evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
o The individual is eligible for Medicare Part B coverage of home health services (the nursing visit to perform the injection may be the individual's qualifying service);   o The individual sustained a bone fracture that a physician, or allowed practitioner, or certified nurse midwife certifies was related to post -menopausal osteoporosis; and  o The individual's physician, or allowed practitioner, or certified nurse midwife certifies that she is unable to learn the skills needed to self -administer the drug or is otherwise physically or mentally incapable of administering the drug, and that her fam ily or caregivers are unable or unwilling to administer the drug.   This drug is considered part of the home health benefit under Part B.  Therefore, Part B deductible and coinsurance apply regardless of whether home health visits for the administration of the drug are covered under Part A or Part B.  For instructions on billing for covered osteoporosis drugs, see Pub. 100- 04, Medicare Claims Processing Manual, chapter 10, section 90.1.  50.4.4 - Negative Pressure Wound Therapy Using a Disposable Device  (Rev. 12382; Issued: 11- 28-23; Effective: 01 -01-24; Implementation:01- 02-24)  For services furnished on or after January 1, 2017 and before January 1, 2024, sections 1834 and 1861(m)(5) of the Act required a separate payment to an HHA for an applicable disposable device, to an individual who received  home health services for which  payment  was made under  the Medicare home  health  benefit.  Section  1834 of the Act defines  an applicable device as a disposable NPWT device that is an integrated system comprised of a non- manual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy used in lieu of a conventional NPWT DME system. As required by 1834 of the Act, the separate payment amount for a disposable NPWT device was set equal to the amount of the payment that would be made under the Medicare Ho spital Outpatient Prospective Payment System (OPPS) using the Level I HCPCS code, otherwise referred to as Current Procedural Terminology (CPT) codes, for which the description for a professional service includes the furnishing of such a device.
(Medicare Benefit Policy Manual)
Payment for HH visits related to wound care, but not requiring the furnishing of an entirely new disposable NPWT device, were covered by the HH PPS period payment and were billed using the HH claim.  Where a home health visit was  exclusively for the purpose of furnishing NPWT using a disposable device, the HHA submitted  only a type of claim that was paid for separately outside the HH PPS (TOB 34x). Where, however, the home health visit included the provision of other home health services in addition to, and separate from, furnishing NPWT using a disposable device, the HHA submitted  both a home health claim and a TOB 34x the  home  health  claim  for other  home  health  services  and the TOB  34x for furnishing NPWT  using a disposable device.   EXAMPLE:   A patient requires dNPWT for the treatment of a wound. On Monday, a nurse assesses a patients wound, applies a new disposable NPWT device, and provides wound care education to the patient and family.  The nurse returns on Thursday for wound assessment and replaces the fluid management system (or dressing) for the  existing  disposable  NPWT,  but does not replace the entire  device.  The nurse  returns  the following Monday, assesses the patients condition and the wound, and replaces the device that had been applied on the previous Monday with a new disposable NPWT device.  In this scenario, the billing procedures are as follows:   For both Monday visits, all the services provided by the nurse were associated with furnishing NPWT using a disposable  device.  The nurse  did not provide  any services  that were not associated  with furnishing NPWT  using a disposable device. Therefore, all the nursing services for both Monday visits should be reported on TOB 34x with CPT code 97607 or 97608. None of the services should be reported on the HH claim.   For the Thursday visit,  the nurse  checked  the wound, but did not apply a new disposable  NPWT  device,  so even though the nurse  provided care related  to the wound,  those  services  would not  be considered  furnishing NPWT  using a disposable  device.  Therefore,  the services  should be reported  on bill type 32x and no services  should be reported on bill type 34x.
