evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
50.5 - RESERVED  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  50.6  Physician Fee Schedule Payment Policy Indicator File Record Layout  (Rev.12326; Issued:10- 26-23; Effective: 01 -29-24; Implementation:01 -29-24)   When a Medicare beneficiary elects hospice services, hospices must complete the data elements  identified  below  for the Uniform  (Institutional Provider)  Bill (Form  CMS -1450)  or its electronic equivalent, which is a Notice of Election (NOE).   The information on the Physician Fee Schedule Payment Policy Indicator file record layout is used for processing Method II CAH professional services with revenue codes 96X, 97X or 98X.     FIELD NAME & DESCRIPTION LENGTH & PIC Position  File Year  This field displays the effective year of the file.  4 Pic x(4)  1-4 HCPCS Code   This field represents the procedure code.   Each Current Procedural Terminology (CPT) code and alpha -numeric HCPCS codes that are currently returned on the MPFS supplemental file will be included when the MPFS Status Indicator is A, C, T, and some with R.  The standard sort for this field is blanks, alpha, and numeric in ascending order.  5 Pic x(5)  5-9 Modifier   For diagnostic tests, a blank in this field denotes the global service and the following modifiers identify the components:  26 = Professional component; and TC = Technical component.  For services other than those with a professional and/or technical component, a blank will appear in this field with one exception: the presence of CPT modifier -53 which indicates that separate Relative Value Units (RVUs) and a fee schedule amount have be en established for procedures which the physician terminated before completion.  This modifier is used only with colonoscopy code 45378 and screening colonoscopy codes G0105 and G0121.  Any other codes billed with modifier -53 are subject 2 Pic x(2)  10-11 FIELD NAME & DESCRIPTION LENGTH & PIC Position  to medical review and priced by individual consideration.
(Medicare Claims Processing Manual)
Modifier -53 = Discontinued Procedure -  Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure.  Due to extenuating circumstances, or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. Code Status   This 1 position field provides the status of each code under the full fee schedule.  Each status code is explained in Pub. 100-04, Chapter 23, 30.2.2.  1 Pic x(1)  12 Global Surgery   This field provides the postoperative time frames that apply to payment for each surgical procedure or another indicator that describes the applicability of the global concept to the service.   000 = Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.   010 = Minor procedure with preoperative relative values on the day of the procedure and postoperative relative 3 Pic x(3)  13-15 FIELD NAME & DESCRIPTION LENGTH & PIC Position  values during a 10 -day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during this 10- day postoperative period generally not payable.   090 = Major surgery with a 1- day preoperative period and 90- day postoperative period included in the fee schedule payment amount.  MMM = Maternity codes; usual global period does not apply.   XXX = Global concept does not apply.  YYY = A/B MAC (A) determines whether global concept applies and establishes postoperative period, if appropriate, at time of pricing.  ZZZ = Code related to another service and is always included in the global period of the other service.  (NOTE: Physician work is associated with intra -service time and in some instances the post service time.)  Preoperative Percentage (Modifier 56)
(Medicare Claims Processing Manual)
This field contains the percentage (shown in decimal format) for the preoperative portion of the global package.  For example, 10 percent will be shown as 010000.  The total of the preoperative percentage, intraoperative percentage, and the postoperative p ercentage fields will 6 Pic 9v9(5)  16-21 FIELD NAME & DESCRIPTION LENGTH & PIC Position  usually equal one.  Any variance is slight and results from rounding. Intraoperative Percentage (Modifier 54)  This field contains the percentage (shown in decimal format) for the intraoperative portion of the global package including postoperative work in the hospital.  For example, 63 percent will be shown as 063000.  The total of the preoperative percentage, int raoperative percentage, and the postoperative percentage fields will usually equal one.  Any variance is slight and results from rounding. 6 Pic 9v9(5)  22-27 Postoperative Percentage (Modifier 55)   This field contains the percentage (shown in decimal format) for the postoperative portion of the global package that is provided in the office after discharge from the hospital.  For example, 17 percent will be shown as 017000.  The total of the preoperat ive percentage, intraoperative percentage, and the postoperative percentage fields will usually equal one.  Any variance is slight and results from rounding.  6 Pic 9v9(5)  28-33 Professional Component (PC)/Technical Component (TC) Indicator   0 = Physician service codes: This indicator identifies codes that describe physician services.  Examples include visits, consultations, and surgical procedures.  The concept of PC/TC does 1 Pic x(1)  34 FIELD NAME & DESCRIPTION LENGTH & PIC Position  not apply since physician services cannot be split into professional and technical components.  Modifiers 26 & TC cannot be used with these codes.  The total Relative Value Units (RVUs) include values for physician work, practice expense and malpractice ex pense.  There are some codes with no work RVUs.   1 = Diagnostic tests or radiology services: This indicator identifies codes that describe diagnostic tests, e.g., pulmonary function tests, or therapeutic radiology procedures, e.g., radiation therapy.  These codes generally have both a professional and te chnical component.  Modifiers 26 and TC can be used with these codes.
