evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Input item: A single Y/N character to indicate if a claim must be paid a partial period payment adjustment. Medicare claims processing systems set a Y if the patient discharge status code of the claim is 06. An N is set in all other cases.  97-101 X(5)  HRG -INPUT -CODE  Input item:  Medicare claims processing systems must copy the HIPPS code from the 0023 revenue code line.   102-104 9(3) HRG -NO-OF - DAYS  Input item:  A number of days calculated by the shared systems for each HIPPS code.  The number is determined by the span of days from and including the first line item service date provided under that HIPPS code to and including the last line item service  date provided under that HIPPS code.  105-110 9(2)V9(4)  HRG -WGTS  Output item:  The weight used by the Pricer to determine the payment amount on the claim.  111-119 9(7)V9(2)  HRG -PAY  Output item:  The payment amount calculated by the Pricer for the HIPPS code.  120-123 X(4)  REVENUE - CODE  Input item:  One of the six home health discipline revenue codes (042x, 043x, 044x, 055x, 056x, 057x).  All six revenue codes must be passed by the Medicare claims processing systems even if the revenue codes are not present on the claim.  File Position  Format  Title  Description  124-126 9(3) REVENUE -QTY -  COV-VISITS  Input item:  A quantity of covered visits corresponding to each of the six revenue codes.  Medicare claims processing systems must count the number of covered visits in each discipline on the claim.  If the revenue codes are not present on the claim, a zer o must be passed with the revenue code.  127-131 9(5) REVENUE -QTY -  OUTLIER -UNITS  Input item: The sum of the units reported on all covered lines corresponding to each of the six revenue codes. Medicare claims processing systems accumulate the number of units in each discipline on the claim, subject to a limit of 32 units per date of ser vice.  If any revenue code is not present on the claim, a zero must be passed with that revenue code.  132-139 9(8) REVENUE -EARLIEST -DATE  Input item:  The earliest line item  date for the corresponding revenue code.  Date format must be
(Medicare Claims Processing Manual)
any revenue code is not present on the claim, a zero must be passed with that revenue code.  132-139 9(8) REVENUE -EARLIEST -DATE  Input item:  The earliest line item  date for the corresponding revenue code.  Date format must be CCYYMMDD.  140-148 9(7)V9(2)  REVENUE -DOLL -RATE  Output item:  The dollar rates used by the Pricer to calculate the payment for the visits in each discipline if the claim is paid as a LUPA.   149-157 9(7)V9(2)  REVENUE - COST  Output item:  The dollar amount determined by the Pricer to be the payment for the visits in each discipline if the claim is paid as a LUPA.   158-166 9(7)V9(2)  REVENUE -ADD- ON-VISIT -AMT  Output item:  The add -on amount to be applied to the earliest line item date with the corresponding revenue code.
(Medicare Claims Processing Manual)
If revenue code 055x, then this is the national per -visit amount multiplied by 1.8451.  If revenue code 042x, then this is the national per -visit amount multiplied by 1.6700.  If revenue code 043x and the Through date is on or after January 1, 2022, then this is the national per-visit amount multiplied by 1.6700.  If revenue code 044x, then this is the national per -visit amount multiplied by 1.6266.  168-401 Defined above  Additional REVENUE data Five more occurrences of all REVENUE related data defined above.  File Position  Format  Title  Description  402-403 9(2) PAY -RTC  Output item:  A return code set by Pricer to define the payment circumstances of the claim or an error in input data.     Payment return codes:     00 Final payment where no outlier applies  01 Final payment where outlier applies  02 Final payment where outlier applies, but is not payable due to limitation.  03 Not used.  04 Not used.  05 Not used.  06 LUPA payment only     07 Not used.     08 Not used.     09 Final payment, partial period payment     11 Final payment, partial period payment with outlier     12 Not used.     13 Not used.     14  LUPA payment, add -on payment applies     Error return codes:     10 Invalid TOB  15 Invalid PEP days  16 Invalid HRG days, greater than 30  20 PEP indicator invalid  25 Med review indicator invalid  30 Invalid CBSA code  31 Invalid/missing County Code  35 Invalid Initial Payment Indicator  40 Dates before January 2020 or invalid  70 Invalid HRG code  75 No HRG present in 1st occurrence  80 Invalid revenue code
(Medicare Claims Processing Manual)
