evekhm/cms_iom_500 huggingface dataset:
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Medicare contractors must calculate overall cost -to-charge ratios for hospitals paid under OPPS and for CMHCs using the providers most recent full year cost reporting period, whether tentatively settled or final settled, in accordance with the instruction s in 10.11.7, 10.11.7.1, 10.11.8, 10.11.8.1 or 10.11.9 as applicable. The contractor must calculate a provider overall CCR whenever a more recent full year cost report becomes available. If a CCR is calculated based on the tentatively settled cost report , the contractor must calculate another overall CCR when the cost report is final or when a cost report for a subsequent cost reporting period is tentatively settled, whichever occurs first. If a CCR is based on a final settled cost report, the contractor must calculate the CCR when a cost report for a subsequent cost reporting period is tentatively settled.  10.11.2 - Circumstances in Which CCRs are Used  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  The contractors must apply CCRs prospectively to calculate outlier payments (for hospitals paid under OPPS and CMHCs), Transitional Outpatient Payment System (TOPS) payments (for hospitals paid under OPPS), device pass -through payments (for hospitals paid under OPPS), and items and services paid at charges adjusted to cost (for hospitals paid under OPPS).   10.11.3 - Selection of the CCR to be Used  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Contractors will use the CCR calculated for the most recent period of time, whether based on a tentatively settled cost report or a final settled cost report.  For example, if the CCR being used is the tentatively settled CCR for FY 2008, and a tentatively settled CCR for FY 2009 is determined before the final settled CCR for FY 2008, then the contractor uses the CCR based on the tentatively settled 2009 cost report.   10.11.3.1 - CMS Specification of Alternative CCR (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)
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All diagnostic services (including non- patient laboratory tests) provided to a Medicare beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital) on the date of the beneficiarys inpatient admission or during the 3 calendar days (or, in the case of a non -subse ction (d) hospital, 1 calendar day) immediately preceding the date of admission are required to be included on the Part A bill for the inpatient stay.  Outpatient non- diagnostic services that are related to an inpatient admission must be bundled with the Part A billing for the inpatient stay.  An outpatient service is related to the admission if it is clinically associated with the reason for a patients inpatient admission.  In accordance with section 102 of Pub. L. 111- 192, for services furnished on or after June 25, 2010, all outpatient non- diagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are deemed related to the admission, and thus, must be billed to Part A with the inpatient stay.  Also, outpatient non- diagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second, and third calendar days for a subsection (d) hospital paid under the IPPS (first calendar da y for non- subsection (d) hospitals) preceding the date of a beneficiarys inpatient admission are deemed related to the admission, and thus, must be billed to Part A with the inpatient stay, unless the hospital attests to specific non -diagnostic services a s being unrelated to the hospital claim (that is, the preadmission non- diagnostic services are clinically distinct or independent from the reason for the beneficiarys admission).  Outpatient non- diagnostic services provided during the payment window that are unrelated to the admission, and are covered by Part B, may be separately billed to Part B.  The June 25, 2010 effective date of section 102 of Pub. L. 111- 192 applies to outpatient services provided on or after June 25, 2010.
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20.1 - General  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Reporting of HCPCS codes is required of acute care hospitals including those paid under alternate payment systems, e.g., Maryland, long- term care hospitals.  HCPCS codes are also required of rehabilitation hospitals, psychiatric hospitals, hospital -based RHCs, hospital -based FQHCs, and CAHs reimbursed under Method II (HCPCS required to be billed for fee reimbursed services).  This also includes all -inclusive rate hospitals.  HCPCS includes the American Medical Associations Current Procedural Terminology, 4th Edition, (CPT -4) for physician services and CMS developed codes for certain nonphysician services.  All of the CPT -4 is contained within HCPCS, and is identified as Lev el I CPT codes consist of five numeric characters.  The CMS developed codes are known as Level II.  Level II codes are five- character codes that begin with an alpha character that is followed by either numeric or alpha characters.   Hospital -based and independent ESRD facilities must use HCPCS to bill for blood and blood products, and to bill for drugs and clinical laboratory services paid outside the composite rate.  In addition, the hospital is required to report modifiers as applic able and as described in 20.6.   The CAHs are required to report HCPCS only for Part B services not paid to them on a reasonable cost basis, e.g., screening mammographies and bone mass measurements.   The HCPCS codes are required for all outpatient hospital services unless specifically excepted in manual instructions.  This means that codes are required on surgery, radiology, other diagnostic procedures, clinical diagnostic laboratory, durable medical equipment, orthotic -prosthetic devices, take- home surgical dressings, therapies, preventative services, immunosuppressive drugs, other covered drugs, and most other services.