(Medicare Claims Processing Manual)
The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense, and malpractice expense.   The total RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only.  The total RVUs for codes reported without a modifier equals the sum of RVUs for both the professional and technical component.   2 = Professional component only codes: This indicator identifies stand alone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test onl y and another associated code that describes the global test.  FIELD NAME & DESCRIPTION LENGTH & PIC Position   An example of a professional component only code is 93010, Electrocardiogram; interpretation and report.  Modifiers 26 and TC cannot be used with these codes.  The total RVUs for professional component only codes include values for physician work, practice  expense, and malpractice expense.   3 = Technical component only codes: This indicator identifies stand alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic tests only.  An example of a technical component code is 93005, Electrocardiogram, tracing only, without interpretation and report.  It also identifies codes that are covered only as diagnostic tests and therefore do not have a related professional code.  Modifiers 26 and TC cannot be used with these codes.   The total RVUs for technical component only codes include values for practice expense and malpractice expense only.   4 = Global test only codes: This indicator identifies stand alone codes for which there are associated codes that describe: a) the professional component of the test only and b) the technical component of the test only.  Modifiers 26 and TC cannot be used with these codes.  The total RVUs for global procedure only FIELD NAME & DESCRIPTION LENGTH & PIC Position  codes include values for physician work, practice expense, and malpractice expense.  The total RVUs for global procedure only codes equals the sum of the total RVUs for the professional and technical components only codes combined.  5 = Incident to Codes: This indicator identifies codes that describe services covered incident to a physicians service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision.
(Medicare Claims Processing Manual)
5 = Incident to Codes: This indicator identifies codes that describe services covered incident to a physicians service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision.  Payment may not be made by carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient department.  Modifiers 26 and TC cannot be used with these codes.   6 = Laboratory physician interpretation codes: This indicator identifies clinical laboratory codes for which separate payment for interpretations by laboratory physicians may be made.  Actual performance of the tests is paid for under the lab fee schedule.   Modifier TC cannot be used with these codes.  The total RVUs for laboratory physician interpretation codes include values for physician work, practice expense and malpractice expense.   7 = Physical therapy service: Payment may not be made if the service is provided to either a hospital outpatient or inpatient by an independently practicing physical or occupational therapist. FIELD NAME & DESCRIPTION LENGTH & PIC Position   8 = Physician interpretation codes: This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.  This applies only to code 85060.  No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate.   No payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients.  The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test.  9 = Concept of a professional/technical component does not apply Multiple Procedure (Modifier 51)  Indicator indicates which payment adjustment rule for multiple procedures applies to the service.   0 = No payment adjustment rules for multiple procedures apply.  If the procedure is reported on the same day as another procedure, base payment on the lower of: (a) the actual charge or (b) the fee schedule amount for the procedure.
(Medicare Claims Processing Manual)
0 = No payment adjustment rules for multiple procedures apply.  If the procedure is reported on the same day as another procedure, base payment on the lower of: (a) the actual charge or (b) the fee schedule amount for the procedure.   1 = Standard payment adjustment rules in effect before January 1, 1996, for multiple procedures apply.  In the 1996 MPFSDB, this indicator only applies to codes with procedure status of D. If a procedure is reported on the same day as 1 Pic (x)1  35 FIELD NAME & DESCRIPTION LENGTH & PIC Position  another procedure with an indicator of 1,2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 25 percent, 25 percent, 25 percent, and by report).  Base payment on the lower of: (a) t he actual charge or (b) the fee schedule amount reduced by the appropriate percentage.   2 = Standard payment adjustment rules for multiple procedures apply.  If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report).  Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.   3 = Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).  The base procedure for each code with this indicator is identified in the endoscopic base code field.   Apply the multiple endoscopy rules to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure).  FIELD NAME & DESCRIPTION LENGTH & PIC Position   If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure.  Payment for the base procedure is included in the payment for the other endoscopy.