85 No revenue code present on adjustment TOB  404-408 9(5) REVENUE - SUM 1 -6-QTY- ALL  Output item:  The total number of visits used by the Pricer to determine if the claim must be paid as a LUPA.  This amount will be the total of all the covered visit quantities input with all six HH discipline revenue codes.  409-417 9(7)V9(2)  OUTLIER - PAYMENT  Output item:  The outlier payment amount determined by the Pricer to be due on the claim in addition to any HRG payment amounts.  Added to the claim as a value code 17 amount.  File Position  Format  Title  Description  418-426 9(7)V9(2)  TOTAL - PAYMENT  Output item:  The total payment determined by the Pricer to be due on the claim.  427-435 S9(7)V9(2)  VBP -ADJ-AMT  Output item: The HHVBP adjustment amount, determined by subtracting the HHVBP adjustment total payment from the HH PPS payment that would otherwise apply to the claim.  Added to the claim as a value code QV amount.  436-444 9(7)V9(2)  PPS-STD -VALUE  Output item:  Standardized payment amount  the HH PPS payment without applying any provider -specific adjustments.  Informational only.  Subject to additional calculations before entered on the claim in PPS -STNDRD -VALUE field.  445-452 X(8)  RECEIPT -DATE  Input item: The receipt date of the corresponding NOA for this claim.  Date format must be CCYYMMDD.   453 X OVERRIDE -IND Input item:  An indicator of whether an exception request to the late filing penalty has been granted by the MAC.  Valid values:  Y = Exception has been granted, no late filing penalty will be calculated  N = No exception applies, calculate late filing penalty, if applicable.  454-462 9(7)V9(2)  LATE -SUB -PENALTY -AMT  Output item: The late submission penalty amount, determined by subtracting the total payment after the late submission penalty from the HH PPS payment that would otherwise apply to the claim.  Added to the claim as a value code QF amount.  463-650 X(188)  FILLER
(Medicare Claims Processing Manual)
Input records on claims must include all input items.  Output records will contain all input and output items.  If an output item does not apply to a particular record, Pricer will return zeroes.   The Medicare claims processing system will move the following Pricer output items to the claim record.  The return code will be placed in the claim header.  The HRG -PAY amount for the HIPPS code will be placed in the revenue code 0023 line.  The OUTLIER -PAYMENT amount, if any, will be placed in a value code 17 amount.  If the return code is 06 or 14 (indicating a low utilization payment adjustment), the Medicare claims processing system will apportion the REVENUE -COST amounts to the appropriate line items in order for the per -visit payments to be accurately reflected on the remittance advice.  If the return code is 14, the Medicare claims processing system will apply the H -HHA- REVENUE -ADD- ON-VISIT -AMT to the earliest line item with the corresponding revenue code.  70.3 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  70.4 - Decision Logic Used by the Pricer on Claims (Rev. 10919, Issued:08- 06-21, Effective:01 -01-22, Implementation: 01- 03-22)  On input records with TOB 329, 327, 32F, 32G, 32H, 32I, 32J, 32K, 32M, 32Q, 33Q or 32P (that is, all provider submitted claims and provider or A/B MAC (HHH) initiated adjustments), Pricer will perform the following calculations in the numbered order.   If the SERV -FROM -DATE is on or after January 1, 2020, the Pricer shall perform the following:   Prior to these calculations, determine the applicable Federal standard rate to apply by reading the value in INIT -PAY- QRP -INDICATOR.  If the value is 0, use the full standard rate in subsequent calculations.  If the value is 2, use the standard rate whic h has been reduced by 2 percent due to the failure of the provider to report required quality data.   1. Low Utilization Payment Adjustment (LUPA) calculation.
(Medicare Claims Processing Manual)
1. Low Utilization Payment Adjustment (LUPA) calculation.   1.1 If the REVENUE -SUM1 -6-QTY -ALL is less than the LUPA threshold associated with the HRG -INPUT -CODE (e.g. threshold is 6, sum is 5 or less), read the national standard per visit rates for each of the six REVENUE -QTY- COV -VISITS fields from the revenue code table for the calendar year in which the SERV -THRU- DATE falls.  Multiply each quantity by the corresponding rate.  Wage index adjust each value and report the payment in the associated REVENUE -COST field.   1.2 If the following conditions are met, calculate an additional LUPA add- on payment:   the dates in the SERV -FROM -DATE and ADMIT -DATE fields match   the first position of the HIPPS code is a 1 or a 2   the value in LUPA -SRC- ADM is not a B AND   the value in RECODE -IND is not a 2.   Compare the earliest line item dates for revenue codes 042x, 044x and 055x and select the revenue code with the earliest date.   If the earliest date for revenue codes 042x, 043x (CY 2022 and after) or 044x match the revenue code 055x date, select revenue code 055x.   If the earliest date for revenue codes 042x and 044x match and revenue code 055x is not present, select revenue code 042x.  For claims with Through dates on or after January 1, 2022:   If the earliest date for revenue codes 042x and 043x match and revenue code 055x is not present, select revenue code 042x.  If the earliest date for revenue codes 043x and 044x match and revenue code 055x is not present, select revenue code 043x.  1.3  Apply the appropriate LUPA add- on factor to the selected earliest dated line.
