evekhm/cms_iom_500 huggingface dataset:
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In a few cases, there are codes that are acceptable as a principal diagnosis if a secondary diagnosis is coded.  If no secondary diagnosis is present the message "requires secondary dx" will be returned by the MCE.  The A/B MAC (A) may review claims with c odes from the Unacceptable Principal Diagnosis section and a secondary diagnosis.  A/B MACs (A) may choose to review as a principal diagnosis if data analysis deems it a priority.  If codes from the unacceptable principal diagnosis edit code list are identified without a secondary diagnosis, the A/B MAC (A) returns the claim to the hospital and requests that the applicable secondary diagnosis be entered.  Also, any claims containing other "unacceptable principal diagnosis" codes are returned.   The hospital reviews the EHR, paper medical record, and/or face sheet and enters the appropriate principal diagnosis that describes the illness or injury before resubmitting the claim.  10. Nonspecific O.R. Procedures   Effective October 1, 2007 (FY 2008), the non- specific O.R. procedure edit was discontinued and is only applicable when processing claims using MCE version 2.0- 23.0 only.  11. Noncovered O.R. Procedures   There are some O.R. procedures for which Medicare does not provide payment. The A/B MAC (A) will return the claim requesting that the non -covered procedure and its associated charges be removed from the claim, Type of Bill (TOB) 11X.  If the hospital wishes to receive a Medicare denial, etc., the hospital may submit a non- covered claim, TOB 110, with the non- covered procedure/charges.  (For more information on billing non- pay claims, see Chapter 1 of this Manual, Section 60.1.4).  12. Open Biopsy Check   Effective October 1, 2010, the open biopsy check edit was discontinued and is only applicable when processing claims using MCE version 2.0 -  26.0.   13. Bilateral Procedure   Effective October 1, 2015, the bilateral procedure edit was discontinued and is only used when processing claims using MCE version 2.0- 33.0.  14. Invalid Age
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13. Bilateral Procedure   Effective October 1, 2015, the bilateral procedure edit was discontinued and is only used when processing claims using MCE version 2.0- 33.0.  14. Invalid Age   If the hospital reports an age over l24, the A/B MAC (A) requests the hospital confirm if it made a claim preparation error.  If the beneficiary's age is confirmed to be over l24, the hospital enters 123.  15. Invalid Sex  A patient's sex is sometimes necessary for appropriate MS -DRG assignment. The sex code reported must be either 1 (male) or 2 (female).   16. Invalid Discharge Status   A patient's discharge status is sometimes necessary for appropriate MS -DRG assignment.  Discharge status must be coded according to the Form CMS -1450 and UB -04 conventions.  See Chapter 25.   17. Limited Coverage   For certain procedures whose medical complexity and serious nature incur extraordinary associated costs, Medicare limits coverage to a portion of the cost.   18. Wrong Procedure Performed   Certain external causes of morbidity codes indicate that the wrong procedure was performed.   19. Procedure inconsistent with length of stay (LOS)   The following procedure code should only be coded on claims when the respiratory ventilation is provided for greater than four consecutive days during the length of stay.  Effective with discharges on and after October 1, 2015, ICD -10-PCS code, 5A1955Z -  Respiratory Ventilation, Greater than 96 Consecutive Hours   Prior to this date, discharges on and after October 1, 2012, ICD -9-CM procedure code, 96.72, Continuous invasive mechanical ventilation for 96 consecutive hours or more   20. Unspecified Code   Unspecified codes exist for circumstances when documentation in the medical record does not provide the level of detail needed to support reporting a more specific code. However, in the inpatient setting, there should generally be very limited and rare circumstances for whi ch the laterality (right, left, bilateral) of a condition is unable to be documented and reported.
