS Payment (claim page 14)  Difference between these amounts  Original PPS Return Code (claim page 14) Revised PPS Return Code (claim page 14)  DRG  MSP Indicator (Value Codes 12 -16 & 41 -43 - indicator indicating the claim is MSP; Y = MSP, blank = no MSP  Reason Code  HMO -IME Indicator  Filler
(Medicare Claims Processing Manual)
10.8 - Geographic Adjustments  (Rev. 1, 10- 03-03) A-01-93  Adjustments for differences in wages across geographical areas are made using inpatient hospital PPS wage index (post -reclassification, post -floor).   It is estimated that 60 percent of the group payment represents labor -related costs and are subject to the geographic adjustment.  10.8.1 - Wage Index Changes  (Rev. 1, 10- 03-03) A-02-026 XIII, A -01-144  Refer to the CMS Web site http://www.cms.gov/medicare/hopsmain.htm  for wage index change information.  10.9 - Updates  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    Section 1833(t) of the Social Security Act (the Act) as amended by 4533 of the  Balanced Budget Act (BBA) of 1997, authorizes CMS to implement a Medicare prospective payment system for hospital outpatient services, including partial hospitalization and intensive outpatient  services; Certain Part B services furnished to hospital inpatients who have no Part A coverage; Partial hospitalization and intensive outpatient  services furnished by CMHCs; Hepatitis B vaccines and their administration, splints, cast, and antigens provided by HHAs that provide medical and other health services; Hepatitis B vaccines and their administration provided by CORFs; and Splints, casts, a nd antigens provided to hospice patients for treatment of non-terminal illness.    By statute, CMS is required to review and revise the APC groups, relative payment rates, wage adjustments, outlier payments and other adjustments required under the OPPS on an annual basis.  These annual updates are made final through the publication of pr oposed and final rules in the Federal Register.  The annual update Federal Register rules can be accessed on the OPPS Web site at:   http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/HospitalOutpatientPPS/