evekhm/cms_iom_500 huggingface dataset:
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30.1 - Maintenance Process for the Medicare Physician Fee Schedule Database (MPFSDB)  (Rev. 1, 10- 01-03)  The CMS calculates the fee schedule payment amounts and releases them to the A/B MACs (B) in the Medicare Physician Fee Schedule Database (MPFSDB).  A/B MACs (B) implement those payment amounts on January 1 of each year.  The CMS maintains the payment file s centrally and is responsible for recalculating any revised payment amounts.  Any revisions initiated by Central Office (fee schedule amounts or payment policy indicators) are issued to the A/B MACs (B) on a quarterly basis.   The information for the ongoing maintenance of the MPFSDB is stated below.   CMS calculates the new fee schedule amounts.  The CMS Central Office issues the revised data to the ROs in the same format of the MPFSDB.    A/B MACs (B) receive a file containing data with revisions for the quarter.  This file is released electronically via CMS Mainframe Telecommunications System.    A/B MACs (B) must allow providers 30 days notification before revised payment amounts are implemented.  The revised payment amounts are implemented the beginning of the following quarter.    CMS furnishes the recalculated payment amounts to the A/B MACs (B) in data files to ensure accuracy.  A/B MACs (B) overlay these files into their existing file, to eliminate the potential for errors.    A/B MACs (B) must make adjustments on those claims that were processed incorrectly if the adjustment is requested by the physician/supplier.  Adjustments are made retroactively to January 1 of the current year, unless otherwise specified.  This directive a pplies in all instances unless the situation requires special consideration.  In those instances, instructions on handling adjustments will be provided on a case -by-case basis.   Separate instructions are issued describing the data exchange for the A/B MACs (A) and (HHH)    .In summary, A/B MACs (A) and (HHH) receive the revised payment amounts two to three weeks after the A/B MACs (B) receive the data from CMS.  A/B MACs (A) and (HHH) do not implement the revised payment amounts prior to the A/B MACs (B)s implementation date.
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 A/B MACs (B) are required to furnish the revised payment information to the State Medicaid Agencies upon their request one month following receipt of the data from CMS.  Those State agencies with Internet access capability will download the data directly f rom CMS Web site.   The CMS publishes a schedule for Medicare Physician Fee Schedule updates and participation physician enrollment procedures annually for all MACs.  30.2 - MPFSDB Record Layout  (Rev. 4298, Issued: 05- 03-19, Effective: 01 -01-19, Implementation 10- 07-19)  The CMS MPFSDB includes the total fee schedule amount, related component parts, and payment policy indicators.  The record layout is provided in the Addendum below.  30.2.1 - Payment Concerns While Updating Codes  (Rev. 1, 10- 01-03)  The following instructions apply in situations where the CMS CO does NOT provide pricing guidance via the Medicare Physician Fee Schedule Database (MPFSDB) for physicians services.   If a new code appears, A/B MACs (B) make every effort to determine whether the procedure, drug or supply has a pricing history and profile.  If there is a pricing history, map the new code to previous customary and prevailing charges or fee schedule amount s to ensure continuity of pricing.  Since there are different kinds of coding implosions and explosions, the way the principle is applied varies.  For example, when the code for a single procedure is exploded into several codes for the components of that procedure, the total of the separate relative value unit or other charge screens established for the components must not be higher than the relative value units or other charge screens for the original service.  However, when there is a single code that describes two or more distinct complete  services (e.g., two different but related or similar surgical procedures), and separate codes are subsequently established for each, continue to apply the payment screens that applied to the single code to each of the services described by the new codes.   If there is no pricing history or coding implosion and explosion, A/B MACs (B) must make an individual consideration determination for pricing and payment of a covered service.
