evekhm/cms_iom_500 huggingface dataset:
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Mod ifier HCPCS Modifier  Definition  HCPCS Coverage/  Payment/  Administrative Instruction  Notice Requirement/ Liability  Billing Use  Payment Result  EY No Physician or Other Licensed Health Care Provider Order for this Item or Service  None  None, cannot be used when HHABN or ABN is required, recommend documenting records; liability is provider unless other modifiers are used  (-GL or -GY) To signify a line -item should not receive payment when Medicare requires orders to support delivery of a item or service (i.e., TOBs 21x, 22x, 32x, 33x, 34x, 74x, 75x, 76x, 81x, 82x, 85x) When orders required, line item is submitted as non-covered and services will be denied  Mod ifier HCPCS Modifier  Definition  HCPCS Coverage/  Payment/  Administrative Instruction  Notice Requirement/ Liability  Billing Use  Payment Result  GA Waiver of Liability Statement Issued, as Required by Payer Policy  None  ABN required; beneficiary liable  To signify a line item is linked to the mandatory use of an ABN when charges both related to and not related to an ABN must be submitted on the same claim  Line item must be submitted as covered ; Medicare makes a determination for payment GK Reasonable and Necessary Item/Service Associated with a  GA or GZ modifier  None  ABN required if GA is used; no liability assumption since this modifier should not be used on institutional claims  Not used on institutional claims. Use GA or  GZ modifier as appropriate instead  Institutional claims submitted using this modifier are returned to the provider  GL Medically Unnecessary Upgrade Provided instead of Non-Upgraded Item, No Charge, No ABN  None  Cant be used if ABN/HHABN is required, COPs may require notice, recommend documenting records; beneficiary liable  Use only with durable medical equipment (DME) items billed on home health claims (TOBs: 32x, 33x, 34x) Lines submitted as non- covered  and will be denied  GY Item or Service Statutorily Excluded or Does Not Meet the Definition of Any Medicare Benefit  Non-covered by Medicare Statute (ex., service not part of recognized Medicare benefit)  Optional notice only, unless required by COPs; beneficiary liable  Use on all types of line items on provider claims.  May be used in association with modifier
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by Medicare Statute (ex., service not part of recognized Medicare benefit)  Optional notice only, unless required by COPs; beneficiary liable  Use on all types of line items on provider claims.  May be used in association with modifier GX.  Lines submitted as non- covered  and will be denied  Mod ifier HCPCS Modifier  Definition  HCPCS Coverage/  Payment/  Administrative Instruction  Notice Requirement/ Liability  Billing Use  Payment Result  GZ Item or Service Expected to Be Denied as Not Reasonable and Necessary  May be non -covered by Medicare  Cannot be used when ABN or HHABN is actually given, recommend documenting records; provider liable Available for optional use on demand bills NOT related to an ABN by providers who want to acknowledge they didnt provided an ABN for a specific line  Lines submitted as non- covered  and will be denied  KB Beneficiary Requested Upgrade for ABN, more than 4 Modifiers on a Claim  None  ABN Required; if service denied in development, beneficiary assumed liable   Use only on line items requiring more than [2 or ] 4* modifiers on home health DME claims (TOBs 32x, 33x, 34x)  Line item submitted as covered , claim must suspend for development  QL Patient pronounced dead after ambulance called  None  None, recommend documenting records; provider liable Use only for ambulance services  (TOBs: 12x, 13x, 22x, 23x, 83x, 85x) Mileage lines submitted as non-covered  and will be denied; base rate line submitted covered  TQ Basic life support transport by a volunteer ambulance provider  Not payable by Medicare  None, recommend documenting records; provider liable Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 83x, 85x) Lines submitted as non- covered  and will be denied  GX Notice of Liability Issued, Voluntary Under Payer Policy  None  Used when a provider issued an ABN on a voluntary basis; beneficiary liable  Use on all types of provider claims when a voluntary notice has been issued.  May be used in association with modifiers GY or used separately.   Lines submitted as non- covered  and will be denied   * NOTE : Many provider systems will not allow the submission of more than two modifiers.  In such cases, despite the official definition and the capacity of the Medicare systems to take in five modifiers on a line with direct EDI submission, contractors processin g home health claims
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systems will not allow the submission of more than two modifiers.  In such cases, despite the official definition and the capacity of the Medicare systems to take in five modifiers on a line with direct EDI submission, contractors processin g home health claims should educate that it is appropriate to use this modifier when three modifiers are needed if there is a two -modifier limit.
