evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Ambulance services which are subject to the ambulance fee schedule.   150 - Hospitals That Do Not Provide Outpatient Services  (Rev. 1, 10- 03-03) HO- 440.1, A -00-21, A -02-064  Covered Part B -only services furnished to inpatients when they are furnished by a hospital that does no Medicare billing for hospital outpatients services under Part B are excluded from OPPS.  The Part B -only services, which are payable for hospital inpati ents who have either exhausted their Part A benefits or who are not entitled to Part A benefits, are specified in Chapter 3.  These services include, but are not limited to, diagnostic tests; x-ray and radioactive isotope therapy; surgical dressings; limb braces and trusses; and artificial limbs and eyes.  Medicare payment for excluded Part B -only services furnished by these hospitals is determined using the method under which the hospital was paid prior to OPPS.   Hospitals must notify their A/B MAC (A) if they do not submit claims for outpatient Part B services, so that their claims can be excluded from the OPPS.  The hospital must also notify the A/B MAC (A) if it begins to furnish Part B outpatient services.  OPP S will apply at that time unless other exclusions are applicable.   160 - Clinic and Emergency Visits  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  CMS has acknowledged from the beginning of the OPPS that CMS believes that CPT Evaluation and Management (E/M) codes were designed to reflect the activities of physicians and do not describe well the range and mix of services provided by hospitals during visits of clinic and emergency department patients.  While awaiting the development of a national set of facility -specific codes and guidelines, providers should continue to apply their current internal guidelines to the existing CPT codes.  Each hospitals  internal guidelines should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.  Hospitals should ensure that their guidelines accurately reflect resource distinctions between the five levels of codes.   Effective January 1, 2007, CMS is distinguishing between two types of emergency departments: Type A emergency departments and Type B emergency departments.
(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 centers/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)
 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. In 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)
NOTE: For a list of revenue codes that are considered repetitive services, see Chapter 1, 50.2.2.    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. Chemotherapy, while commonly administered in multiple encounters across a span of time, is not a repetitive s ervice 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 e ach 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 pa rtial 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., o perating 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)
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)
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)
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Section 1833(t)(1)(B)(i) of the Act allows CMS to define the services for which payment under the OPPS is appropriate and the Secretary has determined that the services designated to be inpatient only services are not appropriate to be furnished in a hos pital outpatient department. Inpatient only services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. An example of an inpatient only service is CPT code 33513, Coronary artery bypass, vein only; four coronary venous grafts. The designation of services to be inpatient -only is open to public comment each year as part of the annual rulemaking process. Procedures removed from the inpatient only list may be appropriately furnished in either the inpatient or outpatient settings and such procedures continue to be payable when furnished in the inpatient setting. There is no payment under the OPPS for services that CMS designates to be inpatient -only services. These services have an OPPS status indicator of C in the OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. For th e most current Addendum B and for Addendum E published with the OPPS notices and regulations, see http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/index.html.  Excluding the handful of exceptions discussed below, CMS does not pay for an inpatient -only service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type (TOB 13X). CMS also does not pay for all other services on the same day as the inpatient only procedure.  There are two exceptions to the policy of not paying for outpatient services furnished on the same day with an inpatient -only service that would be paid under the OPPS if the inpatient service had not been furnished:  Exception 1: If the inpatient -only service is defined in CPT to be a
(Medicare Claims Processing Manual)
the same day with an inpatient -only service that would be paid under the OPPS if the inpatient service had not been furnished:  Exception 1: If the inpatient -only service is defined in CPT to be a separate procedure and the other services billed with the inpatient -only service contain a procedure that can be paid under the OPPS and that has an OPPS SI=T on the same date as the inpatient -only procedure or OPPS SI = J1 on the same claim as the inpatient -only procedure, then the inpatient -only service is denied but CMS makes payment for the separate procedure and any remaining payable OPPS services. The list of separate procedures is available with the Integrated Outpatient Code Editor (I/OCE) documentation. See http://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/. Exception 2: If an inpatient -only service is furnished but the patient expires before inpatient admission or transfer to another hospital and the hospital reports the inpatient only service with modifier CA, then CMS makes a single payment for all se rvices reported on the claim, including the inpatient only procedure, through one unit of APC 5881, (Ancillary outpatient services when the patient dies.) Hospitals should report modifier CA on only one procedure.  As of January 1, 2020, procedures that have been removed from the inpatient -only (IPO) list are exempt from certain medical review activities related to compliance with the 2 -midnight rule, which states that generally services are considered appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the patient to require a stay that crosses at least 2 midnights and admits the patient to the hospital based upon that expectation (78 FR 50913 through 50954).    Specifically, procedures that have been removed from the IPO list are not eligible for referral to Recovery Audit Contractors (RACs) for noncompliance with the 2- midnight rule within the 2 -calendar years following their removal from the IPO list. These procedures will not be considered by the Beneficiary and Family- Centered Care Quality Improvement Organizations (BFCC -QIOs) in determining whether a provider exhibits persistent noncompliance with the 2- midnight rule
(Medicare Claims Processing Manual)
from the IPO list. These procedures will not be considered by the Beneficiary and Family- Centered Care Quality Improvement Organizations (BFCC -QIOs) in determining whether a provider exhibits persistent noncompliance with the 2- midnight rule for purposes of referral to the RAC nor wi ll these procedures be reviewed by RACs for patient status within the 2 -calendar years following their removal from the IPO list.  During the 2- year exemption period, BFCC -QIOs will have the opportunity to review claims for procedures that have been recently removed from the IPO list in order to provide education for practitioners and providers regarding compliance with the 2-midnight  rule, but claims identified as noncompliant with the 2 -midnight rule will not be denied with respect to the site -of-service under Medicare Part A.  190  Payer Only Codes Utilized by Medicare  (Rev. 4391, Issued: 09- 06-19, Effective: 07 -01-19, Implementation: 07- 01-19)
(Medicare Claims Processing Manual)
ME -  Hereditary Hemolytic and Sickle Cell Anemia. (Bill Type 72x)   MF -  Monoclonal Gammopathy. (Bill Type 72x)   MG  Grandfathered Tribal Federally Qualified Health Centers.   MH-MO  Not currently used by Medicare.   MP  PHP claim contains initial admit week   MQ  PHP claim contains final discharge week    MR-MW  Not currently used by Medicare.   MX  Wrong Surgery on Patient (Inpatient)   MY  Surgery Wrong Body Part (Inpatient)   MY  Outlier Cap Bypass (CMHC)   MZ  Surgery Wrong Patient (Inpatient)   MZ  IOCE error code bypass   UU  Not currently used by Medicare.   Occurrence Codes   23 - Date of Cancellation of Hospice Election period.  48 - Date hospice face- to-face encounter was untimely   49  Original Notice of Election (NOE) receipt date  Occurrence Span Codes   79 - Verified non- covered stay dates for which the provider is liable.   Value Codes   17- Operating Outlier Amount  The A/B MAC (A) reports the amount of operating outlier payment amount made (either cost or day (day outliers have been obsolete since 1997)) in CWF with this code.  It does not include any capital outlier payment in this entry.  18  Operating Disproportionate Share Amount  The A/B MAC (A) REPORTS THE OPERATING DISPROPORTIONATE SHARES AMOUNT APPLICIALBE.  It uses the amount provided by the disproportionate share field in PRICER.  It does not include any PPS capital IME adjustment  entry.   19  The Medicare shared system will display this payer only code on the claim for low volume providers to identify the amount of the low volume adjustment being included in the providers reimbursement.  This payer only code 19 is also used for IME on hos pital claims.  This instruction shall only apply to ESRD bill type 72x and must not impact any existing instructions for other bill types.   19 - Operating Indirect Medical Education Amount  The A/B MAC (A) reports operating indirect medical education amount applicable.  It uses the amount provided by the indirect medical education field in PRICER.  It does not include any PPS capital IME adju stment in this entry.