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Effective April 1, 2022, the Unspecified Code edit will be triggered for certain unspecified diagnoses codes currently designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC), that include other codes available in  that code subcategory that further specify the anatomic site, when entered on the claim. This edit message indicates that a more specific code is available to report. It is the providers responsibility to determine if a more specific code from that subcategory is available in the medical record documentation by a clinical provider.   If, upon review, additional information to identify the laterality from the available EHR or paper medical record, or documentation by any other clinical provider is unable to be obtained or there is documentation in the record that the physician is clinic ally unable to determine the laterality because of the nature of the disease/condition, then the provider must enter that information into the remarks section.    The provider should submit the billing note/remarks that best identifies the primary reason why specificity could not be determined:    Billing Note/Remarks  Definition  UNABLE TO DET LAT 1  Provider is unable to obtain additional information to specify laterality.  UNABLE TO DET LAT 2  Physician is clinically unable to determine laterality.   20.2.1.1 - Paying Claims Outside of the MCE  (Rev. 1649; Issued:  12- 18-08; Effective/Implementation Date:  11 -25-08)  All institutional inpatient claims are routed through the MCE before they are processed to payment.  There may be special circumstances, however, when it is necessary to pay claims bypassing MCE edits. The CMS will notify the contractor of these instances.  They include:    New coverage policies are enacted by Congress with effective dates that preclude making the necessary changes timely; and    Errors are discovered that cannot be corrected timely.  A/B MACs (A) are responsible for reporting problems timely.  20.2.1.1.1 - Requesting to Pay Claims Without MCE Approval  (Rev. 1649; Issued:  12- 18-08; Effective/Implementation Date:  11 -25-08)  The contractor may also request approval from the RO in specific situations to pay claims without first sending them through the MCE. Examples of such situations are:    A systems error cannot be corrected timely, and the provider's cash flow will be substantially impacted; and/or
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 Administrative Law Judge (ALJ) decisions, court decisions, and CMS instructions in particular cases may necessitate that payment be made outside the normal process.   20.2.1.1.2 - Procedures for Paying Claims Without Passing through the MCE  (Rev. 2117, Issued: 12- 10-10, Effective: 01 -12-11, Implementation: 01- 12-11)  Before an inpatient claim may be paid without first going through the MCE, the contractor shall obtain approval from CMS Central Office or the RO.   Note:  In certain situations, contractors bypass the MCE through an established, CMS -instructed claim processing procedure (e.g., to verify a facility is certified to perform a specified service after a MCE limited coverage edit is applied).  Such scenario s do not require approval from the RO as the approval for such a bypass was inherently implied when the established procedure was first implemented.   In all instances involving payment outside the normal inpatient editing process, the contractor applies the following procedures:    Contractors shall submit the claim overriding the MCE using the appropriate field in FISS.    Pay interest accrued through the date payment is made on clean claims. Do not pay any additional interest.    Maintain a record of payment and implement controls to be sure that incorrect payment is not made, i.e., when the claim is paid without being subject to normal editing.   Monitor MCE software to determine when the impediment to processing is removed.    Consider the claim processed for workload and expenditure reports when it is paid.   Submit to the RO Consortium Contractor Manager (CCM) by the 20th of each month a report of all inpatient claims paid without processing through the MCE with the exception of override situations explained in the Note above (e.g., for limited coverage edits) .  The list of claims paid outside of the MCE is to include the following information:   o HIC o DCN o TOB  o DOS (From/Through)  o Provider Number  o MCE/OCE OVR (Claim/Line)  o Reimbursement Amount  o Receipt Date  o Process Date  o Paid Date
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o HIC o DCN o TOB  o DOS (From/Through)  o Provider Number  o MCE/OCE OVR (Claim/Line)  o Reimbursement Amount  o Receipt Date  o Process Date  o Paid Date   Also, include summary data for each edit code showing claim volume and payment.  Any override approvals received and/or relevant JSM references should be annotated on the reports.  20.2.2 - DRG GROUPER Program  (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)   The A/B MAC (A) pays for inpatient hospital services on the basis of a rate per discharge that varies according to the MS -DRG to which a beneficiary's stay is assigned.  Each MS -DRG represents the average resources required to care for a case in that parti cular MS -DRG relative to the national average of resources consumed per case.  The MS -DRG weights used to calculate payment are in the Pricer DRGX file.   The A/B MAC (A) uses the GROUPER program to assign the MS -DRG number.  GROUPER determines the MS-DRG from data elements reported by the hospital.  This applies to all inpatient discharge/transfer bills received from both PPS and non- PPS facilities, including those from waiver States, long- term care hospitals, and excluded units.   The Pricer (PPSMAIN) driver program calls the correct fiscal year GROUPER based upon the discharge date.  If the A/B MAC (A) or shared system writes its own driver program, it must access the GROUPER for the correct FY based on discharge date.  GROUPER doe s not determine the MS -DRG price.  GROUPER input/output are specified below.  The A/B MAC (A) determines the best place in its total system to place the GROUPER program.   Grouper requires the following items:   1. Principal and up to 24 other diagnoses   2. Principal and up to 24 additional procedures   3. Age at last birthday at admission   4. Sex (1=male and 2=female)   5. Discharge destination (patient status code from the claim)