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20.3 - Line Item Dates of Service  (Rev. 1, 10- 03-03)  Where HCPCS is required a line item date of service is also required.  (FL 45 on Form CMS -1450).  The A/B MAC (A) will return claims to hospitals where a line item date of service is not entered for each HCPCS code reported or if the line item dates of service reported are outside of the statement -covers period.  20.4 - Reporting of Service Units  (Rev. 1, 10- 03-03)  The definition of service units (FL 46 on the Form CMS -1450) where HCPCS code reporting is required is the number of times the service or procedure being reported was performed.   EXAMPLES:   If the following codes are performed once on a specific date of service, the entry in the service units field is as follows:  HCPCS Code  Service Units  90849 -  Multiple -family group psychotherapy  Units >  1 HCPCS Code  Service Units  92265 -  Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report  Units >  1 95004 -  Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, specify number of tests. Units = no.  of tests performed 95861 -  Needle electromyography two extremities with or without related paraspinal areas  Units >  1  6 Units >  83 min.  to < 98 min. 7 Units >  98 min.  to < 113 min. 8 Units >  113 min.  to < 128 min.  The pattern remains the same for treatment times in excess of two hours.  Hospitals should not bill for services performed for less than eight minutes.  The expectation (based on the work values for these codes) is that a providers time for each unit will  average 15 minutes in length.  If hospitals have a practice of billing less than 15 minutes for a unit, their A/B MAC (A) will highlight these situations for review.   The above schedule of times is intended to provide assistance in rounding time into 15-minute increments.  It does not imply that any minute until the eighth should be excluded from the total count as the timing of active treatment counted includes time.
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The following subsections provide information on the use of certain modifiers under the hospital OPPS. For information on additional modifiers not described below, refer to your MAC website(s) for guidance.  20.6.1 - Where to Report Modifiers on the Hospital Part B Claim  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  Modifiers are reported on the hardcopy Form CMS -1450 with the HCPCS code. See Chapter 25 of this manual for related instructions. For electronic submissions, see  the ASC X12 837 Institutional Claim implementation guide for instructions related to HCPCS modifiers when using the ASC X12 837 institutional claim format. Note there is space for four modifiers on the hardcopy and electronic forms.   HOPDs are reminded that the most specific modifier should be used first. That is, when modifiers E1 through E4, FA through F9, LC, LD, RC, and TA through T9 apply, they should be used before modifiers LT, RT, or 59.   20.6.2 - Use of Modifiers -50, -LT, and -RT (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  50: Bilateral Procedure   Modifier 50 is used to report bilateral procedures that are performed on both sides of the body at the same operative session. Do not report modifiers RT and LT when modifier 50 applies. Do not submit two line items to report a bilateral procedure using modifier 50. Report one line with modifier 50 using one unit of service.   Modifier 50 applies to any bilateral procedure performed on both sides at the same operative session. The bilateral modifier 50 is restricted to operative sessions only. Modifier 50 may not be used:   To report surgical procedures identified by their terminology as bilateral, or  To report surgical procedures identified by their terminology as unilateral or bilateral.   The unit entry to use when modifier 50 is reported is one unit.  20.6.3 - Modifiers -LT and - RT (Rev. 11937; Issued: 03 -31-23; Effective: 04 -01-23; Implementation: 04 -03-23)
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must have been reported.    In addition, OPPS hospitals were required to report modifier FB on the same line as the surgical or procedure code (not the HCPCS Level II device code) for a service that required a device for which neither the hospital, nor the beneficiary, was liable to the manufacturer. Similarly, hospitals were required to report modifier FB on the same line as the surgical or procedure code (not the device code) for a service that required a device when the manufacturer gave credit for a devi ce that was replaced with a more costly device.  Refer to section 61.3 of this manual for instructions regarding charges for items billed with the FB modifier.   