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All modifiers listed in the chart immediately above need to be used only when non-covered services cannot be split to entirely non- covered claims.  Modifiers indicating provider liability cannot be used on entirely no payment claims for which the beneficia ry has liability. Inappropriate use of these modifiers may result in entire claims being returned to providers.   60.4.3  Liability Considerations for Bundled Services  (Rev. 2783, Issued: 09- 10-13, Effective: 09 -30-13, Implementation: 09- 30-13)  Some Medicare payment policies, for outpatient services, group or bundle several items or services into a single unit for payment.  Questions arise in such cases, in terms of notifying beneficiaries of liability and billing, when some of the services in the bundle are thought to be covered, and some are not.  Chapter 30 of this manual states in several sections that ABNs may not be used to shift liability to a beneficiary in the case of services or items for which full payment is bundled into other payments; that is, where the beneficiary would otherwise not be  liable for payment for the service or item because bundled payment is made by Medicare.  Using an ABN to collect a charge for an individual items or service from a beneficiary where full payment is made for that and other care on a bundled basis constitut es double billing.
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As a result of this policy, an ABN has to apply to all of a bundled service, or none of it.  This means all of a bundled service must be billed as noncovered, or none of it. Therefore, as long as part of a bundled service is certain to be covered or medica lly necessary, billing the entire bundled service as covered is appropriate. Medicare adjudication may still result in all, part or none of such services being paid, or something submitted as one type of bundled payment being re -grouped into another type of payment.  If the entire bundle is certain to be non- covered, the service should be billed as noncovered.  If there is overall doubt as to the medical necessity of the bundle, such as when a Medicare benefit does not seem to be medically necessary, then the instructi ons for billing in association with an ABN or for demand billing would apply.  This is always true when necessity is in doubt relative to all services in the bundle, but may also be used if a provider is uncertain of necessity of the majority services, or if there is discomfort in billing the entire bundle as covered for a specific reason.   60.5- Coding That Results from Processing Noncovered Charges  (Rev.  3510, Issued: 04- 29-16, Effective:  10-01-16, Implementation; 10- 03-16)  Codes Returned to Providers and Beneficiaries   After processing is complete, remittance advice notices are used to explain to providers the difference between the charges they submitted for payment and what Medicare paid on their claim.  The Medicare Summary Notice, or MSN, is used at the same time to inform beneficiaries about any payments made on their behalf.  Liability for noncovered charges is communicated using the Group Code on the remittance advice.  When the beneficiary is liable, contractors use Group Code PR.  When the provider is liable, contractors use Group Code CO.  Contractors shall deny services that are submitted with modifier GZ.
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The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.  Group Code: CO CARC: 50  RARC: N/A  MSN: 8.81  Contractors shall deny services that are submitted with modifier GY.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.  Group Code: PR CARC: 96  RARC: N425  MSN: 16.10  Codes Used by Medicare Contractors  Medicare contractors use nonpayment codes when transmitting institutional claims to CWF in cases where payment is not made.  Claims where partial payment is made do not require nonpayment codes.  Both the shared system for institutional claims and CWF react to CMS -created non -payment codes on entirely noncovered claims.  The standard system must enter the appropriate code in the "Non-payment Code" field of the CWF record if the non-payment situatio n applies to all services present on the claim.  It does not enter the nonpayment code when either partial payment is made, or payment is made in full by an insurer primary to Medicare.  These codes alert CWF to bypass edits in processing that are not appropriate in nonpayment cases.  Nonpayment codes also alert CWF to update a beneficiarys utilization records (deductible, spell of illness, etc.) in certain situations.  Nonpayment codes themselves do not assign liability to provider or beneficiary on Medicare claims.
(Medicare Claims Processing Manual)
Medicare contractors and systems use the following nonpayment codes:  Code  Contractor Uses  Effect on Processing  B Placed on Part B -paid inpatient claims when prior to claim From date either:   Benefit and/or lifetime reserve days are exhausted;  Full day or coinsurance days are exhausted;  Beneficiaries elected not to use lifetime reserve days.   Charges are processed as noncovered;  utilization not chargeable;   cost report days not applied. R Placed on claims when:    SNF inpatient services are denied for reasons other than lack of medical necessity or care being custodial in nature;   Provider failed to file claims within timely filing limits;   Beneficiary refused to request benefit on a claim.   Charges are processed as noncovered and there is no payment;   utilization is chargeable and some charges may go to CWF as covered to update utilization correctly;   cost report days not applied. N Placed on claims when the provider is liable and:   The provider knew, or should have known, Medicare Part A or B would not pay;  Care billed was not paid by Medicare because either custodial or not reasonable or necessary;   Provider failed to submit requested documentation.  Charges are processed as noncovered;   utilization not chargeable;   cost report days are applied. N Placed on claims when the beneficiary is liable and:  Charges are shown as noncovered ; Code  Contractor Uses  Effect on Processing   Statutory exclusions (e.g., most dental care and cosmetic surgery that Medicare never covers);   Claims not filed within timely filing limits BUT provider not at fault;  Medicare decision find the beneficiary at fault under limitation of liability   Inpatient psychiatric reduction applies because days are used in advance of admission (see IOM Pub. 100-02, Chapter 4);  All services provided after date active care in psychiatric hospital ended;   Inpatient hospital or SNF benefit provided after date covered care ended;   MSP cost avoidance denials (see IOM Pub. 100-05).  neither utilization nor cost report days are reported.
