evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Cargos por servicios/suministros que no estn cubiertos por Medicare.  Es posible que usted no tenga que pagar por ciertos cargos se servicios denegados.  De ser el caso, una NOTA en la parte del frente le indicar.   Also, A/B MACs (A) print the following message in the General Information Section:    If the coinsurance amount you paid is more than the amount shown on your notice, you are entitled to a refund.  Please contact y our provider.   Spanish Version:   Si la cantidad de coaseguro que usted pag es mayor que la cantidad que muestra su notificacin, tiene derecho a un reembolso.  Por favor comunquese con su proveedor.   110 - Procedures for Submitting Late Charges Under OPPS  (Rev. 1, 10- 03-03) A-01-93  Hospitals and CMHCs may not submit a late charge bill (code 5 in the third position of the bill type) for bill types 12X, 13X, 14X, and 76X effective for claims with dates of service on or after August 1, 2000.  They must submit an adjustment bill for any services required to be billed with HCPCS codes, units and line item dates of service.  A 7 in the third position of the bill type indicates an adjustment.  See Chapter 25 f or additional instructions for reporting adjustments.  Separate bills containing only late charges will not be permitted for these bill types.   The submission of an adjustment bill, instead of a late charge bill, will ensure proper duplicate detection, bundling, correct application of coverage policies and proper editing by OCE and payment under OPPS.  120 - General Rules for Reporting Outpatient Hospital Services  (Rev. 3019, Issued: 08- 07-14, Effective: 01- 01-12, ICD -10: Upon Implementation of ICD-  10, Imp lementation: 09 -08-14, ICD -10: Upon Implementation of ICD - 10)
(Medicare Claims Processing Manual)
Hospitals use the electronic ASC X12 837 institutional claim transaction format or the hardcopy Form CMS -1450 to bill for covered outpatient services (type of bill 13X or 83X, and 85X).  The ASC X12 837 institutional claim transaction is required unless the hospital meets certain exception criteria.  These criteria are described in Chapter 24, 90- 90.5.4 of this manual.  See:   Medicare Benefit Policy Manual, Chapter 6, for definition of an outpatient;  Medicare Claims Processing Manual, Chapter 3, Inpatient Part A Hospital Billing, for outpatient services treated as inpatient services;   Medicare Claims Processing Manual Chapter 24, 90- 90.5.4 for when paper billing is permissible; and   Medicar e Claims Processing Manual, Chapter 25, for general instructions for completing the hospital claim data set.    The HCPCS code is used to describe services where payment is under the Hospital OPPS or where payment is under a fee schedule or other outpatient payment methodology.  Line item dates of service are reported for every line where a HCPCS code is required under OPPS.  For providers paid via OPPS, A/B MACs (A) return to provider (RTP) bills where a line item date of service is not entered for each HCPC S code reported, or if the line item dates of service reported are outside of the statement -covers period.  This includes those claims where the from and through dates are equal.   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).   120.1 - Bill Types Subject to OPPS  (Rev. 795, Issu ed:  12 -30-05; Effective:  10- 01-04; Implementation: 04 -03-06)  The following bill types are subject to OPPS:
(Medicare Claims Processing Manual)
The following bill types are subject to OPPS:    All outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 14X and 13X without condition code 41) with the exception of bil ls from hospitals in Maryland, Indian Health Service, CAHs, hospitals located in Saipan, American Samoa, the Virgin Islands and Guam; and hospitals that provide Part B only services to their inpatients.  Effective 4/1/06 the 14X type of bill is for non-patient laboratory specimens and is no longer applicable for partial hospitalization billing.    CMHC bills (bill type 76X);   CORF claims for hepatitis B vaccines (bill type 75X);   HHA claims for antigens, hepatitis B vaccines, splints and casts  (bill type 34X); and   For splints, casts and antigens when provided to hospice patients for treatment of a non- terminal illness by other than a hospital outpatient department.  This requires reporting of condition code 07.  As a result, A/B MACs (A) shall instruct CO RFs, HHAs, and other providers to report HCPCS for these services, in order to assure payment under this system.  Payment will continue to be made for vaccines provide to hospice patients by the Medicare A/B MAC (B).  The appropriate HCPCS codes are as fol lows:   Categories of Services Requiring HCPCS Codes  Category  HCPCS Codes  Antigens  95144 -95149, 95165, 95170, 95180, and 95199  Vaccines  90657 -90659, 90732, 90744, 90746, 90747, 90748, G0008, G0009, and G0010   Category  HCPCS Codes  Splints  29105 -29131, 29505 -29515  Casts  29000 -29085, 29305, 29325 -29445, 29450, 29700 -29750, 29799
(Medicare Claims Processing Manual)
NOTE:   A/B MACs (HHH) shall advise their HHAs to report the above HCPCS codes with the exception of vaccines under Revenue Code 0550 (Skilled Nursing).  The only time revenue code 0550 may be reported is when the HHA is billing for antigens, splints, or casts.  See Chapter 18 for the reporting of vaccines by HCPCS codes.  120.2 - Routing of Claims (Rev. 1, 10- 03-03) A-02-00-026  Effective April 1, 2002, the following types of bills (TOBs) should b e rerouted back to the OPPS OCE:   TOB  Description  22X Skilled Nursing Facility (SNF) Inpatient Part B  23X SNF/Outpatient  24X SNF Part B  32X Home Health Agency (HHA) visits under a Part B Plan of Treatment (POT)  33X HHA visits under a Part A (POT)  34X HHA visits under a POT  71X Rural Health Clinic  72X Hospital Based or Independent Renal Dialysis Center  73X Federally Qualified Health Center  74X Other Rehabilitation Facility  75X Comprehensive Outpatient Rehabilitation Facility (CORF)  81X Hospice (n on-hospital based)  82X Hospice (hospital based)   Claims containing the above TOBs, other than 32X and 33X, with services that span beyond April 1, 2001, must be split prior to their submittal.  For example, if a claim contains services prior to and after  April 1, 2002, the provider must submit two separate claims.  One for the services prior to April 1, 2002, which will be routed to the non- OPPS OCE and another claim for the services April and later which will be routed to the OPPS OCE.  In the event the A/B MAC (A) receives a claim containing pre-  and post -April 1, 2002, dates of service, it returns it to the provider requesting that the claim be split as indicated above.   Claims containing the above TOBs with dates of service January 1, 2002, through Mar ch 31, 2002, should continue to be routed through the non- OPPS OCE.
