evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
50 - Billing and Payment for Services Unrelated to Terminal Illness  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  Any covered  Medicare services  not related  to the treatment  of the terminal condition for which  hospice  care was elected,  and which  are furnished during a  hospice  election  period, may  be billed  by the rendering provider  using professional or institutional claims  for non- hospice  Medicare payment.  On professional claims, these services are coded with the GW modifier service not related to the hospice patients terminal condition.  On institutional claims, these services are coded with condition code 07 Treatment of Non-terminal Condition for Hospice. A/B MACs (A) and (B) process services coded with the GW modifier or condition code 07 in the normal manner for coverage and payment determinations. See the related chapter of the Medicare Claims Processing Manual chapte r for the  type  of service involved (i.e., Chapter 12 for physician services)  for billing  instructions.  If warranted, A/B MACs (A) and (B) may conduct pre -payment development or post -payment review to validate that services billed with the GW modifier or  condition code 07 are not related to the patients terminal condition.  60 - Billing and Payment for Services Provided by Hospices Under  Contractual Arrangements With Other Institutions  (Rev. 1, 10- 01-03) A-02-102  There may be circumstances in which another health care entity may wish to purchase some of the highly specialized staff time or services of a hospice to better meet the needs of their specific patient population. In these cases, the services are not hospice services in terms of Medicare payment but become part of the service package of the provider under whose care the patient is. Examples of such circumstances are provided below.   EXAMPLE 1
(Medicare Claims Processing Manual)
EXAMPLE 1   A dually eligible Medicare/Medicaid beneficiary enrolled in the Program of All -Inclusive Care for the Elderly (PACE) program for approximately two years has been diagnosed with a life limiting terminal illness with a prognosis of six months or less. In the  course of routine assessments, the PACE provider recognizes that the beneficiary would benefit from the specialized services of a pain management specialist or a grief counselor. The PACE provider would then enter into a contractual arrangement with a Medicare certified hospice to purchase these specialized services. The hospice provider would bill the PACE provider for the services, and the PACE provider would in turn pay the hospice provider directly. Neither provider type would be allowed to bill Medica re separately for the contracted services (which in this example are PACE services and included in the PACE providers capitated rate). In this example, the PACE provider would maintain a medical record on the patient and the hospice provider would submit any documentation related to the care of the PACE patient to the PACE provider.  EXAMPLE 2   A Medicare beneficiary is receiving skilled services from a Medicare certified home health agency (HHA). The beneficiary has been diagnosed with a life limiting terminal illness, but chooses to continue curative treatments, thereby rendering him ineligible  for the Medicare hospice benefit. The beneficiary is experiencing a period of intractable pain, and the HHA wishes to purchase specialized pain control services from the hospice provider. The HHA would then enter into a contractual arrangement with a Medi care certified hospice to purchase specialized nursing services. The hospice would bill the HHA and the HHA would pay the hospice provider directly. Neither provider type would be allowed to bill Medicare separately for the contracted services (which, in t his example, are home health services and therefore included in the HHAs episode payment). In this example, the HHA would maintain a medical record on the patient, and the hospice submits any documentation related to the pain management to the HHA.  EXAMPLE 3
(Medicare Claims Processing Manual)
A Medicare beneficiary (non -dual eligible) resides in a skilled nursing facility (SNF) and has a diagnosis of Alzheimers disease. The beneficiarys disease process has progressed to a stage in which he/she can no longer ingest food or fluids. The benefici arys family has been approached by the SNF regarding the placement of a feeding tube and has been told, their loved one may not live much longer. The family is struggling with this concept and has requested assistance from the SNF regarding hospice care and grief counseling. The SNF has provided information about the Medicare hospice benefit to the family, but the patients legal representative has made a decision not to elect hospice care at this time. The SNF does not have a trained grief counselor or full-time social worker on staff, but has a business relationship with a local hospice and has requested the services of a pastoral or grief counselor. The SNF and hospice enter into a contractual arrangement for the provision of grief counseling to this beneficiarys family by a pastoral care counselor. The hospice provider would bill the SNF, and the SNF would pay the hospice provider directly. Neither provider type would be allowed to bill Medicare Part A or B separately for the pastoral care services (which in this example are included in the Medicares Resource Utilization Group or RUG payments to the SNF). The SNF maintains the medical record on this patient and the hospice provider would submit any documentation related to the pastoral care services provided to the SNF.  60.1 - Instructions for the Contractual Arrangement  (Rev. 1, 10-01-03) A-02-102  A contractual agreement between both parties must be on file and available for review by the state survey agency responsible for conducting surveys on behalf of CMS to assess compliance with the relevant conditions of participation for the provider contracting for the hospice services. Where a PACE organization contracts with a hospice organization, the contract, which is reviewed by CMS, must meet the requirements specified in 42 CFR 460.70.  Go to http://www.gpo.gov/fdsys/browse/collectionCfr.action; select the applicable year, choose title42, and select Chapter IV - Centers for Medicare & Medicaid Services and then locate 460.70.  The agreement must specify each of the services to be
(Medicare Claims Processing Manual)
select the applicable year, choose title42, and select Chapter IV - Centers for Medicare & Medicaid Services and then locate 460.70.  The agreement must specify each of the services to be provided, the credentials required for any of the professionals providing the services, the billing method and payment amounts, and any required documentation.