(Medicare Claims Processing Manual)
No code entered  Despite no payment, no code is entered because:   Deductible/coinsurance exceeds the payment amount;  Other payer paid for all Medicare covered care such as: EGHP; LGHP; auto, no- fault, WC or other liability insurance (including BL); NIH, PHS, VA or other governmental entity or liability insurance;  Care was provided to a MA (Medicare Part C) enrollee when that part of Medicare, not Original Medicare, has jurisdiction for payment.   Other than the distinct codes used for Medicare Secondary Payer (MSP) cost-avoided claims, entirely noncovered outpatient claims use either an N or R nonpayment code.  Generally, the R code should be used instead of the N code in all cases where a spel l of illness must be updated.  The HH spell of illness must be updated when processing noncovered HH PPS claims in certain situations.  Accordingly, the shared systems must update home health value codes 62-65 when the R code is used, filling the values associated with the codes as zeros, since these value codes are needed to effectuate information related to the A -B Shift in the home health spell.  CWF consistency edits related to the R nonpayment code will be bypassed in these cases.  The CWF will update the dates of earliest and latest billing  activity (DOEBA and DOLBA) for the benefit period, but not for the episode  70 - Time Limitations for Filing Part A and Part B Claims (Rev. 2140, Issued: 01- 21-11, Effective: 01-01-10, Implementation: 02-22-11)  Medicare regulations at 42 CFR 424.44 define the timely filing period for Medicare fee for service claims. In general, such claims must be filed to the appropriate Medicare claims processing contractor no later than 12 months, or 1 calendar year, after the date the services were furnished. (See section 70.7  below for details of the exceptions to the 12 month timely filing limit.)   70.1 - Determining Start Date of Timely Filing Period -- Date of Service  (Rev. 2140, Issued: 01- 21-11, Effective: 01-01-10, Implementation: 02 -22-11)
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70.1 - Determining Start Date of Timely Filing Period -- Date of Service  (Rev. 2140, Issued: 01- 21-11, Effective: 01-01-10, Implementation: 02 -22-11)  In general, the start date for determining the 12 month timely filing period is the date of service or From date on the claim.  For institutional claims (Form CMS -1450, the UB-04 and now the 837 I or its paper equivalent) that include span dates of servi ce (i.e., a From and Through date span on the claim), the Through date on the claim is used for determining the date of service for claims filing timeliness.  Certain claims for services require the reporting of a line item date of service.  For prof essional claims (Form CMS -1500 and 837-P) submitted by physicians and other suppliers that include span dates of service, the line item From date is used for determining the date of service for claims filing timeliness.  (This includes DME supplies and r ental items.)  If a line item From date is not timely but the To date is timely, contractors must split the line item and deny the untimely services as not timely filed.  Claims having a date of service on February 29 must be filed by February 28 of the following year to be considered timely filed.  What constitutes a claim is defined below.   70.2 - Definition of a Claim for Payment  (Rev. 2140, Issued: 01- 21-11, Effective: 01-01-10, Implementation: 02-22-11)
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70.2 - Definition of a Claim for Payment  (Rev. 2140, Issued: 01- 21-11, Effective: 01-01-10, Implementation: 02-22-11)  Medicare regulations at 42  CFR  424.5 describe basic conditions for Medicare payment. These regulations at paragraphs (5) and (6) define a claim for payment as a request for payment from a provider, supplier, or beneficiary, and the provider, supplier, or beneficiary requesting payment must furnish the appropriate Medicare contractor with sufficient information to determine the amount of payment. Institutional claims are in all cases filings by the provider and issues of assigned or non-assigned claims do not apply.  Medicare regulations at 42  CFR  424.32 describe the basic requirements for all claims. Specifically, 42  CFR  424.32 (a) (1) states, A claim must be filed with the appropriate intermediary or carrier on a form prescribed by CMS in accordance with CMS instructions. Therefore, this regulation se ts out three distinct conditions that must be satisfied in order for a provider submission to be considered a claim   it must be filed with the appropriate Medicare contractor,   it must be filed on the prescribed form and    it must be filed in accordance with all pertinent CMS instructions. The sections below define each of these conditions in greater detail.   70.2.1 - Appropriate Medicare Contractor  (Rev. 2140, Issued: 01- 21-11, Effective: 01-01-10, Implementation: 02-22-11)  Submissions for services must be filed with the appropriate Medicare contractor. It is the providers or suppliers responsibility to submit each claim to the appropriate contractor. Medicare contractors may attempt to re -route claims appropriately if they have enough information to do so. In the case of re- routed claims, services submitted for payment are not considered claims under Medicare regulations until received by the appropriate Medicare contractor.