(Medicare Claims Processing Manual)
1.3  Apply the appropriate LUPA add- on factor to the selected earliest dated line.   If revenue code 055x, multiply the national per -visit amount by 1.8451.  If revenue code 042x, multiply the national per -visit amount by 1.6700.  If revenue code 043x, multiply the national per -visit amount by 1.6700.  If revenue code 044x, multiply the national per -visit amount by 1.6266.  Return the resulting payment amount in the REVENUE -ADD- ON-VISIT -AMT field.   1.4  Return the sum of all REVENUE -COST amounts and the REVENUE -ADD- ON-VISIT -AMT amount, if applicable, in the TOTAL -PAYMENT field.  If the LUPA payment includes LUPA add- on amount, return 14 in the PAY -RTC field.  Otherwise, return 06 in the PAY -RTC field.  No further calculations are required.   1.5  If REVENUE -SUM1 -6-QTY- ALL is greater than or equal to the LUPA threshold associated with the HRG -INPUT -CODE, proceed to the HRG payment calculation in step 2.  2. HRG payment calculations.   2.1. If the PEP -IND is an N:   Find the weight for the HRG -INPUT -CODE from the weight table for the calendar year in which the SERV -THRU- DATE falls.  Multiply the weight times the applicable period of care rate for the calendar year in which the SERV -THRU -DATE falls.  The product is the case- mix adjusted rate.     Multiply the case -mix adjusted rate by the current labor -related percentage to determine the labor portion.  Multiply the labor portion by the wage index corresponding to the CBSA field.  Multiply the case -mix adjusted rate by the current nonlabor -related percentage to determine the nonlabor portion.  Sum the labor and nonlabor portions.  The sum is the wage index and case -mix adjusted payment for this HRG.  Proceed to the outlier calculation in step 3.    2.2. If the PEP -INDICATOR is a Y:
(Medicare Claims Processing Manual)
2.2. If the PEP -INDICATOR is a Y:   Perform the calculation of the case- mix and wage index adjusted payment for the HRG amount, as in 3.1.  Determine the proportion to be used to calculate this PEP by dividing the PEP -DAYS amount by 30.  Multiply the case -mix and wage index adjusted payment by this proportion.  The result is the partial period payment due on the claim.  Proceed to the outlier calculation in step 3.   3. Outlier calculation:   3.1. Wage index adjust the outlier fixed loss amount for the Federal fiscal year in which the SERV -THRU -DATE falls, using the CBSA code in the CBSA field.  Add the resulting wage index adjusted fixed loss amount to the total dollar amount resulting from the HRG payme nt calculation.  This is the outlier threshold for the period.   3.2. For each quantity in the six REVENUE -QTY - OUTLIER -UNITS fields, read the national standard per unit rates from the revenue code table for the year in which the SERV -THRU- DATE falls.  Multiply each quantity by the corresponding rate.  Sum the six r esults and wage index adjust this sum as described above, using the CBSA code in the CBSA field.  The result is the wage index adjusted imputed cost for the period.   3.3. Subtract the outlier threshold from the imputed cost.  3.4. If the result determined in step 3.3 is greater than $0.00, calculate .80 times the result.  This is the outlier payment amount.   3.5. Determine whether the outlier payment is subject to the 10% annual limitation on outliers as follows:    Multiply the amount in the PROV -PAYMENT -TOTAL field by 10 percent to determine the HHAs outlier limitation amount.    Deduct the amount in the PROV -OUTLIER -PAY -TOTAL from the outlier limitation amount.   This result is the available outlier pool for the HHA.