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2. Principal and up to 24 additional procedures   3. Age at last birthday at admission   4. Sex (1=male and 2=female)   5. Discharge destination (patient status code from the claim)   The claim sex coding is M for male and F for female while GROUPER is l for male and 2 for female.  Discharge destination codes are similar to claim definitions for patient status except codes 20 -29 are summarized as 20.  The A/B MAC (A) calculates age at admission.  GROUPER needs age rather than date of birth.  Grouper responds with the following information:   1. Major diagnostic category   2. MS-DRG number   3. Grouper return code (a one position code indicating the action taken by the program)   4. Procedure code used in determining the MS -DRG  5. Diagnosis code used in determining the MS -DRG  6. Secondary diagnosis code used in determining the MS -DRG, if applicable   20.2.3 - PPS Pricer Program  (Rev. 1, 10- 01-03)  A3-3615.3, A3- 3656.3   The CMS provides a Pricer program to determine the price upon which to base payment under prospective payment.  A separate Pricer installation guide is provided.  The A/B MAC (A) uses the Pricer appropriate for the date of discharge.   After GROUPER determines the DRG, the A/B MAC (A) 's system calls the Pricer program.  Pricer determines the price to pay and prepares a report.   Four data files are included.  CMS maintains three:    DRGX file -  contains DRG weights, average length of stay and outlier cutoff points.   MSAX file -  contains urban and rural wage indexes used in calculating payment.  CMS may request that the A/B MAC (A) make interim changes to this file when index changes are issued for individual hospitals after issuance of Pricer for the period.   RATE file -  contains census division values and updating amounts used in calculating payment.   The A/B MAC (A) maintains the provider -specific file, (PROV file).  This contains information about the facts specific to the provider that affect computations, e.g., effective dates for PPS, type of provider (for application of special computation rules), census division, MSA, adjusted cost per discharge, disproportionate share adjustment percentage, and capital data.
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Pricer also calculates the disproportionate share adjustment and adds it to the DRG payment.  Correct calculation depends upon the accuracy of related information the A/B MAC (A) includes in the PRICER PROV file.   The Pricer program applies the DRG relative weights, hospital urban or rural and census division location, provider -specific data, and beneficiary hospital data from the bill to determine the amount payable for each PPS discharge bill.   Pricer uses the Intern -to-Bed ratio in calculating the indirect teaching adjustment for operating costs for the A/B MAC (A) to accumulate and use in related payments.  Pricer uses the intern -to-average daily census ratio to calculate the indirect teaching adjustment for capital costs.  The A/B MAC (A) ensures that these ratios are available for Pricer to compute payment for teaching hospitals.  It includes the ratios in its PROV file to ensure that cost outliers are not overpaid to its teaching hospitals.   Pricer does not calculate utilization days required for the PS&R, CWF, or cost report.  It does not determine the amount to pay after deduction for deductible, coinsurance, or the primary payment where Medicare is secondary.  The A/B MAC (A) must calculate the price and make adjustments to the price furnished before making payment.  The A/B MACs (A) use the Pricer implementation guide for information concerning Pricer processing reports, input parameters and data requirements.   20.2.3.1 - Provider -Specific File  (Rev. 3836, Issued: 08 -18-17, Effective: 11-21-17, Implementation: 11-21-17)  The PROV file contains needed information about each provider to enable the pricing software to calculate the payment amount.  The FI maintains the accuracy of the data in accordance with the following criteria.   Whenever the status of any element changes, the FI prepares an additional record showing the effective date.  For example, when a hospital's FY beginning date changes as a result of a change in ownership or other "good cause," the FI makes an additional record showing the effective date of the change.   The format and data required by the PRICER program and by the provider-specific file is found in Addendum A.
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The format and data required by the PRICER program and by the provider-specific file is found in Addendum A.  The FIs submit a file of provider-specific payment data to CMS CO every three months for PPS and non- PPS hospitals, inpatient rehabilitation hospitals or units (referred to as IRFs), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs), SNFs, and hospices, including those in Maryland.  Regional home health FIs (RHHIs) submit a file of provider specific data for all home health agencies.  FIs serving as the audit FI for hospital based HHAs do not submit a file of provider specific data f or HHAs.   The FIs create a new record any time a change occurs for a provider.  Data must be reported for the following periods:  October 2 - January 1, January 2 - April 1, April 2 - July 1, and July 2 - October 1.  This file must be received in CO within seven business days after the end of the period being reported.  NOTE:   FIs submit the latest available provider -specific data for the entire reporting period to CO by the seven -business day deadline.  If CO fails to issue applicable instructions concerning changes or additions to the file fields by 10 calendar days before the end of the reporting period, the FI may delay reporting of data related to the CO instructions until the next file due date.  For example, if CO instructions changing a file field are issued on or after September 21 with an effective date of October 1, the FI may exclude the October 1 CO-required changes from the file submitted by October 9.  The FI includes the October 1 CO-required changes, and all subsequent changes through January 1 in the file submitted in January.  A.  PPS Hospitals  The FIs submit all records (past and current) for all PPS providers every three months.  Duplicate the provider file used in the "PRICER" module of the claims processing system.   B.  Non- PPS Hospitals and Exempt Units   The FIs create a provider specific history file using the listed data elements for each non -PPS hospital and exempt hospital unit.  Submit the current and the preceding fiscal years every three months.  Code Y in position 49 (waiver code) to maintain the r ecord in the PRICER PROV file.