(Medicare Benefit Policy Manual)
For services furnished on or after January 1, 2024, Division FF, section 4136 of the Consolidated Appropriations Act of 2023 (CAA, 2023) (Pub. L.117- 328) requires that beginning in CY 2024, there will be a separate payment amount for an applicable dNPWT device only and does not include payment for the nursing and therapy services.  Payment for the device is equal to the supply price used to deter mine the relative value for the service under the Medicare Physician Fee Schedule (as of January 1, 2022) for the applicable disposable device and updated by the consumer price index for all urban consumers minus the productivity adjustment for each future  year.   Payment for nursing or therapy services, described in section 1861(m), to apply a disposable NPWT device would now be made under the prospective payment system established under section 1895, the HH PPS, and is no longer separately billable. Additionally, beginning in CY 2024 and each subsequent year, claims for the separate payment amount of an applicable dNPWT device would now be accepted and processed on claims submitted using the type of bill that is most commonly used by home health agencies to bill se rvices under a home health plan of care (TOB 032x). That is, claims with a date of service on or after January 1, 2024 for an applicable dNPWT device will no longer be submitted on TOB 034x.   EXAMPLE:
(Medicare Benefit Policy Manual)
EXAMPLE:   A patient requires dNPWT  for the treatment of a wound. On Monday, a nurse assesses a patients wound, applies a new disposable NPWT device, and provides wound care education to the patient and family.  The nursing visit is reported on the home health claim as a home health visit using the appropriate G -code, revenue code and units of time on TOB 032x. Payment for these services are included in the overall HH PPS payment rate for the 30-day period of care if the LUPA threshold has been met for the period. The HHA would report the H ealthcare Common Procedure Coding System (HCPCS) code A9272 (for the device only) on the home health type of bill TOB 032x. A separate payment is made for the device only. The nurse returns on Thursday for follow up teaching and assessment of the device. T he nurse does not replace the dNPWT device at this visit. Only the nursing visit is reported on the home health claim using TOB 032x. No separate reporting for the device would be included on the claim since the device was not replaced during this visit.    For instructions  on billing  for NPWT  using a disposable  device,  see Pub. 100-04, Medicare  Claims  Processing Manual, chapter 10, Section 90.3  Billing Instructions for Disposable Negative Pressure Wound Therapy Services.    50.5 - Services of Interns and Residents  (Rev. 10438, Issued: 11- 06-20, Effective: 03 -01-20, Implementation: 01-  11-21)  Home health services include the medical services of interns and residents -in-training under an approved hospital teaching program if the services are ordered by the physician or allowed practitioner who is responsible for the plan of care and the HHA is a ffiliated with or is under common control of a hospital furnishing the medical services.  Approved means:    Approved by the Accreditation Council for Graduate Medical Education;   In the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association;   In the case of an intern or resident- in-training in the field of dentistry, approved by the Council on Dental Education of the American Dental Association; or
(Medicare Benefit Policy Manual)
 In the case of an intern or resident- in-training in the field of dentistry, approved by the Council on Dental Education of the American Dental Association; or   In the case of an intern or resident- in-training in the field of podiatry, approved by the Council on Podiatric Education of the American Podiatric Association.  50.6 - Outpatient Services  (Rev. 1, 10-01-03) A3-3119.6, HHA-206.6  Outpatient services include any of the items or services described above which are provided under arrangements on an outpatient basis at a hospital, skilled nursing facility, rehabilitation center, or outpatient department affiliated with a medical school,  and (1) which require equipment which cannot readily be made available at the patient's place of residence, or (2) which are furnished while the patient is at the facility to receive the services described in (1). The hospital, skilled nursing facility, or outpatient department affiliated with a medical school must all be qualified providers of services.  However, there are special provisions for the use of the facilities of rehabilitation centers.  The cost of transporting an individual to a facility cannot be reimbursed as home health services.   50.7 - Part -Time or Intermittent Home Health Aide and Skilled Nursing Services  (Rev. 1, 10-01-03) A3-3119.7, HHA- 206.7, A3-3119.7A, HHA-206.7A, A3-3119.7.B, HHA-206.7.B  Where a patient is eligible for coverage of home health services, Medicare covers either part-time or intermittent home health aide services or skilled nursing services subject to the limits below.  The law at 1861(m) of the Act  clarified: "the term "part- time or intermittent services" means skilled nursing and home health aide services furnished any number of days per week as long as they are furnished (combined) less than 8 hours each day and 28 or fewer hours each week (or, subject to review on a case-by- case basis as to the need for care, less than 8 hours each day and 35 or fewer hours each week).