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If there is no pricing history or coding implosion and explosion, A/B MACs (B) must make an individual consideration determination for pricing and payment of a covered service.   Conversely, when the codes for the components of a single service are combined in a single global code, A/B MACs (B) establish the payment screens for the new code by totaling the screens used for the components (i.e., use the total of the customary charge s for the components as the customary charge for the global code; use the total of the prevailing charges for the components adjusted for multiple surgical rules if applicable as the prevailing charge for the global code, etc.).  However, when the codes for several different services are imploded into a single code, A/B MACs (B) set the payment screens at the average (arithmetic mean), weighted by frequency, of the payment screens for the formerly separate codes.   30.2.2 - MPFSDB Status Indicators  (Rev. 4418, Issued: 10- 18- 19, Effective: 01 -01- 20 Implementation: 11-  19 19)
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A = Active code.  These codes are separately paid under the physician fee schedule if covered.  There will be RVUs and payment amounts for codes with this status.  The presence of an A indicator does not mean that Medicare has made a national coverage determ ination regarding the service; A/B MACs (B) remain responsible for coverage decisions in the absence of a national Medicare policy.  B = Payment for covered services are always bundled into payment for other services not specified.  There will be no RVUs or payment amounts for these codes and no separate payment is ever made.  When these services are covered, payment for them is subsumed by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse regarding care of a patient).  C = A/B MACs (B) price the code.  A/B MACs (B) will establish RVUs and payment amounts for these services, generally on an individual case basis following review of documentation such as an operative report.  D =*  Deleted/discontinued codes.  E = Excluded from physician fee schedule by regulation.  These codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation.  No RVUs or payment amounts are shown and no payment may be made under the fee schedule fo r these codes.  Payment for them, when covered, continues under reasonable charge procedures.  F = Deleted/discontinued codes.  (Code not subject to a 90 day grace period.) These codes are deleted effective with the beginning of the year and are never subject to a grace period.  This indicator is no longer effective beginning with the 2005 fee schedule as of January 1, 2005. G = Not valid for Medicare purposes.  Medicare uses another code for reporting of, and payment for, these services.  (Code subject to a 90 day grace period.)  This indicator is no longer effective beginning with the 2005 fee schedule as of January 1, 2005.  H =*  Deleted modifier.  For 2000 and later years, either the TC or PC component shown for the code has been deleted and the deleted component is shown in the data base with the H status.  I = Not valid for Medicare purposes.  Medicare uses another code for reporting of, and payment for, these services.  (Code NOT subject to a 90 day grace period.)  J= Anesthesia services (no relative value units or payment amounts for anesthesia codes on the database, only used to facilitate the identification
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for reporting of, and payment for, these services.  (Code NOT subject to a 90 day grace period.)  J= Anesthesia services (no relative value units or payment amounts for anesthesia codes on the database, only used to facilitate the identification of anesthesia services.)  L = Local codes.  A/B MACs (B) will apply this status to all local codes in effect on January 1, 1998 or subsequently approved by central office for use.  A/B MACs (B) will complete the RVUs and payment amounts for these codes.  M= Measurement codes, used for reporting purposes only.  N = Non-covered service.  These codes are carried on the HCPCS tape as noncovered services.  P = Bundled/excluded codes.  There are no RVUs and no payment amounts for these services.  No separate payment is made for them under the fee schedule.  If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident (an example is an elastic bandage furnished by a physician incident to a physician service).  If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (for example, colostomy supplies) and is paid under the other payment provision of the Act.  Q =  Therapy functional information code (used for required reporting purposes only). This indicator is no longer effective beginning with the 2020 fee schedule as of January 1, 2020.  R = Restricted coverage.  Special coverage instructions apply.  T = There are RVUs and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider.  If any other services payable under the physician fee sched ule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made.  X = Statutory exclusion.  These codes represent an item or service that is not in the statutory definition of physician services for fee schedule payment purposes.  No RVUs or payment amounts are shown for these codes and no payment may be made under the phy sician fee schedule.  (Examples are ambulances services and clinical diagnostic laboratory services.)  *Codes with these indicators had a 90 day grace period before January 1, 2005 30.3 - Furnishing Pricing