(Medicare Claims Processing Manual)
If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure.  Payment for the base procedure is included in the payment for the other endoscopy.   4 = Subject to 25% reduction of the TC diagnostic imaging (effective for services January 1, 2006 through June 30, 2010). Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1, 2010 and after). Subject to 25% reduction of the  PC of diagnostic imaging (effective for services January 1, 2012 through December 31, 2016).  Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2017 and after).   5 = Subject to 20% reduction of the practice expense component for certain therapy services furnished in office and other non- institutional settings, and 25% reduction of the practice expense component for certain therapy services furnished in institutional settings (effective for services January 1, 2011 and after). Subject to 50% reduction of the practice expense component for certain therapy services furnished in both institutional and non- institutional settings (effective for services April 1, 2013 and after).   6 = Subject to 25% reduction of the TC diagnostic cardiovascular services (effective for services January 1, 2013 and after).  FIELD NAME & DESCRIPTION LENGTH & PIC Position   7 = Subject to 20% reduction of the TC diagnostic ophthalmology services (effective for services January 1, 2013 and after).    9 = Concept does not apply.   Codes with RVUs equal to zero are not included in the payment indicator file. These codes may have multiple procedure indicators not shown. See note below this table for instructions on these codes.  Bilateral Surgery Indicator (Modifier 50) This field provides an indicator for services subject to a payment adjustment.   0 = 150 percent payment adjustment for bilateral procedures does not apply.  The bilateral adjustment is inappropriate for codes in this category because of:  (a) physiology or anatomy, or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.   1 = 150 percent payment adjustment for bilateral procedures applies.  If code is billed with the bilateral modifier base payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides, or 1 Pic (x)1  36 FIELD NAME & DESCRIPTION LENGTH & PIC Position  (b) 150 percent of the fee schedule amount for a single code.
(Medicare Claims Processing Manual)
If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any applicable multiple procedure rules.   2 = 150 percent payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure.   The RVUs are based on a bilateral procedure because: (a) the code descriptor specifically states that the procedure is bilateral; (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally; or (c) the procedure is  usually performed as a bilateral procedure.   3 = The usual payment adjustment for bilateral procedures does not apply.   Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.  If a procedure is billed with the 50 modifier, base payment on the lesser of the tota l actual charges for each side or 100% of the fee schedule amount for each side.   9 = Concept does not apply. FIELD NAME & DESCRIPTION LENGTH & PIC Position  Assistant at Surgery (Modifiers AS, 80, 81 and 82)   This field provides an indicator for services where an assistant at surgery may be paid:   0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.   1 = Statutory payment restriction for assistants at surgery applies to this procedure.  Assistant at surgery may not be paid.   2 = Payment restriction for assistants at surgery does not apply to this procedure.  Assistant at surgery may be paid.   9 = Concept does not apply. 1 Pic (x)1  37 Co-Surgeons (Modifier 62)   This field provides an indicator for services for which two surgeons, each in a different specialty, may be paid.   0 = Co -surgeons not permitted for this procedure.   1 = Co -surgeons could be paid; supporting documentation required to establish medical necessity of two surgeons for the procedure.  1 Pic (x)1  38 FIELD NAME & DESCRIPTION LENGTH & PIC Position   2 = Co -surgeons permitted; no documentation required if two specialty requirements are met.   9 = Concept does not apply. Team Surgeons (Modifier 66)   This field provides an indicator for services for which team surgeons may be paid.  0 = Team surgeons not permitted for this procedure.   1 = Team surgeons could be paid; supporting documentation required to establish medical necessity of a team; pay by report.