(Medicare Claims Processing Manual)
60.2 - Clarification of the Payment for Contracted Services  (Rev. 1, 10-01-03) A-02-102  In all of the examples provided above, the billing and payment for the services are between each of the providers. It is our expectation that Medicare will not be billed separately for any of the contracted services referred to in the examples provided above.  70 - Deductible and Coinsurance for Hospice Benefit  (Rev. 1, 10- 01-03) HSP 410  70.1 - General  (Rev. 1, 10- 01-03) A3-3142   There is no deductible.  The payment rates have been reduced by a coinsurance amount on outpatient drugs and biologicals, and inpatient respite care as required by law. No other coinsurance or deductibles may be imposed for services furnished to beneficiaries during the period of an election, regardless of the setting of the services. Hospices may charge beneficiaries for the applicable coinsurance amounts only for drugs and biologicals and for inpatient respite care.   The hospice is responsible for billing and collecting any coinsurance amounts from the beneficiary.   70.2 - Coinsurance on Outpatient Drugs and Biologicals  (Rev. 1, 10- 01-03)  The hospice may charge the beneficiary a coinsurance amount equal to 5 percent of the reasonable cost of the drug or biological to the hospice, but not more than $5, for each prescription furnished on an outpatient basis.  The hospice is not required to make this charge but may do so in accordance with the following.   The hospice must establish a drug copayment schedule that specifies each drug and the copayment to be charged. The copayment charges included on the schedule must approximate 5 percent of the cost of the drugs or biologicals to the hospice, up to a $5 ma ximum.  Additionally, the cost of the drug or biological may not exceed what a prudent buyer would pay in similar circumstances.  The hospice must submit this schedule to the A/B MAC (HHH) in advance for approval.   70.3 - Coinsurance on Inpatient Respite Care  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)
(Medicare Claims Processing Manual)
70.3 - Coinsurance on Inpatient Respite Care  (Rev. 4280, Issued: 04- 19-2019, Effective: 07 -21-19, Implementation: 07- 21-19)  The hospice may charge the beneficiary a coinsurance amount  equal to 5 percent of the national Medicare respite care rate, after adjusting the national rate for local wage differences.  This coinsurance is not counted toward the hospital deductible, but it is limited to the same amount.   EXAMPLE    Assume a wage adjusted inpatient respite care rate for the year (as provided by the A/B MAC (HHH)) of $100. The maximum coinsurance rate would be $5.  The hospice may charge any amount up to and including $5 for inpatient respite care only.   The total amount of coinsurance for inpatient respite care for any beneficiary during a hospice coinsurance period may not exceed the amount of the inpatient hospital deductible applicable for the year in which the hospice coinsurance period began.  A hospice coinsurance period begins with the first day for which an election for hospice services is in effect for the beneficiary and ends with the close of the first period of 14 consecutive days on which no such election is in effect for the beneficiary.   EXAMPLE   Mr. Brown elected an initial 90- day period of hospice care. Five days after the initial period of hospice care ended, Mr. Brown began another period of hospice care under a subsequent election. Immediately after that period ended, he began a third period of hospice care under an additional election period. Since these election periods were not separated by 14 consecutive days, they constitute a single hospice coinsurance period. Therefore, the maximum coinsurance for respite care during all three periods of  hospice care may not exceed the amount of the inpatient hospital deductible for the year in which the first period began.   No other coinsurance may be charged by the hospice.   80 - Caps and Limitations on Hospice Payments  (Rev. 2482, Issued: 06- 01-12, Effective: 04 -14-11 for the 2011 Cap Year and Prior Cap Years; October 1, 2011 for the 2012 Cap Year and Subsequent Cap Years; Implementation Date: 07 -02-12)
(Medicare Claims Processing Manual)