As of January 1, 2014, modifier FB is no longer required on OPPS claims, and has been replaced with value code FD (credit received from the manufacturer for a replaced medical device) as discussed in the CY 2014 OPPS/ASC final rule (78 FR 75006 through 75007), as well as in section 61.3.6 of this manual.  Specifically, effective January 1, 2014, HOPDs are no longer required to report modifier FB, and instead, must report value code FD to indicate the amount of the credit in the amount portion for value code  FD when the hospital receives a credit for a replaced device that is 50 percent or greater than the cost of the device. For more information on value code FD, refer to MLN Factsheet MLN909368 dated May 2022, which is available on the cms.gov website, specifically, at https://www.cms.gov/Outreach -and-Education/Medicare -Learning -Network -MLN/MLNProducts/Downloads/cardiacdevicecredits -ICN909368.pdf   Although no longer required for OPPS claims, modifier FB is still required on ASC claims.   20.6.10 - Modifier  FC (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  FC: Partial credit received for replaced device    A. General
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Off-campus provider -based departments should not report both the PO and PN modifiers on the same claim line. However, if services reported on a claim reflect items and services furnished from both an excepted and a nonexcepted off -campus PBD of the hospita l, the PO modifier should be used on the excepted claim lines and the PN modifier should be used on the nonexcepted claim lines.  Neither the PO nor the PN modifier is to be reported by the following hospital departments:    A dedicated emergency department as defined in existing regulations at 42 CFR 489.24(b);   A PBD that is on the campus, or within 250 yards, of the hospital or a remote location of the hospital as defined under 42 CFR 413.65.   20.6.12 - Modifier PN  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  PN: Non -excepted service provided at an off -campus, outpatient, provider -based department of a hospital   A. General    In accordance with Section 1833(t)(21) of the Act, as added by section 603 of the Bipartisan Budget Act of 2015 (Pub. L. 114- 74), CMS established modifier PN to identify and pay nonexcepted items and services billed on an institutional claim. Effective Jan uary 1, 2017, non- excepted off -campus provider -based departments of a hospital are required to report this modifier on each claim line for non- excepted items and services. The use of modifier PN will trigger a payment rate under the Medicare Physician Fee Schedule (PFS). This modifier must be reported with each nonexcepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services. Nonexcepted items and services are described in the regulations at 42 CFR 419.48.
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Off-campus provider -based departments should not report both the PO and PN modifiers on the same claim line. However, if services reported on a claim reflect items and services furnished from both an excepted and a nonexcepted off -campus PBD of the hospita l, the PO modifier should be used on the excepted claim lines and the PN modifier should be used on the nonexcepted claim lines.  Neither the PO nor the PN modifier is to be reported by the following hospital departments:   A dedicated emergency department as defined in existing regulations at 42 CFR 489.24(b);   A PBD that is on the campus, or within 250 yards, of the hospital or a remote location of the hospital as defined under 42 CFR 413.65.  B. Effect on Payment   Payment for nonexcepted items and services furnished at nonexcepted off -campus provider -based departments reported with modifier PN will result in a payment rate under the PFS effective January 1, 2017. The PN modifier is required to be reported on each claim line with each nonexcepted item and service including those for which payment will not be adjusted, such as separately payable drugs, clinical laboratory tests, and therapy services.   20.6.13 - Modifier CT  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  CT: Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR-29-2013 Standard   A. General    In accordance with section 1834(p) of the Act, CMS established modifier CT (Computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association (NEMA) XR -29-2013 standard) effective January 1, 2016, to identify computed tomography (CT) scans that are furnished on equipment that does not meet the National Electrical Manufacturers Association (NEMA) Standard XR -29-2013, titled Standard Attributes on CT Equipment Related to Dose  Optimization and Management.