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70.2.2 - Form Prescribed by CMS  (Rev. 3086, Issued: 10- 03-14, Effective: ICD -10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD-10; ASC X12: November 4, 2014)  Refer to section 2 for the acceptable claim formats.  As noted in section 2, ASCA law requires that claims sent to Medicare be sent electronically unless an exception is met. Claims submitted on paper forms are entered into Medicares electronic claims processing system and converted into electronic records in order to be processed. After the point of entry into the electronic system, handling of claims submitted on the prescribed electronic format and on its paper equivalent is identical with regard to determining timely filing.  Regulations at 42 CFR 424.32 (b) prescribe the claim forms to be used for a paper claim submission.  70.2.3 - In Accordance with CMS Instructions  (Rev. 3086, Issued: 10- 03-14, Effective: ICD -10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD-10; ASC X12: November 4, 2014)  The CMS instructions for submitting institutional claims to Medicare are contained in this manual.  General instructions that reflect guidance on reporting institutional claim data are found in Chapter 25.  These instructions apply to all institutional claim types, whether paper or electronic.  Additional chapters in this manual supplement these general instructions.  For example, see instructions for inpatient hospital billing in Chapter 3, or inpatient skilled nursing billing in Chapter 6.  General information about billing for physician and other supplier services and about the CMS 1500 claim form can be found in Chapter 26, Completing and Processing Form CMS- 1500 Data Set, as well as chapters throughout this manual relative to specific policies and topic s.  For example see Chapter 12, Physicians/Nonphysician Practitioners, Chapter 13, Radiology Services and Other Diagnostic Services, or Chapter 16, Laboratory Services for detailed instructions for specific services.
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In order to constitute a Medicare claim, services submitted for payment must be submitted to the appropriate Medicare contractor (70.2.1), in a proper claim format (70.2.2), and in accordance with these CMS claim completion instructions.  Services submit ted for payment in a manner not complete and consistent according to these instructions will not be accepted into Medicares electronic claims processing system and will not be considered filed for purposes of determining timely filing.   70.2.3.1 - Incomplete or Invalid Submissions  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   Services not submitted in accordance with CMS instructions include:    Incomplete Submissions -  Any submissions missing required information (e.g., no provider name).    Invalid submissions -  Any submissions that contains complete and required information; however, the information is illogical or incorrect (e.g., incorrect Medicare beneficiary identifier, invalid procedure codes) or does not conform to required claim forma ts.  The following definitions may be applied to determine whether submissions are incomplete or invalid:    Required -  Any data element that is needed in order to process the submission (e.g., Provider Name).    Not Required -  Any data element that is optional or is not needed in order to process the submission (e.g., Patients Marital Status).    Conditional -  Any data element that must be completed if other conditions exist (e.g. if there is insurance primary to Medicare, then the primary insurers group name and number must be entered on a claim). If these conditions exist, the data element becom es required.
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Submissions that are found to be incomplete or invalid are returned to the provider (RTP). The incomplete or invalid information is detected by the FIs claims processing system. The electronic submission is returned to the provider of service electronical ly, with notation explaining the error(s).  Assistance for making corrections is available in the on- line processing system (Direct Data Entry) or through the FI. In the limited cases where paper submission are applicable, paper submissions found to be inc omplete or invalid prior to or during entry into the contractors claims processing system are returned to the provider of service by mail, with an attached form explaining the error(s).   The electronic records of claims that are RTP are held in a temporary storage location in the FIs claims processing system. The records are held in this location for a period of time that may vary among FIs, typically 60 days or less. During this period, the provider may access the electronic record and correct it, enabling the submission to be processed by the FI. If the incomplete or invalid information is not corrected within the temporary storage period, the electronic record is purged by the FI. There  is no subsequent audit trail or other record of the submission being received by Medicare. These submissions are never reflected on a RA. No permanent record is kept of the submissions because they are not considered claims under Medicare regulation.   70.2.3.2 - Handling Incomplete or Invalid Submissions  (Rev. 4201, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   The A/B MACs (A) should take the following actions upon receipt of incomplete or invalid submissions:    If a required data element is not accurately entered in the appropriate field, RTP the submission to the provider of service.