evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
 Laboratory tests furnished to a hospital inpatient whose stay is covered under Part A;   Laboratory tests performed by a Skilled Nursing Facility (SNF) for its own SNF inpatients and reimbursed under Part A or Part B and any laboratory tests furnished under arrangements to an SNF inpatient with Part A coverage.  (The only covered source for laboratory services furnished under Part A is the SNF itself or a hospital with w hich the facility has a transfer agreement in effect.)    Laboratory tests furnished by hospital -based or independent ESRD dialysis facilities that are included under the ESRD composite rate payment;    Laboratory tests furnished by hospitals in States or areas which have been granted demonstration waivers of Medicare reimbursement principles for outpatient services.  The State of Maryland has been granted such demonstration waivers;    Laboratory tests furnished to inpatients of a hospital with a waiver under 602(k) of the 1983 Amendments to the Act.  This section of the Act provides that an outside supplier may bill under Part B for laboratory and other nonphysician services furnished to inpatients that are otherwise paid only though the hospital;    Laboratory tests furnished to patients of rural health clinics (RHCs) under an all inclusive rate;    Laboratory tests provided by a participating health maintenance organization (HMO) or health care prepayment plan (HCPP) to an enrolled member of the plan; and   Laboratory tests furnished by a hospice.   40.1 - Access to Clinical Diagnostic Lab Fee Schedule Files  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  The annual laboratory fee schedule data file should be retrieved electronically through CMS mainframe telecommunications system.
(Medicare Claims Processing Manual)
The annual laboratory fee schedule data file should be retrieved electronically through CMS mainframe telecommunications system.   For each test code, if the MACs system retains only the pricing amount, they should load the data from the field named 60% Pricing Amt.  For each test code, if the MACs system has been developed to retain the local fee and the NLA, they may load the da ta from the fields named 60% Local Fee Amt and 60% Natl Limit Amt to use to determine payment.  For clinical laboratory test codes for cervical or vaginal smear tests (listed in Chapter 16, Laboratory Services from Independent Labs, Physicians, and Providers, 80.3) load the data from the field named 60% Pricing Amt to reflect the lower of the local fee or the NLA, but not less than the national minimum payment amount.  The fields named 62% Local Fee Amt, 62% Natl Limit Amt, and 62% Pricing Amt  should be used by A/B MACs (A) for payment of clinical laboratory tests performed by a sole community hospitals qualified laboratory.   The annual laboratory fee schedule data is available via the CMS website.  It is available in multiple formats: Excel, text, and comma delimited.   40.2 - A/B MAC (B) Record Layout for Clinical Laboratory Fee Schedule  (Rev. 1, 10- 01-03) PM AB -01-162, AB -02-163  The instructions for each annual update contain the actual data set name for that year.  The
(Medicare Claims Processing Manual)
The instructions for each annual update contain the actual data set name for that year.  The Data Set Name is included with each annual update instructions.  Data Element Name  Picture  Location  Comment  HCPCS Code  X(05)  1-5  A/B MAC (B) Number  X(05)  6-10  Locality  X(02)  11-12 00 = Denotes Single A/B MAC (B) State  01 = North Dakota  02 = South Dakota  20 = Puerto Rico 40 = New Hampshire  50 = Vermont  60% Local Fee  9(05)V99  13 - 19  62% Local Fee  9(05)V99  20 - 26  60% Natl Limit Amt 9(05)V99  27 - 33  62% Natl Limit Amt 9(05)V99  34 - 40  60% Pricing Amt  9(05)V99  41 - 47  62% Pricing Amt  9(05)V99  48 - 54  Gap -  Fill Indicator  X(01)  55 - 55 0 = No Gap -fill Required  1 = A/B MAC (B) Gap -fill 2 = Special Instructions Apply Modifier  X(02)  56 - 57 Where modifier is shown, QW denotes a CLIA waive test.  Data Element Name  Picture  Location  Comment  Filler  X(03)  58 - 60   40.3 - Institutional Claim Record Layout for Clinical Laboratory Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  The CMS will provide the specific file names when the prices are released.  The file name will contain the label CLAB.
(Medicare Claims Processing Manual)
The CMS will provide the specific file names when the prices are released.  The file name will contain the label CLAB.   Record Length =  60 Record Format =  FB Block Size =  6000 Character Code =  EBCDIC  Sort Sequence =  A/B MAC (B), Locality, HCPCS Code  Header Record  Data Element Name  Picture  Location  Comment  1-Label  X(03)  1 - 3 Value = Lab  2-Filler  X(07)  4 - 10  3-Filler  X(08)  11 - 15  4-Filler  X(04)  16 - 22  5-Date Fee Update  X(08)  23 - 30 YYYYMMDD  6-Filler  X(22)  31 - 52  7-Date File Created  X(08)  53 - 60 YYYYMMDD  Data Record  Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Filler  X(04)  6 - 9  3-60% Fee  9(05)V99  10 - 16  Data Element Name  Picture  Location  Comment  4-62% Fee  9(05)V99  17 - 23  5-Filler  X(07)  24 - 30  6- A/B MAC (B) Number  X(05)  31 - 35  7- A/B MAC (B) Locality  X(02)  36 - 37 00 = Single State A/B MAC (B)  01 = North Dakota  02 = South Dakota  20 = Puerto Rico  8-State Locality  X(02)  38 - 39 Separate instructions will be used for the use of this field at a later date.   9-Filler  X(02)  40 - 41  10-Effective Date  X(08)  42 - 49 Update effective date (YYYYMMDD)  11-Filler  X(11)  50 - 60   40.4 - Gap-Filled Fees Submitted to CMS by A/B MACs (B)  (Rev. 1, 10- 01-03) AB-01-162, AB -02-163
(Medicare Claims Processing Manual)
40.4 - Gap-Filled Fees Submitted to CMS by A/B MACs (B)  (Rev. 1, 10- 01-03) AB-01-162, AB -02-163   In accordance with 531(b) of the Benefits Improvement and Protection Act of 2000 (BIPA), CMS solicits public comments on determining payment amounts for new laboratory tests.  The CMS hosts an annual public meeting to allow parties the opportunity to provide input to the payment determination process.  The CMS employs one of two approaches to establishing payment amounts for new laboratory test codes, crosswalking and gap- filling.  After considering public input regarding the new test codes, CMS determines  which approach is most appropriate for each new test code.   If the new test is comparable to an existing test, the new test is crosswalked to the existing test, and it is assigned the local fee for the existing test and the corresponding NLA.  The new test code and payment amounts are included in the updated laboratory fee schedule annually.  If CMS determines that the laboratory fee schedule includes no sufficiently comparable test to permit crosswalking, CMS instructs A/B MACs (B)  to gap -fill the payment amount for the new test code.  Gap -filling is an empirical process of determining a payment amount in a locality using available information sources.  Usually the period during which gap-filled payment amounts are instructed is the year following the introduction of a new code.  During this period, A/B MACs (B)  establish and use these payment amounts; they may be revised in the course of the year.  Also during this period, A/B MACs (B)  must report the gap-fill amounts to their ROs which are then forwarded to CMS C O.  The CMS considers the gap -fill amounts and uses them to establish the fees for the new test code in the next update of the laboratory fee schedule.
(Medicare Claims Processing Manual)
In determining gap- fill amounts, the sources of information A/B MACs (B)  should examine, if available, include: charges for the test and routine discounts to charges; resources required to perform the test; payment amounts determined by other payers; and charges, payment amounts, and resources required for other tests that may be comparable or otherwise relevant.  A/B MACs (B)  may consider other sources of information as appropriate, including clinical studies and information provided by clinicians practicing in the area, manufacturers, or other interested parties.  To assist each A/B MAC (B)  in establishing a gap- fill amount, A/B MACs (B)  Medical Directors may meet and share information regarding the new test, though without reaching a formal consensus.  Establishing payment amounts for new laboratory tests is inherently difficult, precisely because these tests are new and as a result the types and extent of information available about them may be limited.  Because the circumstances of different tests may vary significantly, specifying in detail a method of using the various information sources outlined above does not appear appropriate at this time.  However, CMS designates a new test code for gap -filling in instances where no test code seems sufficiently similar to make a crosswalk approach appropriate.  Accordingly, A/B MACs (B)  should not determine a gap-fill amount by crosswalking to the payment amount for another test code.   After determining a gap -fill amount, an A/B MAC (B)  may consider if a least costly alternative to a new test exists.  If an A/B MAC (B)  determines a least costly alternative test exists, the A/B MAC (B)  may adopt the payment amount of the least costly alternative test as the gap -fill amount for the new test code.  The least costly alternative amount will be considered the local fee, and CMS will use this payment amount in establishing the NLA.  However i n this case, the A/B MAC (B)  must report two payment a mounts, the gap- fill amount prior to determination of a least costly alternative and the payment amount that the A/B MAC (B)  has determined to be the least costly alternative.
(Medicare Claims Processing Manual)
A/B MACs (B)  should also communicate the gap -fill amounts to corresponding A/B MACs (A) and (HHH).  A/B MACs (B)  can seek assistance from RO staff to facilitate communication of the gap- fill amounts to A/B MACs (A) and (HHH) .  The list of codes which A/B MACs (B)  are required to gap -fill each year are communicated in the annual instructions.  A/B MACs (B) provide their RO with gap- fill fees according to the date communicated by CMS (usually May), to be used by CMS -Central for the development of subsequent or later laboratory fee schedules.  A/B MACs (B) submit the gap- fill fees in a right- justified format.  These gap -fill data should be transmitted in an ASCII file with the following file specifications to MStevenson@cms.hhs.gov with a copy to Agreenberg@cms.hhs.gov to assist with coordinated collection of the gap- fill fees.   Data Set Name: CLXXXXX.TXT* (ASCII File)   (*Denotes A/B MAC (B) 5 -  digit number)   Gap-filled Fees Record Layout   Data Element Name  Picture  Location  Comment  Year  X(4)  1 - 4 Set to Year (e.g., 2003)  HCPCS Code  X(5)  5 - 9  Modifier  X(2)  10 - 11  A/B MAC (B) Number  X(5)  12 - 16  Locality  X(2)  17 - 18 00 = Denotes Single State A/B MAC (B)  01 = North Dakota  02 = South Dakota  20 = Puerto Rico 40 = New Hampshire  50 = Vermont  Gap-fill Amount 9(5)V99  19 - 25 Prior to any determination of a least costly alternative  Least Costly Alternative Amount  9(5)V99  26-32  Least Costly Alternative Code  X(5)  33-37   40.4.1 - A/B MACs (B) Forward HCPCS Gap Fill Amounts to A/B MACs (A) and (HHH)  (Rev. 1, 10- 01-03)  CMS Memo 9 -13-02 HCPCS Gap -fillR3.doc
(Medicare Claims Processing Manual)
CMS Memo 9 -13-02 HCPCS Gap -fillR3.doc   Any A/B MAC (B) that establishes a HCPCS gap fill payment rate for its own use, or at the request of an A/B MAC (A) or (HHH), must forward the information to the contacts at all A/B MACs (A) or (HHH) with providers in the A/B MAC (B) service area.   A/B MACs (B) that establish HCPCS gap -fill payment rates for their own needs should forward the information to A/B MACs (A) and (HHH) as soon as practicable.  A/B MACs (A) and (HHH) are to contact the appropriate A/B MAC (B) to request a gap fill payment rate with 5 working days of the suspension of claims containing HCPCS codes(s) for which payment rate is needed and has not been forwarded.  A/B MACs (B) must provide the payment rate to the requesting A/B MAC (A) or (HHH) (and all other A/B MACs (A) or (HHH) with providers in that common jurisdiction) within 10 working days of receipt of the request.   Requests for policy clarification in A/B MAC (B) establishing the HCPCS gap fill payment rates or A/B MAC (A) or (HHH) procedures for the use thereof should be directed to the respective Regional Office HCPCS business function experts (BFE).  Examples of t he need for A/B MAC (A) or (HHH) consultation with the BFE are coverage questions and receipt of unresolved significant inconsistencies in fee amounts from different A/B MACs (B) for the same HCPCS.  The A/B MAC (A) or (HHH) should consult the A/B MACs (B)  with disparate fees before contacting the BFE.
(Medicare Claims Processing Manual)
An A/B MAC (A) or (HHH) experiencing delay in replies or nonresponses from an A/B MAC (B) should alert it respective Consortium Contractor Management Staff (CCMS) Contract Manager (CM).  The CM will coordinate with his/her counterpart assigned to the A/B M AC (B) to achieve more timely action by the A/B MAC (B).   It is the A/B MAC (A)s or (HHH)s responsibility to ascertain the amount or consult with the A/B MAC (B), CCMS -CM, or BFE timely.  A/B MAC (A or (HHH) requests to apply CC 15 to claims which are paid untimely solely because of a delay in ascertaining a HCPCS gap fill amount from the A/B MAC (B) should be addressed to the respective CM.  The CM will contact the HCPCS BFE for a decision.  Requests for application of CC 15 to claims for which the A/B MAC (A) or (HHH) did not request the gap fill payment rate within 5 working days of the claim suspension and/or did not seek timely advice from the RO BFE concerning application of gap fill amount will not be honored.  Additionally, if the A/B MAC (B) replied at least five days before the expiration of the payment  floor, CC 15 requests will not be honored.   50 - Fee Schedules Used by Medicare A/B MACs (A) and (HHH) Processing Institutional Claims  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  A/B MACs (A) and (HHH) processing institutional claims retrieve multiple files from the CMS mainframe telecommunications system.  The HCPCS data files include deleted codes for the upcoming year.  A/B MACs (A) and (HHH) need to identify deleted codes using the HCPCS files because they are not identifiable solely from the fee schedules.  HCPCS files are also obtained from CMS annually.  New fee schedules are effective for dates of service on and after January 1 of each year.  Quarterly and emergency updates to the fee schedules are also sometimes released.  In that case, A/B MACs (A) and (HHH) implement them according to the instructions accompanying the release.
(Medicare Claims Processing Manual)
Two HCPCS files are furnished by CMS.  They are:    The annual HCPCS file update including procedure and modifier codes and deleted codes; and    A print file of the new year HCPCS codes.  The following fee schedules are furnished by CMS for use in processing institutional claims:   Fees for hospice claims for Part B services provided by the hospice beneficiarys attending physician;    Medicare Physician Fee Schedule;    Clinical Laboratory Fee Schedule discussed in 40.3 above;    Durable Medical Equipment, Prosthetics/Orthotics and Supplies (DMEPOS) Fee Schedule.  A/B MACs (HHH) with home health workloads retrieve data from all categories on this file.  All MACs retrieve data from categories prosthetic/orthotics and surgical dressi ngs;   Outpatient Rehabilitation (Therapy) and CORF Services Fee Schedule Payment Amounts (Therapy/CORF Abstract File);    CORF, outpatient Critical Access Hospital (CAH and Indian Health Services not part of the Outpatient Rehabilitation (therapy) file; and    Skilled Nursing Facility (SNF) extract file for radiology, other diagnostic and other SNF services.   50.1 - Institutional Claim Record Layout for Hospice, Radiology and Other Diagnostic Prices and Local HCPCS Codes  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This file contains hospice fee schedule prices extracted from the Physician Fee schedule.  This file contains pricing data for A/B MAC (B) -priced and local HCPCS codes for radiology, other diagnostic services, and hospice services paid under the physician fee schedule.  This file contains some high volume services such as portable x- rays.  The file is also used to pay claims for Critical Access Hospitals that have elected the optional method.  The CMS will provide the specific file names when the prices are released.  The file name will contain the label HHH.   Record Length  - 60 Record Format  - FB Block Size - 6000 Character Code  - EBCDIC  Sort Sequence  - A/B MAC (B), Locality, HCPCS Code, Modifier
(Medicare Claims Processing Manual)
Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Modifier  X(02)  6 - 7  3-Non-Facility Fee  9(05)V99  8 - 14  4-PCTC Indicator  X(01)  15 - 15 This field is only applicable when pricing Critical Access Hospitals (CAHs) that have elected the optional method (Method 2) of payment.   5-Facility Fee  9(05)V99  16 - 22  6-Effective Date  7- A/B MAC (B) Number  X(08)  X(05)   23 - 30 31 - 35  8-Locality  X(02)  36 - 37  9-**Label**  X(03)  38 - 40 HPH = Hospice Physician Services  ODX = Other Diagnostic Services  PRF = Portable Radiology RAD = Radiology 10-Filler  X(2)  41 - 42  11-Status Code  X(1)  43 - 43 Separate instructions will be used for the use of this field at a later date.  This field indicates whether the code is in the physician fee schedule and whether it is separately payable if the service is covered.  Data Element Name  Picture  Location  Comment  12-Multiple Surgery X(01)  44 - 44 Indicator indicates which payment adjustment rule for multiple procedures apply to the service.   13-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  14-Filler  X(01)  52 - 52  15- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   16-Filler  X(01)  60 - 60   50.2 - Institutional Claim Record Layout for the Durable Medical Equipment, Prosthetic, Orthotic and Supply Fee Schedule  (Rev. 3350, Issued: 09- 11-15, Effective: 01 -01-16, Implementation: 01- 04-16)  This file contains services subject to national Floors and Ceilings under the DMEPOS Fee Schedules including Surgical Dressings.  The CMS will provide the specific file names when the prices are released.   The file name will contain the label DMEPOS.   Record Length  - 60 Record Format  - FB Block Size  - 6000  Character Code  - EBCDIC  Sort Sequence  - Label, HCPCS Code, MOD, State
(Medicare Claims Processing Manual)
Record Length  - 60 Record Format  - FB Block Size  - 6000  Character Code  - EBCDIC  Sort Sequence  - Label, HCPCS Code, MOD, State   Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-MOD  X(02)  6  7  3-MOD 2  X(02)  8  9  4-Fee Schedule Amt  9(05)V99  10  16  5-Filler  X(01)  17  6-Rural Fee Amt 9(05)v99  18  24  7-Filler  X(01)  25  8-Rural Fee indicator  X(01)  26- R = Rural Fee is present  9-Filler  X(04)  27-30  10-State  X(02)  31 - 32  11-Filler  X(05)  33 - 37  12-*Label*  X(3)  38 - 40 DME = Durable Medical Equipment (other than oxygen)  OXY = Oxygen  Data Element Name  Picture  Location  Comment  P/O = Prosthetic/Orthotic  S/D = Surgical Dressings  13-Filler  X(4)  41 - 44  14-*Pricing Change Indicator  X(1)  45 - 45 0 = No change to Update Fee Schedule Amount since previous release  1 = A change has occurred to the Update Fee Schedule Amount since the previous release.  NOTE:  In the initial release of the annual update, this field is initialized to >0 15-Filler  X(02)  46  47  16-Effective Date  X(08)  48  55 Update effective date (YYYYMMDD)  17-Filler  X(05)  56  60   50.3 - Institutional Claim Record Layout for the Outpatient Rehabilitation and CORF Services Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This is a physician fee schedule abstract file for outpatient rehabilitation and CORF services payment.  The CMS will provide the specific file names when the prices are released.  The file name will contain the label ABSTR.   Record Length  - 60 Record Format  - FB Block Size  - 6000 Character Code  - EBCDIC  Sort Sequence  - A/B MAC (B), Locality HCPCS Code, Modifier
(Medicare Claims Processing Manual)
Record Length  - 60 Record Format  - FB Block Size  - 6000 Character Code  - EBCDIC  Sort Sequence  - A/B MAC (B), Locality HCPCS Code, Modifier   Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Modifier  X(02)  6 - 7  3-Non-Facility Fee  9(05)V99  8 - 14  Data Element Name  Picture  Location  Comment  4-PCTC Indicator  X(01)  15 - 15 This field is only applicable when pricing Critical Access Hospitals (CAHs) that have elected the optional method (Method 2) of payment. 5-Facility Fee  9(05)V99  12 - 22  6-Effective Date  X(08)  23 - 30 Update effective date  7- A/B MAC (B) Number  X(05)  31 - 35  8-Locality  X(02)  36 - 37  9-Filler  X(03)  38 - 40  10-Fee Indicator  X(1)  41 - 41 R = Rehab/Audiology function test/CORF services  11-Outpatient Hospital  X(1)  42 - 42 0 = Fee applicable in hospital outpatient setting  1 = Fee not applicable in hospital outpatient setting  12-Status Code  X(1)  43 - 43 Separate instructions will be used for the use of this field at a later date.  This field indicates whether the code is in the physician fee schedule and whether it is separately payable if the service is covered.  13-Multiple Surgery X(01)  44 - 44 Indicator indicates which payment adjustment rule for multiple procedures apply to the service.  14-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  15-Filler  X(01)  52 - 52  16- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   17-Filler  X(01)  60 - 60   50.4 - Institutional Claim Record Layout for the Skilled Nursing Facility Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)
(Medicare Claims Processing Manual)
50.4 - Institutional Claim Record Layout for the Skilled Nursing Facility Fee Schedule  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)  This section contains the record layout for the SNF extract for radiology Services, other diagnostic services, and other SNF services priced on the MPFS.  The CMS will provide the specific file names when the prices are released.   The file name will contain the label SNF.   Record Length  - 60 Record Format  - FB Block Size  - 6000 Character Code  - EBCDIC   Data Element Name  Picture  Location  Comment  1-HCPCS  X(05)  1 - 5  2-Modifier  X(02)  6 - 7  3-Non-Facility Fee  9(05)V99  8 - 14 The SNF fee schedule amount is based on the non- facility rate which is the fee that physicians may receive if performing the service in the physicians office.  4-PCTC Indicator  X(01)  15 - 15  5-Facility Fee  9(05)V99  16 - 22  6-Effective Date  7- A/B MAC (B) Number  X(08)  X(05)  23 - 30 31 - 35 Update effective date  8-Locality  X(02)  36 - 37  9-Filler  X(05)  38 - 42  Data Element Name  Picture  Location  Comment  10-Status Code  X(1)  43 - 43 Separate instructions will be used for the use of this field at a later date.  This field indicates whether the code is in the physician fee schedule and whether it is separately payable if the service is covered.  11-Multiple Surgery X(01)  44 - 44 Indicator indicates which payment adjustment rule for multiple procedures apply to the service.  12-Non Facility PE  9(05)V99  45 - 51 Non-facility practice expense RVU  13-Filler  X(01)  52 - 52  14- A/B MAC (A) or (HHH) Therapy Reduction 9(05)V99  53 - 59 Reduces payment amount for multiple surgery   15-Filler  X(01)  60 - 60   50.5 - RESERVED  (Rev. 2643, Issued: 01- 31-13, Effective: 07 -01-13, Implementation: 07- 01-13)