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Modifier CT is required to be reported on claims for computed tomography (CT) scans described by applicable HCPCS codes that are furnished on non- NEMA Standard XR -29-2013- compliant equipment. The applicable CT services are identified by HCPCS codes 70450 t hrough 70498; 71250 through 71275; 72125 through 72133; 72191 through 72194; 73200 through 73206; 73700 through 73706; 74150 through 74178; 74261 through 74263; and 75571 through 75574 (and any succeeding codes).   HOPDs are reminded that this modifier should not be reported with codes that describe CT scans not listed above.  B.  Effect on Payment   Effective January 1, 2016, the use of this modifier resulted in a payment reduction of 5 percent for the applicable computed tomography (CT) services when the service was paid separately. However, for CY 2017 and subsequent years, the use of this modifier results in a payment reduction of 15 percent for the applicable computed tomography (CT) services when the service is paid separately. The payment reduction is also applied to the APC payment for the HCPCS codes listed above that are subject to the multipl e imaging composite policy.  20.6.14 - Modifier  FX (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  FX: X -ray taken using film   A. General    Consistent with the requirements set forth in section 1833(t)(16)(F)(i), and in accordance with provisions allowed under section 1833(t)(16)(F)(iv) of the Act, CMS established modifier FX to identify imaging services that are x -rays taken using film. As stated in the CY 2017 OPPS/ASC final rule (81 FR 79729 through 79730), hospitals are required to use this modifier to report imaging services that are X -rays taken using film eff ective January 1, 2017.   B. Effect on Payment
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B. Effect on Payment   Payment for x- ray services taken using film reported with modifier FX will be reduced by 20 percent effective January 1, 2017. We note that when payment for an x- ray service taken using film is packaged into the payment for another item or service under the OPPS, no separate payment for the x- ray service taken using film is made. Accordingly, the payment reduction in this instance would be 0 percent (that is, 20 percent of $0). All imaging services that are x -rays are listed in the OPPS Addendum B, which is  available via the Internet on the CMS Web site.   20.6.15  Modifier  FY (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  FY: X -ray taken using computed radiography technology/cassette -based imaging   A. General    Consistent with the requirements set forth in section 1833(t)(16)(F)(ii) and in accordance with provisions allowed under section 1833(t)(16)(F)(iv) of the Act, CMS established modifier FY to identify an imaging service that is an X -ray taken using computed radiography technology. Effective January 1, 2018, hospitals are required to use this modifier to report imaging services that are X -rays taken using computed radiography technology.  B. Effect on Payment   Payment for x- ray services taken using computed radiography technology will be reduced by 7 percent from January 1, 2018, through December 31, 2022, and thereafter to 10 percent beginning January 1, 2023. We note that when payment for an x- ray service taken using computed radiography technology is packaged into the payment for another item or service under the OPPS, no separate payment for the x -ray service taken using computed radiography technology is made. Accordingly, the payment reduction in this instance would be 0 percent (that is, 20 percent of $0). All imaging services that are x- rays are listed in the OPPS Addendum B, which is available via the Internet on the CMS Web site.
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20.6.16- Modifier  JG (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  JG: Drug or biological acquired with 340b drug pricing program discount, reported for informational purposes   A. General   On January 1, 2018, CMS established HCPCS Level II modifier JG to identify and pay 340B -acquired drugs and biologicals. Specifically, beginning January 1, 2018, hospitals paid under the OPPS that are not excepted from the 340B drug payment adjustment, and beginning January 1, 2019, nonexcepted off -campus PBDs of a hospital (that is not otherwise excepted from the 340B drug payment adjustment) paid under the PFS are required to report modifier JG on the same claim line as the drug or biological HCPCS code to  identify if a drug or biological was acquired under the 340B Program. The phrase acquired under the 340B Program is inclusive of all drugs and biologicals acquired under the 340B Program or PVP, regardless of the level of discount applied to the drug.  Effective January 1, 2023, the JG modifier is required to be used by hospitals (except for rural sole community hospitals, childrens hospitals, and PPS -exempt cancer hospitals) to identify 340B drugs for informational purposes only, with no effect on paym ent.  B. Effect on Payment
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A. General   On January 1, 2018, CMS established HCPCS Level II modifier TB to facilitate the collection and tracking of 340B claims data for OPPS providers that are excepted from the 340B payment adjustment in CY 2018. Beginning January 1, 2019, modifier TB shall be reported by both select hospitals paid under the OPPS and by nonexcepted off -campus PBDs of a hospital paid under the PFS if a drug or biological was acquired under the 340B Program. The phrase acquired under the 340B Program is inclusive of all drugs and biologicals acquired under the 340B Program or PVP, regardless of the level of discount applied to the drug.  Effective January 1, 2023, the TB modifier will be used by rural sole community hospitals, childrens hospitals, and PPS -exempt cancer hospitals to identify 340B drugs for informational purposes. Additionally, all pass -through drugs (reported with the stat us indicator G) purchased through the 340B drug discount program will report with the modifier TB by all OPPS providers.    B. Effect on Payment