evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Effective January 1, 2007, CMS is distinguishing between two types of emergency departments: Type A emergency departments and Type B emergency departments.   A Type A emergency department is defined as  an emergency department that is available 24 hours a day, 7 days a week and is either licensed by the State in which it is located under applicable State law as an emergency room or emergency department or it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.  A Type B emergency department is defined as an emergency department that meets the definition of a dedicated emergency department as defined in 42 CFR 489.24 under the EMTALA regulations.  It must meet at least one of the following requirements:    (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;    (2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or    (3) During the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one -third of all o f its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.   Hospitals must bill for visits provided in Type A emergency departments using CPT emergency department E/M codes.  Hospitals must bill for visits provided in Type B emergency departments using the G -codes that describe visits provided in Type B emergency d epartments.   Hospitals that will be billing the new Type B ED visit codes may need to update their internal guidelines to report these codes.   Emergency department and clinic visits are paid in some cases separately and in other cases as part of a composite APC payment.  See section 10.2.1 of this chapter for further details.    160.1 - Critical Care Services  (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)
(Medicare Claims Processing Manual)
160.1 - Critical Care Services  (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)  Hospitals should separately report all HCPCS codes in accordance with correct coding principles, CPT code descriptions, and any additional CMS guidance, when available.  Specifically with respect to CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30 -74 minutes), hospitals must follow the CPT instructions related to reporting that CPT code.  Prior to January 1, 2011, any services that CPT indicates are included in the reporting of CPT code 9 9291 (including those services that would otherwise be reported by and paid to hospitals using any of the CPT codes specified by CPT) should not be billed separately by the hospital.  Instead, hospitals should report charges for any services provided as pa rt of the critical care services. In establishing payment rates for critical care services, and other services, CMS packages the costs of certain items and services separately reported by HCPCS codes into payment for critical care services and other servic es, according to the standard OPPS methodology for packaging costs.  Beginning January 1, 2011, in accordance with revised CPT guidance, hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care.  CMS will continue to recognize the existing CPT codes for critical care services and will establish payment rates based on historical data, into which the cost of the ancillary services is intrinsically packaged.  The I/OCE conditiona lly packages payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment.  The payment status of the ancillary services does not change when they are not provided in conjunction w ith critical care services.  Hospitals may use HCPCS modifier - 59 to indicate when an ancillary procedure or service is distinct or independent from critical care when performed on the same day but in a different encounter.   Beginning January 1, 2007, critical care services will be paid at two levels, depending on the presence or absence of trauma activation.  Providers will receive one payment rate for critical care without trauma activation and will receive additional paymen t when critical care is associated with trauma activation.
(Medicare Claims Processing Manual)
To determine whether trauma activation occurs, follow the National Uniform Billing Committee (NUBC) guidelines in the Claims Processing Manual, Pub 100- 04, Chapter 25, 75.4 related to the reporting of the trauma revenue codes in the 68x series.  The revenue code series 68x can be used only by trauma c enters/hospitals as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons.  Different subcategory revenue codes are reported by designated Level 1- 4 hospital trauma centers . Only patients for whom there has been prehospital notification based on triage information from prehospital caregivers, who meet either local, state or American College of Surgeons field triage criteria, or are delivered by inter -hospital transfers, and are given the appropriate team response can be billed a trauma activation charge.
(Medicare Claims Processing Manual)
When critical care services are provided without trauma activation, the hospital may bill CPT code 99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30 -74 minutes (and 99292, if appropriate).  If tra uma activation occurs under the circumstances described by the NUBC guidelines that would permit reporting a charge under 68x, the hospital may also bill one unit of code G0390, which describes trauma activation associated with hospital critical care servi ces.  Revenue code 68x must be reported on the same date of service.  The OCE will edit to ensure that G0390 appears with revenue code 68x on the same date of service and that only one unit of G0390 is billed.  CMS believes that trauma activation is a one -time occurrence in association with critical care services, and therefore, CMS will only pay for one unit of G0390 per day.  The CPT code 99291 is defined by CPT as the first 30- 74 minutes of critical care.  This 30 minute minimum has always applied under the OPPS.  The CPT code 99292, Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes, remains a packaged service under the OPPS, so that hospitals do not have the ongoing administrative burden of reporting precisely the time for each critical service provided.  As the CPT guidelines indicate, hospitals that provi de less than 30 minutes of critical care should bill for a visit, typically an emergency department visit, at a level consistent with their own internal guidelines.   Under the OPPS, the time that can be reported as critical care is the time spent by a physician and/or hospital staff engaged in active face -to-face critical care of a critically ill or critically injured patient.  If the physician and hospital staff or mu ltiple hospital staff members are simultaneously engaged in this active face- to-face care, the time involved can only be counted once.   Beginning in CY 2007 hospitals may continue to report a charge with RC 68x without any HCPCS code when trauma team activation occurs.  In order to receive additional payment when critical care services are associated with trauma activation, the hospital mu st report G0390 on the same date of service as RC 68x, in addition to CPT code 99291 (or 99292, if appropriate.)
(Medicare Claims Processing Manual)
 Beginning in CY 2007 hospitals should continue to report 99291 (and 99292 as appropriate) for critical care services furnished without trauma team activation.  CPT 99291 maps to APC 0617 (Critical Care).  (CPT 99292 is packaged and not paid separately, but  should be reported if provided.)   Critical care services are paid in some cases separately and in other cases as part of a composite APC payment.  See Section 10.2.1 of this chapter for further details.  Future updates will be issued in a Recurring Update Notification.   170 - Hospital and CMHC Reporting Requirements for Services Performed on the Same Day  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)   When reporting a HCPCS code for a separately payable, non- repetitive hospital OPPS service, report charges for all services and supplies associated with that service that were furnished on the same date (services subject to the 3- day payment window are an exception to this OPPS policy).    When a hospital provides electroconvulsive therapy (ECT) on the same day as partial hospitalization or intensive outpatient services, both the ECT and partial hospitalization or intensive outpatient services should be reported on the same hospital claim. I n this instance, the claim should contain condition code 41 for partial hospitalization services or condition code 92 for intensive outpatient services. As noted above, report charges for all services and supplies associated with the ECT service that were furnished on the same date(s) on the same claim.    When a hospital provides non- partial hospitalization mental health services to a partial hospitalization patient, all partial hospitalization services and non -partial hospitalization mental health services should be reported on the same hospital claim with condition code 41.    Likewise, when a hospital provides non- intensive outpatient program mental health services to an intensive outpatient program patient, all intensive outpatient services and non- intensive outpatient mental health services should be reported on the same hospital claim with condition code 92.    NOTE: For a list of revenue codes that are considered repetitive services, see Chapter 1, 50.2.2.
(Medicare Claims Processing Manual)
EXAMPLE 1  If a patient receives a laboratory service on May 1st and has an emergency room (ER) visit on the same day, one bill may be submitted since the laboratory service is paid under the clinical diagnostic laboratory fee schedule and not subject to OPPS. In thi s situation, the laboratory service was not related to the ER visit or done in conjunction with the ER visit.    EXAMPLE 2  If the patient receives physical therapy on July 7th, 29th, and 30th, and receives services in the ER on July 28th, the provider shall submit separate claims since the isolated individual service (ER visit) did not occur on the same day as the repetitive service (physical therapy).    EXAMPLE 3  If a patient has an ER visit (OPPS service) on May 15th and also receives a physical therapy visit (repetitive, non- OPPS service) on the same day (as well as other physical therapy visits provided May 1st through May 31st) the services shall be billed on separate claims. The provider would bill the ER service on one claim and the therapy services on the monthly repetitive claim. Please note, as stated above, the procedures for billing repetitive services remains in effect under OPPS. Therefore, in this exam ple, it would not be appropriate to submit one therapy claim for services provided May 1st through May 15th, a second claim for the ER visit provided on May 15th, and a third claim for therapy visits provided on May 16th through May 31st. Providers shall not split repetitive services in mid -month when another outpatient service occurs.   EXAMPLE 4    If a patient receives chemotherapy, or radiation therapy, clinical laboratory services, a CT scan, and an outpatient consultation on the same date of service, the hospital may report all services on the same claim or may submit multiple claims. Chemotherap y, while commonly administered in multiple encounters across a span of time, is not a repetitive service as defined in Chapter 1, Section 50.2.2. The clinical laboratory services may be reported either on the single consolidated claim or on a separate clai m that reports the services furnished on the same date as the laboratory services.
(Medicare Claims Processing Manual)
EXAMPLE 5  If a partial hospitalization patient receives remote non -partial hospitalization mental health services, the hospital should report all partial hospitalization services and non-partial hospitalization remote mental health services on the same claim.  For each date of service with partial hospitalization services (see section 260.1 of this chapter), at least one of which is a partial hospitalization primary service, all partial hospitalization services will be packaged under the appropriate hospital -based partial hospitalization APC, 5863 or 5864.  When APC 5863 or 5864 is assigned, all remote non-partial hospitalization mental health services on the same date of service will be packaged under APC 8010 with no additional payment.  For any dates of service with no partial hospitalization primary service, each remote non- partial hospitalization mental health service will be paid at the corresponding APC payment rate or packaged under the daily mental health composite APC 8010.    180 - Accurate Reporting of Surgical and Medical Procedures and Services  (Rev. 1109, Issued: 11 -09-06, Effective: 10 -01-05, Implementation: 04- 02-07)  180.1 - General Rules  (Rev. 1325; Issued:  08- 29-07; Effective:  01 -01-08; Implementation:  01 -07-08)  Hospitals subject to OPPS are required, beginning with claims with dates of service on or after August 1, 2000, to report in Form Locator 6 Statement Covers Period From Date the earliest date that services were rendered.  As a result, preoperative laboratory services will always have a line item date of service within the from and through dates on the claim.   Indian Health Service hospitals continue to bill for surgeries utilizing bill type 83X.  For other hospitals outpatient surgery subject to the ASC payment limit with dates of service prior to August 1, 2000, is reported on bill type 83X, and surgeries perf ormed August 1, 2000 and later are reported with bill type 13X.  NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims on TOB 83X for ASCs.  All IHS ASC providers must submit their claims to the designated A/B MAC (B).
(Medicare Claims Processing Manual)
180.2 - Selecting and Reporting Procedure Codes  (Rev. 1, 10- 03-03) A-01-50, A3- 3626.4.B.3   Using medical records as basic sources, hospitals report HCPCS surgical procedure codes for outpatient surgery in FL 44 adjacent to the revenue code for the operating room or other room used for the surgery.  The bill includes the hospitals charges for the surgery as well as all other services provided on the day the procedure was performed.  When multiple surgical procedures are performed at the same session, it is not necessary to bill separate charges for each procedure.  It is acceptable to bill a single charge under the revenue code that describes where the procedure was performed (e.g., operating room, treatment room, etc.) on the same line as one of the surgical procedure CPT/HCPCS codes and bill the other procedures using the appropriate CPT/HCPCS code and the same revenue code, but with 0 charges in the charge field.   In the past, some hospitals billed a single emergency room (ER) visit charge, which included charges for any surgical procedures that were performed in the ER at the time of the ER visit.  Under the OPPS, CMS requires hospitals to bill a separate charge fo r ER visits and surgical procedures effective with claims with dates of service on or after July 1, 2001.  If a surgical procedure is performed in the ER, the charge for the procedure must be billed with the emergency room revenue code.  If an ER visit occ urs on the same day, a charge should be billed for the ER visit and a separate charge should be billed for the surgical procedure(s) performed.  As described above, a single charge may be billed for all surgical procedures if more than one is performed in the ER during the same session.   EXAMPLE:  The following is an example of how a claim should be completed under these reporting requirements:   Date of  Service  Revenue  Code  HCPCS  Modifier  Charges  7/5/2001 0450 99283 25 $150 7/5/2001 0450 12011  $300 7/5/2001 0450 12035   7/5/2001 0250   $70 7/5/2001 0270   $85  The charge for both surgical procedures in this example is reflected in the $300 charge shown on the line with procedure code 12011.
(Medicare Claims Processing Manual)
The charge for both surgical procedures in this example is reflected in the $300 charge shown on the line with procedure code 12011.   180.3 - Unlisted Service or Procedure  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  An unlisted HCPCS code represents an item, service, or procedure for which there is no specific CPT or Level II alphanumeric HCPCS code.  The CPT code book lists a number of unlisted service or procedure codes, which can be found at the end of a section or  subsection.  Alternatively, a summary list of the unlisted CPT codes can be found in the Guidelines section for each chapter of the CPT code book.  The long descriptors for these codes start with the term Unlisted and the last 2 digits of the codes ofte n end in 99.   Under the OPPS, CMS generally assigns the unlisted service or procedure codes to the lowest level APC within the most appropriate clinically related series of APCs.  Payment for items reported with unlisted codes is often packaged.   For non- OPPS payment purposes, when an unlisted service or procedure code is reported, a report describing the service or procedure shall be submitted with the claim.  Pertinent information includes a definition or description of the nature, extent, and ne ed for the procedure or service, as well as the providers time, effort, and equipment necessary to provide the service.
(Medicare Claims Processing Manual)
When a Medicare contractor receives a claim with an unlisted HCPCS code for non -OPPS payment, the contractor shall verify that no existing HCPCS code adequately describes the procedure or service.  Unlisted codes should be reported only if no other specifi c HCPCS codes adequately describe the procedure or service.  If an unlisted code is submitted on a claim and the contractor has verified that the code submitted is correct, the contractor pays the claim using the unlisted code, based on the applicable non- OPPS payment methodology.  However, if it is determined that an unlisted code was submitted in error because the procedure or service is described by a specific HCPCS code, the contractor shall advise the hospital or CAH of the appropriate code and process  the claim.  If a procedure or service reported with an unlisted code is reported frequently, the contractor shall advise the provider that a request for a specific CPT code or alphanumeric HCPCS code should be made.   The latest list of Unlisted CPT codes for procedures and services can be found at http://www.cms.hhs.gov/HospitalOutpatientPPS/ .  Select Annual Policy Files from the box at the left, then select the applicable year, and scroll down to Related Links.  Select CYXXXX Unlisted CPT Codes.   Medicare contractors shall review this list once a year since it is updated annually on or about January 1 of the calendar year.   Future updates will be issued in a Recurring Update Notification.   180.4 - Proper Reporting of Condition Code G0 (Zero)  (Rev. 1, 10- 03-03)
(Medicare Claims Processing Manual)
Future updates will be issued in a Recurring Update Notification.   180.4 - Proper Reporting of Condition Code G0 (Zero)  (Rev. 1, 10- 03-03)  Hospitals subject to OPPS report Condition Code G0 on FLs 24- 30 (or the corresponding electronic location) when multiple medical visits occurred on the same day in the same revenue center but the visits were distinct and constituted independent visits.  An example of such a situation would be a beneficiary going to the emergency room twice on the same day, in the morning for a broken arm and later for chest pain.  Multiple medical visits on the same day in the same revenue center may be submitted on separate claims.  Hospitals should report condition code G0 on the second claim.  Appropriate reporting of Condition Code G0 allows for accurate payment under OPPS in this situation.  The OCE contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of Condition Code G0.   To further illustrate, the following table describes actions the OCE takes when multiple medical visits occur on the same day in the same revenue code center:   Evaluation and Management (E&M)  Revenue Center  Condition Code  OCE Action  2 or more  Two or more E&M codes have the same revenue center  No G0  Assign medical APC to each line item with E&M code and deny all line items with E&M code except the line item with the highest APC payment  2 or more  Two or more E&M codes have the same revenue center  G0 Assign medical APC to each line item with E&M code.   180.5 - Proper Reporting of Condition Codes 20 and 21  (Rev. 1, 10- 03-03)  Hospitals and CMHCs report condition codes 20 and 21 when they realize the services are excluded from coverage but:    The beneficiary has requested a formal determination (condition code 20) (claim may contain both covered and noncovered charges); or    The provider is requesting a denial notice from Medicare to bill Medicaid or other insurers (condition code 21).  The A/B MACs (A) advise hospitals and CMHCs when billing condition code 21 that a separate claim must be submitted.  Claims with condition code 21 must be submitted with all noncovered charges.
(Medicare Claims Processing Manual)
The A/B MACs (A) advise hospitals and CMHCs when billing condition code 21 that a separate claim must be submitted.  Claims with condition code 21 must be submitted with all noncovered charges.   180.6 - Emergency Room (ER) Services That Span Multiple Service Dates (Rev. 2361, Issued: 11- 25-11, Effective: 01 -01-12 and 04- 01-12, Implementation; 04-02-12)  Emergency room (ER) services provided by hospital outpatient departments (OPPS & Non-OPPS) should be billed in the following manner:    Emergency room services are reported under the 045x revenue code    The line item date of service for the ER encounter is the date the patient entered the ER even if the patients encounter spans multiple service dates    For all other services related to the ER encounter (i.e., lab, radiology, etc) the line item date of service reported is the date the service was actually rendered   Note:  For patients in a Skilled Nursing Facility (SNF) see Chapter 6, Section 20.1.2.2 Emergency Services for special billing instructions using the ET modifier.  Chapter 6, Section 20.1.2.2 applies to hospital ER services spanning multiple service dates that  are provided to patients in a Part A SNF stay and related CWF SNF consolidated billing edits.   For patients with end stage renal disease (ESRD) see Chapter 8, Section 50.1.6 for billing instructions requiring the use of the ET modifier.  Chapter 8, Section 50.1.6 applies to hospital ER services spanning multiple service dates including laboratory se rvices.   180.7 - Inpatient -only Services                                                            (Rev. 4513, Issued: 02- 04-2020, Effective: 01 -01- 2020, Implementation: 01- 06-2020)