For information regarding caps and limitations on hospice payments, see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 9, section 90.  90 - Frequency of Billing and Same Day Billing (Rev. 3502, Issued: 04- 28-16, Effective: 01 - 01-16, Implementation: 10- 03-16)  Hospices must bill for their Medicare beneficiaries on a monthly basis.  Monthly billing must conform to a calendar month (i.e. limit services to those in the same calendar month if services began mid -month) rather than a 30 day period which could span two calendar months.  Hospices submitting more than one claim in a calendar month for the same beneficiary will have claims returned beginning on dates of service July 1, 2013.   The only exception to this requirement is in the case of the beneficiary being discharged or revoking the benefit and then later re -electing the benefit during the same month.  The monthly billing requirement applies even if the patient is discharged, revokes, or expires on the first of the next calendar month.  For example, if a pati ent is admitted to hospice on August 8th and revokes the benefit on September 1st, the hospice must submit two claims. A claim is submitted for dates of service August 8 to August 31and a separate claim is submitted with dates of service September 1 to September 1.  Hospice claims should not span multiple months.  Any hospice claim spanning multiple months will be returned to the provider for correction.   In cases where one hospice transfers a beneficiary to another hospice that admits the beneficiary on the same day, each hospice is permitted to bill and each will be reimbursed at the appropriate level of care for its respective day of discharge or admissi on.   100 - Billing for Hospice Denials  (Rev. 2748, Issued: 07- 26-13, Effective: 01 -01-14, Implementation: 01- 06-14)  100.1 - Billing for Denial of Hospice Room and Board Charges  (Rev. 2410, Issued: 02- 03-12, Effective: 07 -01-12, Implementation: 07- 02-12)
(Medicare Claims Processing Manual)
100.1 - Billing for Denial of Hospice Room and Board Charges  (Rev. 2410, Issued: 02- 03-12, Effective: 07 -01-12, Implementation: 07- 02-12)  Hospice providers wishing to receive a line item denial for room and board charges may submit the charges as non- covered using revenue code 0659 with HCPCS A9270 and modifier GY on an otherwise covered hospice claim.  100.2 - Demand Billing for Hospice General Inpatient Care  (Rev. 2748, Issued: 07- 26-13, Effective: 01 -01-14, Implementation: 01- 06-14)  The Advanced Beneficiary Notice of Non -coverage (ABN), Form CMS -R-131, is issued by the hospice to Medicare beneficiaries in situations where Medicare payment is expected to be denied.  ABN issuance is mandatory when the level of hospice care is determined  to be not reasonable or medically necessary as defined in 1862(a)(1)(A) or 1862(a)(1)(C).  When a Medicare hospice beneficiary has been receiving covered general inpatient care (GIP) and the hospice determines that continued hospice GIP care is not reas onable and medically necessary, the provider must issue an ABN.  Billing instructions for demand bills associated with ABN issuance are provided in this manual in Chapter 1 General Billing Requirements, section 60.4.1 Outpatient Billing with an ABN (Occurr ence Code 32).
(Medicare Claims Processing Manual)
Hospices should be aware Medicare may require suspension of any claims using occurrence code 32 for medical review of covered charges associated with an ABN.  A/B MACs (HHH)  reviewing GIP reported on a hospice claim with an ABN provided may conclude the care is not reasonable and medically necessary.  When the A/B MAC (HHH)  makes the non -coverage determination, they must non- cover the GIP line item(s) on the claim.  Hospices may be paid the routine home care (RHC) rate in lieu of the denied GIP service.  Th e A/B MAC (HHH)  adds a line item for RHC (revenue code 0651) for each denied GIP line.  The charges associated with the added RHC line should be the RHC charges the hospice reports on their claim or in the absence of a hospice submitted RHC line item, the A/B MAC (HHH)  shall enter the applicable RHC base rate.   These instructions are not applicable when the beneficiary is not questioning the Medicare coverage but needs a Medicare denial for a secondary payer.  In those cases, the provider should submit a non- covered claim with the condition code 21.   120 - A/B MACs (B)  Responsibilities for Publishing Hospice Information  (Rev. 2258, Issued: 07-  29-11, Effective: 01 -01-12, Implementation: 01- 03-12)  A/B MACs (B) processing professional claims shall, at least annually, include in newsletters and bulletins to physicians and suppliers an explanation of the hospice program and the requirements for billing for physicians who serve as the attending physicia n to a hospice patient.  A/B MACs (B) shall include information on the use of special modifiers that are in effect at that time.  A/B MACs (B) may also publish related material on Web pages.