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C.  Hospice  The FIs create a provider specific history file using the following data elements for each hospice.  Submit the current and the preceding fiscal years every three months.  Data elements 3, 4, 5, 6, 9, 10, 13, and 17 are required.  All other data elements are optional for this provider type.  Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required.  Data element 35 is required for all hospices.  Data elements 33 and 38 are optional and may be populated if needed.   Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.   D.  Skilled Nursing Facility (SNF)   The FIs create a provider specific history file using the following data elements for each SNF beginning with their first cost reporting period that starts on or after July 1, 1998. The FIs submit the current and the preceding fiscal years every three months.  For PPS -exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file.  Data elements 3, 4, 5, 6, 9, 10, 13, 19, and 21 are required.  All  other data elements are optional for this provider type.   Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required.  Data element 35 is required for all SNFs.  Data elements 33 and 38 are required if there is a special wage index.  Effective October 1, 2005, through September 30, 2006, data elements 33 and 38 are required since there is a special wage index.   E.  Home Health Agency (HHA)   The FIs create a provider specific history file using the following data elements for each HHA.  Regional home health FIs (RHHIs) submit the current and the preceding fiscal years every three months.  Data elements 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 19 and 30 are required.  All other data elements are optional for this provider type.  All fields must be zero filled if not completed.  Update the effective date in data element 4 annually.  Ensure that the current census division in data element 11 is not zero.  Ensure that the waiver indicator in data element 8 is N.  Ensure that the MSA code reported in data element 13 is a valid MSA code.   F.  Inpatient Rehabilitation Facilities (IRFs)
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F.  Inpatient Rehabilitation Facilities (IRFs)   The FIs create a provider specific history file using the following data elements for each IRF beginning with their first cost reporting period that starts on or after January 1, 2002.  FIs submit the current and the preceding fiscal years every three mont hs.  For PPS -exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file.  Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 18, 19, 21, 25, 27, 28, and 42 are required.  All other data elements are optional for this provider type.  Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required.  Data element 35 is required for all IRFs.  Data elements 17, 33, 38, and 49 are required if applicable to the IRF.   Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.   G.  Long Term Care Hospital (LTCH)   The FIs create a provider specific history file using the following data elements for each LTCH beginning with their first cost reporting period that starts on or after October 1, 2002.  FIs submit the current and the preceding fiscal years every three mon ths.  For PPS -exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file.  Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 18, 19, 21, 22, and 25 are the minimum required fields for entering a provider und er LTCH PPS.   Effective July 1, 2005, data element 35 is required.  Data elements 33 and 38 are optional and may be populated if needed.  Data elements 12, 13, and 14 are no longer applicable.  Effective July 1, 2006, data elements 23, 24, 27, 28, and 49 are required.  Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.   H.  Inpatient Psychiatric Facilities (IPF)
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H.  Inpatient Psychiatric Facilities (IPF)   The FIs create a provider specific history file using the following data elements for each IPF beginning with their first cost reporting period that starts on or after January 1, 2005.  The FIs submit the current and the preceding fiscal years every three months.  For PPS-exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file.  Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 17, 18, 19, 21, 22, 23, 25, 33, 35, 38, and 48 are required.  All other data elements are optional for this provider type.  Although data element 25 refers to the operating cost to charge ratio, ensure that both operating and capital cost- to-charge ratio are entered in dat a element 25 for IPFs.  Ensure that data element 21 (Facility Specific Rate) will be determined using the same methodology to determine the interim payment per discharge under the TEFRA system.  Effective July 1, 2006, data element 13 is no longer required.  Data elements 33 and 38 are optional and may be populated if needed.  Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.  NOTE:  All data elements, whether required or optional, must have a default value of 0 (zero) if numerical, or a blank value if alphanumerical.   The provider specific file (PSF) should be transferred to CO using the Network Data Mover (NDM) system, COPY TO and RUN JOB statements, which will notify CO of PSF file transfer.  FIs must set up an NDM transfer from the FI's system for which it is respons ible.  It is critical that the provider specific data is copied to the CMS Data Center using the following input data set names ("99999" should be changed to the FI's 5-digit number):  Data set Name ---COPY TO: --MU00.@FPA2175.intermediary99999  DCB=(HCFA1.MODEL,BLKSIZE=2400,LRECL=2400,RECFM=FB)  Data set Name ---RUN JOB:  --MU00.@FPA2175.CLIST(intermediary99999)