(Medicare Claims Processing Manual)
 Deduct the amount in the PROV -OUTLIER -PAY -TOTAL from the outlier limitation amount.   This result is the available outlier pool for the HHA.    If the available outlier pool is greater than or equal to the outlier payment amount calculated in step 3.4, return the outlier payment amount in the OUTLIER -PAYMENT field.  Add this amount to the total dollar amount resulting from HRG payment calculatio n.  Return the sum in the TOTAL -PAYMENT field, with return code 01.    If the available outlier pool is less than the outlier payment amount calculated in step 3.4, return no payment amount in the OUTLIER -PAYMENT field.  Assign return code 02 to this record.   a. If the result determined in step 3.3 is less than or equal to $0.00, the total dollar amount resulting from all HRG payment calculations is the total payment.  Return zeroes in the OUTLIER -PAYMENT field.  Return the HRG payment amount in the TOTAL -PAYMENT field, with return code 00.   4. Late- filed NOA payment penalty:   4.1  If the value in OVERRIDE -IND is equal to Y, continue to step 5.   4.2  If the span of days between the FROM -DATE and RECEIPT -DATE is greater than five and the value inOVERRIDE -IND is equal to N, reduce the HRG -PAY and OUTLIER -PAYMENT amounts by the span of days/30.    4.3  Subtract the sum of theHRG -PAY and OUTLIER -PAYMENT amounts reduced by the late -filed NOA penalty from step 4.2 from the sum of the HRG -PAY and OUTLIER -PAYMENT amounts before the penalty.  Return the result in LATE -SUB -PENALTY -AMT. Continue t o step 5.  5.  Value -Based Purchasing Adjustment:
(Medicare Claims Processing Manual)
5.  Value -Based Purchasing Adjustment:   Multiply all payment amounts by adjustment factor in PROV -VBP -ADJ-FAC.  Return the results as the final Medicare payment amounts in all appropriate output fields.   Subtract the total payments calculated in steps 2 through 4 from the total VBP -adjusted payments calculated in step 5.   Return the difference in the VBP -ADJ-AMT field.    70.5 - Annual Updates to the HH Pricer  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Rate and weight information used by the HH Pricer is updated periodically, usually annually.  Updates occur each January, to reflect the fact that HH PPS rates are effective for a calendar year.  Updates may also occur at other points in the year when required by legislation.  The following update items, when changed, are published in the Federal Register :   The Federal standard period of care amount;    The fixed loss amount to be used for outlier calculations;    A table of case- mix weights and LUPA thresholds to be used for each HHRG;    A table of national standardized per visit rates and per unit rates;    The pre -floor, pre -reclassified hospital wage index; and    Changes, if any, to the outlier loss -sharing percentage and the labor and nonlabor percentages.   Whenever these update items change, Medicare also publishes a Recurring Update Notification to inform providers and A/B MACs (HHH) about the changes.  These Recurring Update Notifications also describe how the changes will be implemented through the HH Pri cer.  80  HH Grouper Program  (Rev. 11644, Issued: 10- 13-22, Effective: 04 -01-23, Implementation: 04- 03-23)
(Medicare Claims Processing Manual)
80  HH Grouper Program  (Rev. 11644, Issued: 10- 13-22, Effective: 04 -01-23, Implementation: 04- 03-23)  The Home Health Resource Group (HHRG) used to pay home health services billed on TOB 032x are determined by the HH Grouper program.  HHRGs are represented on claims in the form of HIPPS codes.  Like the HH Pricer, the HH Grouper is a module within Medicare  claims processing systems.  The HHA sends a HIPPS code on the claim, using revenue code 0023.  Medicare systems combine claim data and OASIS data and send the data to the HH Grouper to determine the HIPPS code used for payment.  The HIPPS code from the Gr ouper replaces the provider -submitted HIPPS code on the claim and is then sent to the HH Pricer for payment calculations.   Medicare claims processing systems send an input record to Grouper for all claims and most adjustments.  Medical review or other program integrity contractor adjustments are not sent to the Grouper.  The Grouper returns an output record to the shared syste ms whenever an input record is sent.    No part of the Grouper logic is required to be incorporated into an HHAs billing system in order to bill Medicare, unless the HHA chooses to do so to assist their accounts receivable functions.  The following is presented for A/B MACs (HHH) and as information for the HHAs, in order to help HHAs understand how their HH claims are processed.   80.1  HH Grouper Input/Output Record Layout  (Rev. 11644, Issued: 10- 13-22, Effective: 04 -01-23, Implementation: 04- 03-23)  The required data and format for the HH Grouper input/output record for periods of care beginning on or after January 1, 2020 are shown below:
(Medicare Claims Processing Manual)
File Position  Format  Title  Description  1 - 24 X(24)  Claim ID  Input item: Document control number of the claim record.  25-32 X(8)  From Date  Input item: The Statement Covers From date from the claim, in format CCYYMMDD  33 9 Period Timing  Input item: Set to 1 when claim From  date matches Admission date or when a CWF sequence edit is received.  Otherwise, set to 2.  34 - 35 9(2) Referral Source  Input item: If occurrence code 61 or 62 are present on the claim, the code value is moved to this field.  The occurrence date is not moved.  36 - 42 X(8)  Principal Diagnosis  Input item:  The principal diagnosis code from the claim.  43 - 50 X(8)  Secondary Diagnosis  Input item:  The first secondary diagnosis code from the claim.  51 - 235 Defined above  Additional Secondary Diagnosis data  Input items: 23 additional occurrences of secondary diagnoses from the claim.  236-275 X(40)  Filler  For future use.  276 9 M1033 -HOSP -RISK -HSTRY-FALLS  Input item: Moved from the M1033 -HSTRY -FALL field on the QIES/OASIS screen in FISS.   Valid values: 0,1 277 9 M1033 -HOSP -RISK -WEIGHT -LOSS  Input item: Moved from the M1033 -WEIGHT -LOSS field on the QIES/OASIS screen in FISS.  Valid values: 0,1 278 9 M1033 -HOSP -RISK -MLTPL-HOSPZTN Input item: Moved from the M1033 -MLTPL -HOSPZTN field on the QIES/OASIS screen in FISS.  Valid values: 0,1  File Position  Format  Title  Description  279 9 M1033 -HOSP -RISK -MLTPL-ED-VISIT  Input item: Moved from the M1033 -MLTPL -ED-VISIT field on the QIES/OASIS screen in FISS.  Valid values: 0,1 280 9 M1033 -HOSP -RISK -MNTL -BHV- DCLN  Input item: Moved from the M1033 -MNTL -BHV -DCLN on the QIES/OASIS screen in FISS. Valid values: 0,1 281 9 M1033 -HOSP -RISK -COMPLIANCE Input item: Moved from the M1033 -COMPLIANCE on the
(Medicare Claims Processing Manual)
-DCLN on the QIES/OASIS screen in FISS. Valid values: 0,1 281 9 M1033 -HOSP -RISK -COMPLIANCE Input item: Moved from the M1033 -COMPLIANCE on the QIES/OASIS screen in FISS.  Valid values: 0,1  282 9 M1033 -HOSP -RISK -5PLUS -MDCTN Input item: Moved from the M1033 -5PLUS -MDCTN on the QIES/OASIS screen in FISS.  Valid values: 0,1 283 9 M1033 -HOSP -RISK -CRNT -EXHSTN Input item: Moved from the M1033 -CRNT -EXHSTN on the QIES/OASIS screen in FISS.  Valid values: 0,1 284 9 M1033 -HOSP -RISK -OTHR -RISK  Input item: Moved from the M1033 -OTHER -RISK on the QIES/OASIS screen in FISS.  Valid values: 0,1 285 9 M1033 -HOSP -RISK -NONE -ABOVE  Input item: Moved from the M1033 -NONE -ABOVE on the QIES/OASIS screen in FISS.  Valid values: 0,1 286-287 9(2) M1800 -CRNT -GROOMING  Input item: Moved from the M1800 -CRNT -GROOMING on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03 288-289 9(2) M1810 -CRNT -DRESS -UPPER  Input item: Moved from the M1810 -DRESS -UPPER on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03 290-291 9(2) M1820 -CRNT -DRESS -LOWER  Input item: Moved from the M1820 -DRESS -LOWER on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03 292-293 9(2) M1830 -CRNT -BATHG Input item: Moved from the M1830 -CRNT -BATHG on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03, 04, 05, 06 File Position  Format  Title  Description  294-295 9(2) M1840 -CRNT -TOILTG  Input item: Moved from the
(Medicare Claims Processing Manual)
screen in FISS.  Valid values: 00,01, 02, 03, 04, 05, 06 File Position  Format  Title  Description  294-295 9(2) M1840 -CRNT -TOILTG  Input item: Moved from the M1840 -CRNT -TOILTG on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03, 04 296-297 9(2) M1850 -CRNT -TRNSFRNG Input item: Moved from the M1850 -CRNT -TRNSFRNG on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03, 04, 05 298-299 9(2) M1860 -CRNT -AMBLTN  Input item: Moved from the M1860 -CRNT -AMBLTN on the QIES/OASIS screen in FISS.  Valid values: 00,01, 02, 03, 04, 05, 06 300-599 X(301)  Filler  For future use.  601-607 X(7)  Version Used  Output item:  The version of the HH Grouper which grouped the current claim.  Informational only.  608-612 X(5)  HIPPS Code  Output item:  The HIPPS code determined by grouping the input items above.  Moved to the HCPCS code field of revenue code 0023 line of the claim.  613-614 9(2) Validity Flag  Output item: Beginning April 1, 2023, the specific diagnosis coding issue that requires a claim to be returned to the provider.  615-616 9(2) Grouper Return Code  Output item: Identified technical issues that may cause no HIPPS code to be assigned.  617-700 X(84)  Filler  For future use.