(Medicare Claims Processing Manual)
130 HOSPICE Pricer Program  (Rev. 3930; Issued: 12- 01-17, Effective: 03 -01-18, Implementation: 03- 01-18) Hospice services billed on TOB 081x and 082x are reimbursed based on calculations made by the Hospice Pricer. The Hospice Pricer is a module within Medicare claims processing systems. The Hospice Pricer makes all payment calculations applicable under Hospi ce claims, including all levels of care (Routine Home Care, Continuous Home Care, Inpatient Respite Care, and General Inpatient Care).   Medicare claims processing systems must send an input record to Pricer for all claims with covered visits, and Pricer will return an output record to the shared systems. The following section describes the elements of Hospice claims that are used in the H ospice Pricer and the logic that is used to make payment determinations. The following is presented for A/B MACs (HHH) in order to help understand their Hospice payments and how they are determined.   130.1 Input/Output Record Layout   (Rev. 12083; Issued: 06- 15-23; Effective: 05 -15-23; Implementation: 07- 17-23)
(Medicare Claims Processing Manual)
130.1 Input/Output Record Layout   (Rev. 12083; Issued: 06- 15-23; Effective: 05 -15-23; Implementation: 07- 17-23)  The required data and format for the Hospice Pricer input/output record are shown below:  FIELD NAME  FIELD LAYOUT  POSITION  DESCRIPTION  NPI X(10)  1-10 Input item: The billing provider's National Provider Identifier, copied from the claim.  PROV- NO X(6)  11-16 Input item: The billing provider's CMS Certification Number (CCN), copied from the claim. (FISS crosswalks the CCN based on the NPI submitted by the provider.)  FROM -DATE  9(8) 17-24 Input item: The statement covers period From date, copied from the claim. Date format must be CCYYMMDD.  ADMISSION- DATE  9(8) 25-32 Input item: The admission date, copied from the claim. Date format must be CCYYMMDD.  Filler  x(10)  33-42  PROV-CBSA  X(5)  43-47 Input item: The CBSA code used to wage -adjust inpatient levels of care. Copied from the value code G8 amount on the claim  BENE -CBSA  X(5)  48-52 Input item: The CBSA code used to wage -adjust home levels of care. Copied from the value code 61 amount on the claim  PROV-  WAGE -IND 99V9(4)  53-58 Output item: The wage index value that corresponds to the PROV -CBSA  BENE - WAGE -IND 99V9(4)  59-64 Output item: The wage index value that corresponds to the BENE -CBSA  NA Day 1 Add-on Units  x(2) 65-66 Input item: The number of days from a prior hospice benefit period if identified by CWF as part of the first 60 days of RHC. NA Day 2 Add-on Units  x(2) 67-68 Input item:  Not used  EOL Day 1  Add-on Units  x(2) 69-70 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death. No units input if the lines are not associated with routine home care (revenue code 0651)
(Medicare Claims Processing Manual)
EOL Day 2  Add-on Units  x(2) 71-72 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 1 day. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 3  Add-on Units  x(2) 73-74 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 2 days. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 4  Add-on Units  x(2) 75-76 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 3 days. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 5  Add-on Units  x(2) 77-78 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 4 days. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 6  Add-on Units  x(2) 79-80 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 5 days. No units input if the lines are not associated with routine home care (revenue code 0651)  EOL Day 7  Add-on Units  x(2) 81-82 Input item: The sum of the units associated with revenue codes 055x (if G0299 present) and 056x (other than 0569) on the date of death minus 6 days. No units input if the lines are not associated with routine home care (revenue code 0651)  Filler  x(10)  83-92  QIP- REDUCTION- IND x 93 Input item: An indicator of whether the hospice's payments are subject to the 4%  reduction for not
(Medicare Claims Processing Manual)
not associated with routine home care (revenue code 0651)  Filler  x(10)  83-92  QIP- REDUCTION- IND x 93 Input item: An indicator of whether the hospice's payments are subject to the 4%  reduction for not reporting quality data. Copied from field 74 on the Outpatient Provider Specific File. Valid values: blank = no reduction, 1 = 4%  reduction applies.  REV1  X(4)  94-97 Input item: Revenue code 0651 (if present) copied from the claim.  HCPC1  X(5)  98-102 Input item: HCPCS G code associated with revenue code 0651, copied from the claim. Line Item DOS1  9(8) 103-110 Input item: The line item  date of service associated with revenue code 651, copied from the claim.  UNITS1  9(7) 111-117 Input item: The number of units associated with revenue code 0651, copied from the claim. This represents the number of days of routine home care to be paid.  THEIR -PAY-  CHG1  9(6)V99  118-125 Output item: The total payment to be made on the revenue code 0651 line.  REV2  X(4)  126-129 Input item: Revenue code 0652 (if present) copied from the claim.  HCPC2  x(5) 130-134 Input item: HCPCS G code associated with revenue code 0652, copied from the claim. Line Item DOS2  9(8) 135-142 Input item: The line item  date of service associated with revenue code 652, copied from the claim.  UNITS2  9(7) 143-149 Input item: The number of units associated with revenue code 0652, copied from the claim. This represents the number of 15 minute increments of continuous home care to be paid.  THEIR -PAY-  CHG2  9(6)V99  150-157 Output item: The total payment to be made on the revenue code 0652 line.  REV3  X(4)  158-161 Input item: Revenue code 0655 (if present) copied from the claim.  HCPC3  x(5) 162-166 Input item: HCPCS G code associated with revenue code 0655, copied from the claim. Line Item DOS3  9(8) 167-174 Input item: The line item date of service associated with revenue code 655, copied from the claim.  UNITS3