(Medicare Claims Processing Manual)
This field provides an indicator for services for which team surgeons may be paid.  0 = Team surgeons not permitted for this procedure.   1 = Team surgeons could be paid; supporting documentation required to establish medical necessity of a team; pay by report.   2 = Team surgeons permitted; pay by report.  9 = Concept does not apply. 1 Pic (x)1  39 Endoscopic Base Codes   This field identifies an endoscopic base code for each code with a multiple surgery indicator of 3.  5 Pic (x) 5  40-44 Performance Payment Indicator (For future use)  1 Pic x (1)  45 Diagnostic Imaging Family Indicator  88 = Subject to the reduction for diagnostic imaging (effective for services 2 Pic x (2)  46-47          Multiple procedure indicator 5 is included in this file ; however , the indicator represents the therapy multiple procedure payment reduction which never applies to professional service revenue codes on CAH  outpatient claims.  Multiple procedure indicators 6 and 7 are included in this file , however, since in these cases the reduction only applies to technical component services, they will not affect the cost -based payment on CAH claims.  On CAH claims, technical components are paid on a cost basis and so are not subject to the reductions.    There may be cases when A/B MACs (A) must manually load a HCPCS code that is contractor priced which has a multiple procedure indicator that is not on the payment indicator file.  In these cases, the MAC enters a multiple procedure indicator of 0.   50.7 - Institutional Claim Record Layout for the Mammography Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This is a physician fee schedule abstract file for mammography services payment.  The CMS will provide the specific file names when the prices are released.  The file name will contain the label MAMMO.   Record Length  - 60 Record Format  - FB Block Size  - 6000 Character Code  - EBCDIC  Sort Sequence  - A/B MAC (B), Locality HCPCS Code, Modifier
(Medicare Claims Processing Manual)
Record Length  - 60 Record Format  - FB Block Size  - 6000 Character Code  - EBCDIC  Sort Sequence  - A/B MAC (B), Locality HCPCS Code, Modifier   FIELD NAME & DESCRIPTION LENGTH & PIC Position  January 1, 2011, and after).  99 = Concept Does Not Apply  Effective Date  This field displays the effective date of the file in YYYYMMDD format.  8 Pic x(8)  48 - 55 Filler  30 Pic x(30)  56 -75 Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Modifier  X(02)  6 - 7  3-Non-Facility Fee  9(05)V99  8 - 14  4-PCTC Indicator  X(01)  15 - 15 This field is only applicable when pricing Critical Access Hospitals (CAHs) that have elected the optional method (Method 2) of payment. 5-Facility Fee  9(05)V99  16 - 22  6-Effective Date  7- A/B MAC (B) Number  X(08)  X(05)  23 - 30 31 - 35 Update effective date  8-Locality  X(02)  36- 37  9-Filler  X(05)  38- 42  10-Status Code  X(1)  43- 43 Separate instructions will be used for the use of this field at a later date.  This field indicates whether the code is in the physician fee schedule and whether it is separately payable if the service is covered.  11-Multiple Surgery X(01)  44 - 44 Indicator indicates which payment adjustment rule for multiple procedures apply to the service.  12-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  13-Filler  X(01)  52 - 52  14- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   15-Filler  X(01)  60 - 60   50.8 - Institutional Claim Record Layout for the Ambulance Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This is a physician fee schedule abstract file for ambulance services payment.  The CMS will provide the specific file names when the prices are released.   The file name will contain the label AMBFS.
(Medicare Claims Processing Manual)
This is a physician fee schedule abstract file for ambulance services payment.  The CMS will provide the specific file names when the prices are released.   The file name will contain the label AMBFS.   Record Length  - 80 Record Format  - FB Block Size  - 27920 Character Code  - EBCDIC  Sort Sequence  - HCPCS, A/B MAC (B), Locality    Field Name  Format  Position  Description  1-HCPCS  X(05)  1 - 5 HCFA Common Procedure Coding System  2- A/B MAC (B) Number  X(05)  6 - 10  3-Locality Code  X(02)  11-12  4-Base RVU  9(4)v99  13 - 18 Relative Value Unit  5-Non-Facility PE GPCI  9v9(3)  19 - 22 Geographic Adjustment Factor  6-Conversion Factor  9(5)v99  23 - 29 Conversion Factor  7-Urban Mileage  9(5)v99  30 - 36 Urban payment rate or base rate mileage rate (determined by HCPCS)  8-Rural Mileage  9(5)v99  37 - 43 Rural payment rate or base rate mileage rate (determined by HCPCS)  9-Current Year  9(04)  44- 47 YYYY  10-Current Quarter  9(01)  48 Calendar Quarter -value 1 -4 11-Effective Date  9(8) 49- 56 Effective date of fee schedule file 12-Filler  X(24)  57 - 80 Future Use   60 - Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule  (Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03 -23)  The CMS issues instructions for implementing and/or updating the DMEPOS fee schedule payment amounts on an annual basis (January), with quarterly updates as necessary (April, July and October).  In addition, special instructions may be issued at any time i f necessary for implementation of changes in the statute, regulations, or for other reasons.  The DMEPOS fee schedule is provided to DME MACs, the Pricing, Data Analysis and Coding Contractor (PDAC), and A/B MACs (B) via CMS mainframe telecommunication sy stem.