(Medicare Claims Processing Manual)
Claims containing the above TOBs with dates of service January 1, 2002, through Mar ch 31, 2002, should continue to be routed through the non- OPPS OCE.   NOTE:   TOBs (12X, 13X, 14X, and 85X) from Critical Access Hospitals, Maryland Hospitals, Indian Health Service Hospitals, U.S.  Virgin Island Hospitals, and those  hospitals located in the  Pacific (American Samoa, Guam, and Saipan) do not have to be rerouted since they are sent through the non- OPPS OCE.   140 - All-Inclusive Rate Hospitals  (Rev. 1, 10- 03-03) A-01-93, A -03-066  All-inclusive rate hospitals are required to code with HCPCS the outpatient services they provide and bill charges at the HCPCS level.  In addition, they are required to follow bill reporting instructions contained in 30.  Unlike other hospitals, all -inclusive rate hospitals do not have outpatient departmental cost- to-charge ratios from prior year cost reports that may be used for calculating outlier payments, device pass -through payments, or interim transitional corridor payments.  As a result, A/B MACs (A) use the statewide average urban or rural outpatient cost -to-charge ratio, as appropriate, for all -inclusive rate hospitals.  In the future, once cost and charge data for an all -inclusive rate hospital is available, the A/B MAC (A) will be able to apply a cost -to-charge ratio that is specific to the hospital.  141 - Maryland Waiver Hospitals (Rev. 771; Issued: 12- 02-05; Effective Date: 01 -03-06; Implementation Date: 01 -03-06)  In accordance with 1814 (b)(3) of the Act, services provided by hospitals in Maryland subject to the Health Services Cost Review Commission are paid according to the terms of the waiver, that is 94% of submitted charges subject to any unmet Part B deductible and coinsurance. Payment should not be made under a fee schedule or other payment method for outpatient i tems and services provided except the following situations:    Non-patient laboratory specimens are paid under the clinical diagnostic laboratory fee schedule (bill type 14X); and   Ambulance services which are subject to the ambulance fee schedule.
(Medicare Claims Processing Manual)
 Non-patient laboratory specimens are paid under the clinical diagnostic laboratory fee schedule (bill type 14X); and   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.  OPPS will apply at that time unless other excl usions 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.
(Medicare Claims Processing Manual)
Effective Januar y 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 emerg ency 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 of its outpatient visits for the  treatment of emergency medi cal 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 departments.   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)
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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 99291 (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 part 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 car e services and other services, 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 conditionally 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 paym ent status of the ancillary services does not change when they are not provided in conjunction with critical care services.  Hospitals may use HCPCS modifier - 59 to indicate when an ancillary procedure or service is distinct or independent from critical ca re 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 payment 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 Proces sing 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 authorit y 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 inf ormation 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.   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 trauma 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 services.  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.
(Medicare Claims Processing Manual)
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 t he 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 provide 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 multiple 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 must report G0390 on the same date of service as RC 68x, in addition to CPT code 99291 ( or 99292, if appropriate.)    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. 763, Issued: 11- 25-05, Effective/Implementation Dates:  N/A)
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170 - Hospital and CMHC Reporting Requirements for Services Performed on the Same Day  (Rev. 763, Issued: 11- 25-05, Effective/Implementation Dates:  N/A)   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 services, both the ECT and partial hospitalization services should be reported on the same hospital claim.  In this instance, the claim should contain condition code 41.  As noted above, report charges for all services and supplies associated with the ECT service, which were furnished on the same date(s) on the same claim.   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 O PPS.  In this 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 pr ovider 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
(Medicare Claims Processing Manual)
If a patient has an ER visit (OPPS service) on May 15th and also receives a physica l 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 therap y 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 example, it would not be appropriate to submit one therapy claim for services provid ed 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 occur s.  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 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 claim that reports the services furnished on the same date as the laboratory services.   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.