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payment may be made under the phy sician fee schedule.  (Examples are ambulances services and clinical diagnostic laboratory services.)  *Codes with these indicators had a 90 day grace period before January 1, 2005 30.3 - Furnishing Pricing Files  (Rev. 1, 10- 01-03)
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The CMS provides a schedule for activities related to furnishing these pricing files in advance each year.  The CMS will provide the completed physician fee schedule, the Durable Medical Equipment and Prosthetics and Orthotics and Supplies (DMEPOS) fee schedules and clinical lab data to United Mine Workers and Indian Health Services.  A/B MACs (A), (B), (HHH), and DME MACs are informed where to access the files for FTP (File Transfer Protocol) download.  30.3.1 - RESERVED  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  30.3.2 - A/B MAC (A), (B), or (HHH) Furnishing Physician Fee Schedule Data for National Codes  (Rev. 4131, Issued: 09- 14-18, Effective: 12 -17-18, Implementation: 12 -17-18)  A/B MACs (A), (B), and (HHH) are responsible for furnishing fee schedules to related providers, suppliers, physicians, and practitioners with billing relationships.  A/B MACs (A), (B), and (HHH) may also receive requests for this information from the State Agencies.  The data is available on the CMS website.  The MACs shall direct State Agencies to the appropriate pages on the website to download the data directly.  The CMS will provide the Medicare physician, ambulance, DMEPOS, and clinical laboratory fee schedules and the zip code file to the A/B MACs (A) and (HHH) , Palmetto GBA (the Specialty MAC or S MAC for Railroad Retirement Board), the Indian Health Services, and the United Mine Workers.  MACs  DO NOT NEED TO SEND FILES TO THOSE ENTITIES.   Fee schedules also are available for the public on the CMS Web site.   30.3.3 - Furnishing Other Fee Schedule, Prevailing Charge, and Conversion Factor Data  (Rev. 1, 10- 01-03) B3-4620.3
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30.3.3 - Furnishing Other Fee Schedule, Prevailing Charge, and Conversion Factor Data  (Rev. 1, 10- 01-03) B3-4620.3  A/B MACs (B)  use the file format in 30.3.5 to furnish fee schedule (Excluding Physician Fee Schedule), prevailing charge, and conversion factor information to Palmetto GBA (S MAC for RRB), A/B MACs (A) or (HHH) , State Agencies, Indian Health Services, and United Mine Workers.   A/B MACs (B)  furnish statewide (or A/B MAC (B) -wide for areas less than an entire State) pricing data for certified registered nurse anesthetist conversion factors.  Furnish all fee schedules and conversion factors on tape unless the receiving entity agrees that a paper listing is acceptable.   Clinical Lab pricing files subject to national limitation amounts and DMEPOS pricing files subject to national floor and ceiling limitation amounts will be furnished by CMS to all entities except the State Medicaid Agencies.  The Center for Medicaid and St ate Operations will provide those pricing files to the State Medicaid Agencies.   In addition to the above pricing files, A/B MACs (B)  furnish Palmetto GBA (the S MAC for RRB) with a tape file of locality prevailing charges for ambulance services and inflation indexed prevailing charges for non- physician services subject to the IIC.   Send pricing files for the RRB S MAC to:   Medicare Systems RRB -  AG- 430 Palmetto GBA  Building One  2300 Springdale Drive  Camden, SC 29020  For Indian Health Services, send pricing files to:   IHS Contract Health Services  12800 Indian School Road North East  Albuquerque, NM 87112   For releasing nonphysician pricing files to State Agencies, contact the RO to obtain the name and mailing address of the individual to whom the file should be addressed.  For the United Mine Workers, send the pricing files to:   Government Programs Manager  UMWA Health and Retirement Funds  2121 K Street, NW  Washington, DC 20037, or  MedPricing@umwafunds.org