(Medicare Benefit Policy Manual)
50.7.1 - Impact on Care Provided in Excess of "Intermittent" or "Part -Time" Care  (Rev.  208, Issued: 04-22-15, Effective: 01 -01-15, Implementation: 05-11-15)  Home health aide and/or skilled nursing care, in excess of the amounts of care that meet the definition of part-time or intermittent, may be provided to a home care patient or purchased by other payers without bearing on whether the home health aide and skilled nursing care meets the Medicare definitions of part -time or intermittent.   EXAMPLE:  A patient needs skilled nursing care monthly for a catheter change and the home health agency also renders needed daily home health aide services 24 hours per day that will be needed for a long and indefinite period of time.  The HHA bills Medicare for the skilled nursing and home health aide services, which were provided before the 35th hour of service each week, and bills the beneficiary (or another payer) for the remainder of the care.  If the Medicare contractor determines that the 35 hours of care are reasonable and necessary, Medicare would cover the 35 hours of skilled nursing and home health aide visits.   50.7.2 - Application of this Policy Revision  (Rev. 1, 10-01-03) A3-3119.7.D, HHA-206.7.D  Additional care covered by other payers discussed in 50.7.1 does not affect Medicare coverage when the conditions listed below apply.  A patient must meet the criteria for Medicare coverage of home health services, before this policy revision becomes applicable to skilled nursing services and/or home health aide services.  The definition of "intermittent" with respect to the need for skilled nursing care where the patient qualifies for coverage based on the need for "skilled nursing care on an intermittent basis" remains unchanged.  Specifically:  1.  This policy revision always applies to home health aide services when the patient qualifies for coverage;   2.  This policy revision applies to skilled nursing care only when the patient needs physical therapy or speech-language pathology services or continued occupational therapy, and also needs skilled nursing care; and  3.  If the patient needs skilled nursing care but does not need physical therapy or speech -language pathology services or occupational therapy, the patient must still meet the longstanding and unchanged definition of "intermittent" skilled nursing care in order to qualify for coverage of any home health services.
(Medicare Benefit Policy Manual)
60 - Special Conditions for Coverage of Home Health Services Under Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B)  (Rev. 1, 10-01-03) A3-3122, HHA-212  60.1 - Post-Institutional Home Health Services Furnished During A Home Health Benefit Period - Beneficiaries Enrolled in Part A and Part B (Rev. 1, 10-01-03) A3-3122.1, HHA- 212.1, A3-3122.1, HHA-212.2, PMs A-97-12, A-97- 16, A -98-49   Section 1812(a)(3) of the Act provides post- institutional home health services for individuals enrolled in Part A and Part B and home health services for individuals who are eligible for Part A only.  For beneficiaries who are enrolled in Part A and Part B, Part A finances post- institutional home health services furnished during a home health spell of illness for up to 100 visits during a spell of illness.  Part A finances up to 100 visits furnished during a home health spell of illness if the following criteria are met:   Beneficiaries are enrolled in Part A and  Part B and qualify to receive the Medicare home health benefit;    Beneficiaries must have at least a three consecutive day stay in a hospital or rural primary care hospital; and    Home health services must be initiated and the first covered home health visit must be rendered within 14 days of discharge from a 3 consecutive day stay in a hospital or rural primary care hospital or within 14 days of discharge from a skilled nursing facility in which the individual was provided post-hospital extended care services.  If the first home health visit is not initiated within 14 days of discharge, then home health services are financed under Part B.
(Medicare Benefit Policy Manual)
After an individual exhausts 100 visits of Part A post- institutional home health services, Part B finances the balance of the home health spell of illness.  A home health spell of illness is a period of consecutive days beginning with the first day not included in a previous home health spell of illness on which the individual is furnished post-institutional home health services which occurs in a month the individual is entitled to Part A.  The home health spell of illness ends with the close of the first period of 60 consecutive days in which the individual is neither an inpatient of a hospital or rural primary care hospital nor an inpatient of a skilled nursing facility (in which the individual was furnished post-hospital extended care services) nor provided home health services.   EXAMPLE 1:   An individual is enrolled in Part A and Part B, qualifies for the Medicare home health benefit, has a three consecutive day stay in a hospital, and is discharged on May 1.  On May 5, the individual receives the first skilled nursing visit under the plan of care.  Therefore, post-institutional home health services have been initiated within 14 days of discharge.  The individual is later hospitalized on June 2.  Prior to the June 2 hospitalization, the individual received 12 home health visits.  The individual stays in the hospital for four consecutive days, is discharged and receives home health services.  That individual continues the May 5 home health spell of illness and would ha ve 88 visits left under that home health spell of illness under Part A.  That individual could not start another home health spell of illness (100 visits under Part A) until a 60- day consecutive period in which the individual was not an inpatient of a hospital, rural primary care hospital, an inpatient of a skilled nursing facility (in which the individual was furnished post-hospital extended care services), or provided home health services had passed.   EXAMPLE 2:
(Medicare Benefit Policy Manual)
EXAMPLE 2:   An individual is enrolled in Part A and Part B, qualifies for the Medicare home health benefit, has a three consecutive day stay in a hospital, and home health is initiated within 14 days of discharge.  The individual exhausts the 100 visits under Part A post -institutional home health services, continues to need home health services, and receives home health services under Part B. The individual is then hospitalized for 4 consecutive days.  The individual is again discharged and receives home health service s.  The individual cannot begin a new home health spell of illness because 60 days did not pass in which the individual was not an inpatient of a hospital or rural primary care hospital or an inpatient of a skilled nursing facility in which the individual was furnished post -hospital extended care services.  The individual would be discharged and Part B would continue to finance the home health services.   60.2 - Beneficiaries Who Are Enrolled in Part A and Part B, but Do Not Meet Threshold for Post -Institutional Home Health Services  (Rev. 1, 10- 01-03) A3-3122.1, HHA -212.3   If beneficiaries are enrolled in Part A and Part B and are eligible for the Medicare home health benefit, but do not meet the three consecutive day stay requirement or the 14 day initiation of care requirement, then all of their home health services would be financed under Part B.  For example, this situation would include, but is not limited to, beneficiaries enrolled in Part A and Part B who are coming from the community to a home health agency in need of home health services or who stay less than three consecutive days in a hospital and are discharged.  Any home health services received after discharge would be financed under Part B.   60.3 - Beneficiaries Who Are Part A Only or Part B Only  (Rev. 1, 10- 01-03) A3-3122.1, HHA -212.4
(Medicare Benefit Policy Manual)
60.3 - Beneficiaries Who Are Part A Only or Part B Only  (Rev. 1, 10- 01-03) A3-3122.1, HHA -212.4   If a beneficiary is enrolled only in Part A and qualifies for the Medicare home health benefit, then all of the home health services are financed under Part A.  The 100- visit limit does not  apply to beneficiaries who are only enrolled in Part A.  If a beneficiary is enrolled only in Part B and qualifies for the Medicare home health benefit, then all of the home health services are financed under Part B.  There is no 100- visit limit under Part B.  The new definition of post -institutional home health services provided during a home health spell of illness only applies to those beneficiaries who are enrolled in both  Part A and Part B and qualify for the Medicare home health benefit.  60.4 - Coinsurance, Copayments, and Deductibles  (Rev.  233, Issued: 02-24-17, Effective: 01-01-17, Implementation: 03-27-17)  There is no coinsurance, copayment, or deductible for home health services and supplies other than the following:   coinsurance required for durable medical equipment (DME) and furnishing NPWT using a disposable device covered as a home health service; and    deductible and coinsurance for the osteoporosis drug, which is part of the home health benefit only paid under Part B.  The coinsurance liability of the beneficiary for DME and the osteoporosis drug furnished as a home health service is 20 percent of the fee schedule amount for the services.  Coinsurance for furnishing NPWT using a disposable device as a home health service is 20 percent of the payment amount.  70 - Duration of Home Health Services  (Rev. 1, 10-01-03) A3-3123, HHA-215, A3-3123.1, HHA-215.1  70.1 - Number of Home Health Visits Under Supplementary Medical Insurance (Part B)  (Rev. 1, 10-01-03) A3-3123.2, HHA-215.2
(Medicare Benefit Policy Manual)
70.1 - Number of Home Health Visits Under Supplementary Medical Insurance (Part B)  (Rev. 1, 10-01-03) A3-3123.2, HHA-215.2  To the extent that all coverage requirements are met, payment may be made on behalf of eligible beneficiaries under Part B for an unlimited number of covered home health visits.  The determination of Part A or Part B Trust Fund financing and coverage is made in accordance with the financing shift required by the BBA described above in 60.  70.2 - Counting Visits Under the Hospital and Medical Plans  (Rev. 10438, Issued: 11-06-20, Effective: 03-01-20, Implementation: 01- 11-21)   A.  Visit Defined   A visit is an episode of personal contact with the patient by staff of the HHA, or others under arrangements with the HHA, for the purpose of providing a covered home health service.  Though visits are provided under the HH benefit as part of 30-day periods, and periods are unlimited, each visit must be uniquely billed as a separate line item on a Medicare HH claim, and data on visit charges is still used in formulating payment rates.  B.  Counting Visits  Generally, one visit may be covered each time an HHA employee, or someone providing home health services under arrangements with the HHA, enters the patient's home and provides a covered service to a patient who meets the criteria in 30.  If the HHA furnishes services in an outpatient facility under arrangements with the facility, one visit may be covered for each type of service provided.  If two individuals are needed to provide a service, two visits may be covered.  If two individuals are present, but only one is needed to provide the care, only one visit may be covered.   A visit is initiated with the delivery of covered home health services and ends at the conclusion of delivery of covered home health services.  In those circumstances in which all reasonable and necessary home health services cannot be provided in the cour se of a single visit, HHA staff or others providing services under arrangements with the HHA may remain at the patient's home between visits (e.g., to provide noncovered services).  However, if all covered services could be provided in the course of one visit, only one visit may be covered.  EXAMPLES: