evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Hospitals must include on a Medicare claim for a beneficiarys inpatient stay the diagnoses, procedures, and charges for all preadmission outpatient diagnostic services and all preadmission outpatient nondiagnostic services that meet the above requirements.  For purposes of the Present on Admission Indicator (POA), even if the outpatient services are bundled with the inpatient claim, hospitals shall code any conditions the patient has at the time of the order to admit as an inpatient as POA irrespective of whether or not the patient had the condition at the time of being registered as a hospital outpatient.  In combining on the inpatient bill the diagnoses, procedures, and charges for the outpatient services, a hospital must convert CPT codes to ICD procedure codes and must only include outpatient diagnostic and admission- related nondiagnostic services that span the period of the payment window.   Outpatient nondiagnostic 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.  Hospitals must maintain documentation in the beneficiarys medical record to support their claim that the preadmission outpatient nondiagnostic services are unrelated to the beneficiarys inpatient admission.  Effective for dates of service on or after June 25, 2010, CWF will reject outpatient claims for nondiagnostic services when the following occurs:   1) Condition code 51 (definition 51 - Attestation of Unrelated Outpatient Non -diagnostic Services) is not included on the outpatient claim, and   2) The line item date of service (LIDOS) falls on the day of admission or any of the 3 days immediately prior to an admission to an IPPS hospital (or on the day of admission or one day prior to admission for hospitals excluded from IPPS).  40.3.1 - Billing Procedures to Avoid Duplicate Payments  (Rev. 1, 10- 01-03)  HO- 400H   The hospital must install adequate billing procedures to avoid submission of duplicate claims.  This includes duplicate claims for the same service and outpatient bills for nonphysician services considered included in the DRG for a related inpatient admission in the facility or in another hospital.
(Medicare Claims Processing Manual)
Where the hospital bills separately for nonphysician services provided to a patient either on the day before admission to a PPS hospital or during a patient's inpatient stay, the claim will be rejected by the A/B MAC (A) as a duplicate and the hospital may  be subject to sanction penalties per 1128A  of the Act.   50 - Adjustment Bills (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD - 10, Implementation: ICD - 10: Upon Implementation of ICD - 10, ASC X12: September, 23 2014)   Adjustment bills are the most common mechanism for changing a previously accepted bill.  They are required to reflect the results of A/B MAC (A)s medical review.  Adjustments may also be requested by CMS via CWF if it discovers that bills have been accept ed and posted in error other than the omission of a charge.  Adjustments may be initiated as a result of OIG and MSP requests.  The A/B MAC (A) will ask the provider to submit an adjustment request for certain situations.   For hard copy Form CMS -1450 adjustment requests, the provider places the ICN/DCN of the original bill for Payer A, B, or C.   Where payment is handled through the cost reporting and settlement processes, the provider accumulates a log for those items not requiring an adjustment bill.  For cost settlement, the A/B MAC (A) pays on the basis of the log.  This log must include:    Patient name;    HICN;    Dates of admission and discharge, or from and thru dates;    Adjustment in charges (broken out by ancillary or routine service); and    Any unique numbering or filing code necessary for the hospital to associate the adjustment charge with the original billing.
(Medicare Claims Processing Manual)
 Adjustment in charges (broken out by ancillary or routine service); and    Any unique numbering or filing code necessary for the hospital to associate the adjustment charge with the original billing.   Providers in Maryland, which are not paid under PPS or cost reports, submit an adjustment bill for inpatient care of $500 or more, and keep a log as described above for lesser amounts.  Because there are no adjustment bills, the A/B MAC (A) enters the paym ent amounts from the summary log into the PPS waiver simulation and annually pays the items on the log after the cost report is filed.  NOTE:  Information regarding the claim form locators that correspond with these fields on the Form CMS -1450 is found in chapter 25.  An original bill does not have to be accepted by CMS prior to making related adjustments to the provider.  However, for all adjustments other than QIO adjustments (e.g., provider submitted and/or those the A/B MAC (A) initiates), the A/B MAC (A) submits an  adjustment bill to CWF following its acceptance of the initial bill.  To verify CMS' acceptance, it takes one or both of the following actions:   A. - General Rules for Submitting Adjustment Requests   Adjustment requests that only recoup or cancel a prior payment are "credits" and must match the original in the following fields:    A/B MAC (A) control number (ICN/DCN);    Surname;    HICN;   When a definite match cannot be made on the 3 fields above, the provider's A/B MAC (A) will use the fields below as needed.  Note that for older claims, ICN/DCN probably will not match.   Date of birth;    Admission date (Start of Care Date for Home Health), unless changed by this adjustment requests; and   From/thru dates (Date of First Visit/Date of Last Visit for Home Health), unless changed by this adjustment request.   Cancel -only adjustment requests must be submitted only in cases of incorrect provider identification numbers and incorrect HICNs.  After the cancel -only request for the incorrect bill is resolved, the provider must submit correct information as a new bill.
(Medicare Claims Processing Manual)
Cancel -only adjustment requests must be submitted only in cases of incorrect provider identification numbers and incorrect HICNs.  After the cancel -only request for the incorrect bill is resolved, the provider must submit correct information as a new bill.   The provider must submit all other adjustment requests as debits only.  It shows the ICN/DCN of the bill to be adjusted as described above, with the bill type shown as XX7.  It submits adjustment requests to its A/B MAC (A) either electronically or on hard  copy.  Electronic submission is preferred.  The A/B MAC (A) must enter the following bill types that relate to the entity generating the adjustment request:   Bill Type  Description  XX7  Provider (debit)  XX8  Provider (cancel)  XXF  Beneficiary  XXG  CWF  XXH  CMS  XXI A/B MAC (A)  XXM  MSP  XXP  QIO/QIO  XXJ Other  XXK  OIG  The provider submits adjustment requests as bill type XX7 or XX8.  Since several different sources can initiate an adjustment for MSP purposes, the A/B MAC (A) will change the bill type to XXM, which takes priority over any other source of an adjustment except OIG.  These priorities refer only to the designation of the source of the adjustment.  The difference between CWF generating the adjustment request and CMS generating the request is:   An adjustment is CWF -generated if the A/B MAC (A) receives a CWF alert or a CMS -L1002.  The A/B MAC (A) prepares an adjustment if instructed by CO or RO to make a change.  Typically, the A/B MAC (A) receives such direction from CMS when it decides to retroactively change payment for a class or other group of bills.  Occasionally, CMS will dis cover an error in the processing of a single bill and direct the A/B MAC (A) to correct it.
(Medicare Claims Processing Manual)
If the A/B MAC (A) furnished the A/B MAC (B) a copy of the original bill which is being adjusted, it must furnish them a copy of the adjusted bill.  If adjustment bills are rejected by CWF for additional corrections, they need to be corrected and resubmitted.  Even if the adjustment action is requested by letter from CMS, the A/B MAC (A) must submit the adjustment bill in its CWF record.  If a rejected  adjustment bill is determined to be unnecessary, the A/B MAC (A) stops the adjustment action upon receipt of correction.   Where an adjustment bill changes subsequent utilization, the A/B MAC (A) notes this and processes adjustments to subsequent bills if it services the provider.  If the A/B MAC (A) does not service the provider, CMS will contact the A/B MACs (A), which submitted bills with subsequent billing dates that are affected by the adjustments via an SSA -L389 or SSA -L1001 upon receipt of the adjusted bills in CWF.  (An indic ator is set by CMS on its records upon advising an A/B MAC (A) of the appropriate adjustment actions.)   B. - Adjustment Bills Involving Time Limitation for Filing Claims   If a provider fails to include a particular item or service on its initial bill, an adjustment bill(s) to include such an item(s) or service(s) is not permitted after the expiration of the time limitation for filing a claim.  However, to the extent that an  adjustment bill otherwise corrects or supplements information previously submitted on a timely claim about specified services or items furnished to a specified individual, it is subject to the rules governing administrative finality, rather than the time limitation for filing.   Under prospective payment, adjustment requests are required from the hospital where errors occur in diagnoses and procedure coding that change the DRG, or where the deductible or utilization is affected.  A hospital is allowed 60 days from the date of the A/B MAC (A) payment notice for adjustment bills where diagnostic or procedure coding was in error.  Adjustments reported by the QIO have no corresponding time limit and are adjusted automatically by the A/B MAC (A) without requiring the hospital to submit an adjustment bill.  However, if diagnostic and procedure coding errors have no effect on the DRG, adjustment bills are not required.
(Medicare Claims Processing Manual)
Under PPS, for long- stay cases, hospitals may bill 60 days after an admission and every 60 days thereafter if they choose.  The A/B MAC (A) processes the initial bill through Grouper and Pricer.  The provider must submit an adjustment to cancel the origina l interim bill(s) and rebill the stay from the admission date through the discharge date.  When the adjustment bill is received, it processes it as an adjustment.  In this case, the 60-day requirement for correction does not apply.   Where payment is handled through cost reporting and settlement processes, the provider accumulates a log for those items not requiring an adjustment bill.  Maryland inpatient hospital providers also keep a log of late charges when the amount is under $500.  They submit the  log with their cost reports.  After cost reports are filed, the A/B MAC (A) makes a lump sum payment to cover these charges as shown on the summary log.  The provider uses the summary log for late charges only under cost settlement (outpatient hospital), except in Maryland.   Maryland and cost providers are required to meet the 27- month timeframe for timely filing of claims, including late charges.   NOTE:  Providers in Maryland which are not paid under PPS or cost reports, submit an adjustment bill for inpatient care of $500 or more, and submit a log for the lesser amounts.  50.1 - Tolerance Guidelines for Submitting Adjustment Requests  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   When a bill is submitted and the hospital or the A/B MAC (A) discovers an error, the hospital submits an adjustment request using the ASC X12 837 institutional claim format or the Form CMS -1450, if the error is a change in the:    Number of inpatient days (including a change in the length of stay, or a different allocation of covered/non -covered days;    Blood deductible;    Inpatient cash deductible of more than $1;    Servicing provider;    Discharge status in a PPS hospital;    Diagnosis or Procedures that impact the assigned DRG code; or    Outlier payment amount.
(Medicare Claims Processing Manual)
 Inpatient cash deductible of more than $1;    Servicing provider;    Discharge status in a PPS hospital;    Diagnosis or Procedures that impact the assigned DRG code; or    Outlier payment amount.   The provider submits most adjustment requests as debits, using bill type XX7.  Also, it submits a debit- only adjustment request to the A/B MAC (A) if the hospital previously submitted an interim bill for a PPS hospital stay or wishes to change the number of days in any inpatient stay.  The A/B MAC (A) then submits the adjustment to CWF.  An adjustment from the QIO for any of the above also requires a submission to CMS via CWF.  If PPS is involved and the DRG has been changed as a result of medical review after an original bill has been forwarded to CMS, adjustment debit/credit bills are required.  The corrected bill must be an exact duplicate of the original, except for any changed fields including diagnostic and procedure codes.   50.2 - Claim Change Reasons  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   A. - Claim Change Reason Codes   The provider submits one of the following claim change reason codes to its A/B MAC (A) with each debit -only or cancel -only adjustment request:   Bill Type  Reason Code  Explanation  XX7  D0 (zero)  Change to service dates  XX7  D1 Change in charges  XX7  D2 Change in revenue codes/HCPCS  XX7  D3 Second or subsequent interim PPS bill - inpatient only  XX7  D4 Change in GROUPER input (diagnoses or procedures) - inpatient only  XX8  D5 Cancel -only to correct a HICN or provider identification number  XX8  D6 Cancel -only to repay a duplicate payment or OIG overpayment (includes cancellation of an outpatient bill containing services required to be included on the inpatient bill.)  XX7  D7 Change to make Medicare the secondary payer  XX7  D8 Change to make Medicare the primary payer  XX7  D9 Any other change  XX7  E0 (zero)  Change in patient status
(Medicare Claims Processing Manual)
The provider may not submit more than one claim change reason code per adjustment request.  It must choose the single reason that best describes the adjustment it is requesting.  It should use claim change reason code D1 only when the charges are the only change on the claim.  Other claim change reasons frequently change charges, but the provider may not "add" reason code D1 when this occurs.   The claim change reason code is entered as a condition code on the ASC X12 837 institutional claim format or on the hard copy Form CMS -1450  For reason codes D0- D4 and D7- D9, submit a debit -only adjustment request, bill type XX7.  For reason codes D5 and D 6, submit a cancel -only adjustment request, bill type XX8.   B. - Edits on Claim Change Reason Codes   The following edits are based on the claim change reason code.  The A/B MAC (A) must apply them to each incoming adjustment request.   If the type of bill is equal to XX7 and the claim change reason code is not equal to D0- D4, D7 -D9, or E0, the A/B MAC (A) rejects the request back to the provider with the following error message, "Claim change reason code must be present and equal to D0- D4, D7- D9, or E0 for a debit -only adjustment request."    If the type of bill is equal to XX8 and the claim change reason code is not equal to D5- D6, the A/B MAC (A) rejects the request back to the provider with the following error message, "Claim change reason code must be present and equal to D5- D6 for a cancel -only adjustment request."    If the type of bill is equal to XX7 or XX8 and the ICN/DCN of the claim being adjusted is not present, the A/B MAC (A) rejects the request back to the provider with the following message, "ICN/DCN of the claim being adjusted is required for an adjustment r equest."
(Medicare Claims Processing Manual)
 If more than one claim change reason code is present on the provider's request, the A/B MAC (A) rejects the request back to the provider with the following message, "only one claim change reason code may apply to a single adjustment request from a provider.  Choose the single claim change reason code that best describes the reason for the provider's request and resubmit."    If the provider submits an adjustment request as type of bill not equal to XX7 or XX8, the A/B MAC (A) rejects the request back to the provider with the message, "Provider submitted adjustment request must use type of bill equal to XX7 or XX8."    If the claim change reason code is equal to D0, the A/B MAC (A) compares the beginning and ending dates on the provider's request to those on the claim to be adjusted on its history.  If these dates are the same, it rejects the request back to the provider  with the message, "Dates of service must change for claim change reason code D0."    If the claim change reason code is equal to D1, the A/B MAC (A) compares the total and line item charges on the provider's request to those on the claim to be adjusted on its history.  If these changes are the same, the A/B MAC (A) rejects the request back  to the provider with the message, "Charges must be changed for claim change reason code D1."    If the claim change reason code is equal to D2, the A/B MAC (A) compares revenue codes/HCPCS on the provider's request to those on the claim to be adjusted on its history.  If these codes are the same, it rejects the request back to the provider with the m essage, "Revenue codes/HCPCS must change for claim change reason code D2."
(Medicare Claims Processing Manual)
 If the claim change reason code is equal to D3, the A/B MAC (A) compares the ending date on the provider's request to that on the claim to be adjusted on its history.  If these dates are the same, it rejects the request back to the provider with the message, "Thr u dates must change for the claim change reason code D3."    If the claim change reason code is equal to D4, the A/B MAC (A) compares diagnosis and procedure codes on the provider's request to those on the claim to be adjusted on its history.  If these codes are the same and are in the same sequence, it rejects the request back to the provider with the message, "Diagnoses and/or procedures must change for claim change reason code D4."    If the claim change reason code is equal to D5 or D6, type of bill must be equal to XX8 on the provider's request.  If type of bill is not equal to XX8, the A/B MAC (A) rejects the request back to the provider with the message, "Type of bill must be equal to XX8 for claim change reason codes D5 or D6."    If the claim change reason code is equal to D7, an MSP value code (12 -16, 41- 43, or 47) must be present, if a value code, 12 -16, 41- 43, or 47, is not present, the A/B MAC (A) rejects the request back to the provider with the message, "An MSP value code (12- 16, 41 -43, or 47) must be present for claim change reason code D7."    If the claim change reason code is equal to D7, and one or more of value codes 12- 16, 41- 43, and/or 47 is present but each value amount is equal to 0 (zero) or spaces, the A/B MAC (A) rejects the request back to the provider with the message, "invalid value amount for claim change reason code D7."    If the claim change reason code is equal to D8, and a value code 12 -16, 41- 43, or 47 is present, the A/B MAC (A) rejects the claim back to the provider with the message, "Invalid value code for claim change reason D8."
(Medicare Claims Processing Manual)
 If the claim change reason code is equal to E0, the A/B MAC (A) compares patient status on the provider's request to that on the claim to be adjusted.  If patient status is the same, the A/B MAC (A) rejects the request back to the provider with the message, "Patient status must change for claim change reason E0."   If an adjustment the provider initiates results in a change to a higher weighted DRG, the A/B MAC (A) edits the adjustment request to insure it was submitted within 60 days of the date of the remittance for the claim to be adjusted.  If it is, the A/B MAC (A) processes the claim for payment.  If the remittance date is more than 60 days prior to the receipt date of the adjustment request and results in a change to a lower weighted DRG, the A/B MAC (A) processes the claim for payment and forwards it to CWF.   The A/B MAC (A) must suspend for investigation all adjustment requests with claim change reason codes D4, D8, and D9.  Providers that consistently use D9 will be investigated and, if a pattern of abuse is evident, may be reported to the OIG.   C. - Additional edits   The A/B MAC (A) must perform the following additional edits and investigate adjustment requests the provider submits:    A full denial once the bill is paid, except to accomplish retraction of a duplicate payment;    A change in DRG based on a change in age or sex;    A change in deductible;    An adjustment request that changes a previously submitted QIO adjustment request;    An adjustment of a bill due to a change in utilization or spell data on another bill;    A reopening to change a no- payment bill to a payment bill;    A reopening to pay a previously denied line item;    An adjustment request the provider initiates with a claim change reason code equal to D7, with the Medicare payment amount equal to or greater that the previously paid amount; or    An adjustment request with a claim change reason code equal to E0, and the claim is for a PPS provider.  The A/B MAC (A) must investigate if the change is from patient status 02, transferred to another acute care facility.
(Medicare Claims Processing Manual)
50.3 - Late Charges  (Rev. 1, 10- 01-03)  HO- 411.3, HO -IM411.3  Providers billing under Inpatient Hospital PPS, Outpatient PPS, SNF PPS, or HHA PPS may not bill late charges, nor will the contractor accept such bills, for any type of PPS service, inpatient or outpatient.  Charges omitted from the original bill must be submitted on an adjustment bill that contains all pertinent charges including those billed earlier.  When the provider submits late charges on bills to the A/B MAC (A) as bill type XX5, these bills contain only additional charges.  Adjustment requests and not late charge bills should be submitted for    Services on the same day as outpatient surgery subject to the ASC limit,    ESRD services paid under the composite rate,    All inpatient accommodation charges, and    All inpatient PPS ancillaries as adjustment requests.  The provider may submit the following charges omitted from the original paid bill to the A/B MAC (A) as late charges:    Any outpatient services other than the exceptions stated in this paragraph.  This includes late charges for HHA services under either Part A or Part B, hospice services, hospital outpatient services except those on the day of ambulatory surgery subject to the ASC payment limitation, RHC services, OPT services, SNF outpatient services, CORF services, FQHC services, CHMC services, and ESRD services not included in the composite rate; and    Any inpatient SNF ancillaries or inpatient hospital ancillaries other than from PPS hospitals.  The hospital may not  submit late charges (XX5) for inpatient accommodations.  The hospital must submit these as adjustments (bill type XX7).   The A/B MAC (A) has the capability to accept XX5 bill types electronically and process them as initial bills except as described in the following paragraph.   The A/B MAC (A) also performs the following edit routines on any XX5 type bills received:    Pass all initial bill edits, including duplicate checks.