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Government Programs Manager  UMWA Health and Retirement Funds  2121 K Street, NW  Washington, DC 20037, or  MedPricing@umwafunds.org  You may negotiate agreements with the receiving entity to use an alternate medium (e.g., paper, diskette) or a tape file format other than that specified in 30.3.5.  However, such agreements must be in writing and signed by the affected entities (e.g., A/B MAC (A), (B), (HHH), or DME MAC , RRB S MAC, UMWA, etc.).  Furnish your RO with a copy of written agreements for using mediums other than tape or tape file formats other than that in 30.3.5.  30.3.4 - Responsibility to Obtain and Implement Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedules  (Rev. 1, 10- 01-03) B3-4622  The A/B MACs (A), (B), (HHH), and DME MACs must download and implement the DMEPOS fee schedules for the items and services within their jurisdiction.  DME MACs must also forward the DMEPOS fee schedule to Medicaid State Agencies.  The CMS releases new fee schedules on an annual basis, with updates being issued quarterly, if needed.  The CMS issues separate instructions for downloading and implementing fee schedule updates as appropriate.  Central office (CO) will issue annual updates describing the maintenance process for each year.  These instructions provide A/B MACs (A), (B), (HHH), and DME MACs the due dates.  The instructions will also list the date th e release will be made available and an implementation date for each release.   30.3.5 - File Specifications  (Rev. 1, 10- 01-03) B3-4621  The following guidelines are used to create the pricing files.  1. Recommended Physical File Specifications -Magnetic Tape - Tape characteristics -9 track, 8 2 to 10 2 reels with silver mylar reflector (standard reels) with write ring removed.   Parity  Odd   Recording Density -  6250 bytes per inch   Recording Code -  Extended Binary Coded Decimal
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Parity  Odd   Recording Density -  6250 bytes per inch   Recording Code -  Extended Binary Coded Decimal   File Label - IBM standard label.  The tape must have an end of file mark.  The first data record on the file identifies the submitter and the receiver and serves the function of a file label.   Physical Record Length -  60 characters   Blocking Factor -  100 records per block   The external label on the reel must appear as:   From   To  Reel number HCPCS (see footnote (a) below for entry) number (the unique number by which the tape is identified in your library).   Date (MMDDYYYY)   2. Record Specifications.  The logical HCPCS record is made up of a series of 60 character physical records.   3. Blocking factor of 100 (100 records per data block).   4. Header Type Specifications   Field No. Field Name  Size Picture  Specification  Field Remarks  1 Label  3 X(3)  L See Footnote (b)  2 Filler  7 X(7)  L  3 A/B MAC (B) #  5 9(5) L  4 Filler  1 X(1)    5 Interm.  #  5 9(5) L  6 Filler  1 X(1)  L  7 Date Fee Updated  8 X(8)  L MMDDYYYY  8 Filler  22 X(22)    9 Date File Created  8 X(8)  L MMDDYYYY   5. Detail Record   Field No. Field Name  Size Picture  Specification  Field Remarks  1 HCPCS  5 X(5)  L  2 Filler  2 XX L  3 Filler  2 XX L  4 Fee/CF/Prev.  7 9(5)V99  R See Footnote (c) for applicable category  5 Fee 7 9(5)V99  R See Footnote (d)  6 Fee 7 9(5)V99  R See Footnote (e)  7 A/B MAC (B) #  5 X(5)  L  8 Locality  2 99 L  9 Filler  23 X(23)
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(a) Identify the type of information furnished:   DME fee schedule (includes supplies, inexpensive/routinely purchased, frequency service, and capped rental);   Surgical Dressings;   Prevailing charges applicable to hospice physician services;   Lab fee schedule;   Other diagnostic service prevailing charges;   Oxygen fee schedule;   Prosthetic/orthotic fee schedule (includes ostomy, tracheostomy, and urologicals);   Radiology conversion factors;   Portable radiology fee schedule; or   Certified registered nurse anesthetist conversion factors. (b) Show the label for category as:   DME -  durable medical equipment;   S/D -  surgical dressings;   HPH -  prevailing charges for pricing hospice physician services;   LAB -  laboratory;   ODX -  other diagnostic services;   OXY -  oxygen;   P/O -  prosthetic/orthotic;  RAD -  radiology;   PRF -  portable radiology; or   CNA -  certified nurse anesthetist.  (c, d, e)  DME  (c) purchase new  (d) purchase used  (e) monthly rental  NOTE:  When a HCPCS code has multiple fees, list all the fees.  A/B MACs (HHH) are not able to accept procedure codes with modifiers. HPH (c) locality prevailing charge for physician services  LAB  (c) fee schedule amount -  60%  (d) fee schedule amount -  62%  ODX  (c) locality prevailing charge amounts  OXY  (c) purchase new/purchased oxygen contents  (d) purchase used  (e) monthly rental  P/O (c) purchase new  RAD (c) conversion factors  NOTE:   HCPCS codes are not necessary for radiology. PRF (c) fee schedule amount  CNA (c) conversion factor -  medically directed CRNA services  (d) conversion factor -  non-medically directed CRNA services   30.5 - Payment Amounts for Portable X- Ray Transportation Services  (Rev. 1, 10- 01-03) B-02-075
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30.5 - Payment Amounts for Portable X- Ray Transportation Services  (Rev. 1, 10- 01-03) B-02-075  Transportation for portable x- ray services (HCPCS code R0070) is paid under the Medicare physician fee schedule.  There are no national values for this service.  The CMS has not established national relative values for this service because there are no national data for these services and because there are significant differences in the delivery of this service in different geographic areas.  Instead, each A/B MAC (B) is required to determine the payment amounts for its geographic areas.   The CMS has not established specific criteria that A/B MACs (B) should use in determining the payment amounts they establish for A/B MAC (B) priced services.  The CMS has not established a specific annual update factor to be applied to these services.  Mid-year adjustments are possible if the A/B MAC (B) believes such adjustments are appropriate.  Such an appropriation provides A/B MACs (B) with the flexibility to take into account local factors affecting the level of resources required to perform this se rvice.   A/B MACs (B) should periodically review (at least every five years, or more frequently if local conditions warrant) their locally determined payment amounts to determine whether the payment amounts reflect the relative resources (e.g., staff, equipment, supplies and general expenses) required to perform A/B MAC (B) -priced services.  Such periodic reviews for A/B MAC (B) priced services would be consistent with statutory requirements.  If portable x -ray transportation suppliers request such a review, A/B MACs (B) should work with the local suppliers to review the payment amounts for R0070, taking into account local factors and any data available regarding the resources required to provide these services.   40 - Clinical Diagnostic Laboratory Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  The Medicare Claims Processing Manual, Chapter 16, Laboratory Services From Independent Labs, Physicians, and Providers, provides background and additional information for payment of laboratory services.   Clinical diagnostic laboratory tests -  whether performed in a physicians office, by an independent laboratory, or by a hospital laboratory for its outpatients -  are paid based on fee schedules.  This section sets out rules for use of these schedules.
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Clinical diagnostic laboratory tests -  whether performed in a physicians office, by an independent laboratory, or by a hospital laboratory for its outpatients -  are paid based on fee schedules.  This section sets out rules for use of these schedules.   The fee schedule amounts are adjusted annually to reflect changes in the Consumer Price Index (CPI) for all Urban Consumers (U.S. city average), or as otherwise specified by legislation.  Adjustments are applied and amounts are determined by CMS and publis hed for A/B MAC (A), (B), and (HHH) use and also on CMS Web site.  A/B MACs (A), (B), and (HHH) are notified when and where updates are published.   For a cervical or vaginal smear test (pap smear), payment is the lesser of the local fee or the national limitation amount, but not less than the national minimum payment amount.  However, in no case may payment for these tests exceed actual charges.  The Part B deductible and coinsurance do not apply.   Regardless of whether a diagnostic laboratory test is performed in a physicians office, by an independent laboratory, or by a hospital laboratory for its outpatients or nonpatients, it is considered a laboratory service.  When a hospital laboratory perfor ms diagnostic laboratory tests for nonhospital patients, the laboratory is functioning as an independent laboratory.   National minimum limitation amounts are established each year for cervical or vaginal smear clinical laboratory tests.  These payment amounts are published each year in a Recurring Update Notification issued by CMS.  The affected CPT laboratory test codes for the national minimum payment amount are also identified in the annual Recurring Update Notification.  National maximum limitation amounts may also be established for certain services and are also published each year this Recurring Update Notification.  A/B MACs (A), (B), and (HHH) pay the lowest of the applicable current fee schedule, the actual charge, or the NLA.  This applies to all clinical diagnostic laboratory tests except:    Laboratory tests furnished to a hospital inpatient whose stay is covered under Part A;