evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
3439 R370CP  11/19/2004 New Case -Mix Adjusted End Stage Renal Disease (ESRD) Composite Payment Rates and New Composite Rates and New Composite Rate Exceptions Window for Pediatric ESRD Facilities  04/04/2005 3572 R351CP  10/29/2004 Editing of Hospitals and Skilled Nursing Facilities Part B Inpatient Services (Full Replacement of Change Request 3366)  01/03/2005 3531 R336CP  10/29/2004 Indian Health Service (IHS) or Tribal Hospitals including Critical Access Hospitals (CAH) Payment Methodology for Inpatient Social Admissions and Outpatient Services Occurring During Concurrent S tays 04/04/2005 3452 R301CP  09/17/2004 Editing Of Hospital And Skilled Nursing Facility Part B Inpatient Services  01/03/2005 3366 R270CP  08/03/2004 Update to the Frequency of Billing 01/03/2005 3382 R262CP  07/30/2004 Bonus Payment to Physicians That Render Services in a CAH in a Designated  Physician Scarcity Area  01/03/2005 3262  Rev #  Issue Date  Subject  Impl Date  CR#  R251CP  07/23/2004 Editing Of Hospital And Skilled Nursing Facility Part B Inpatient Services  01/03/2005 3366 R243CP  07/23/2004 Patient Status Code and Reason for Patient Visit for the Hospital Outpatient Prospective Payment System (OPPS)  01/03/2005 2800 R239CP  07/23/2004 Update to the Frequency of Billing 01/03/2005 3382 R231CP  07/23/2004 Indian Health Service (I HS) or Tribal Critical Access Hospital (CAH) Payment Methodology for Inpatient and Outpatient Services  01/03/2005 3235 R180CP  05/14/2004 Hospital Partial Hospitalization Services Bil ling Requirements  N/A 3297 R167CP  04/30/2004 Discontinued Use of Revenue Code 0910 10/04/2004 3194 R156CP  04/30/2004 Payment Procedure for Maryland Hospitals Under the Jurisdiction of the Health Services Cost Review Commission  10/04/2004 3200 R152CP  04/30/2004 Inclusion of Core -Based Statistical Area (CBSA) Data Elements to the Provider Specific Files  10/04/2004 3272 R132CP  03/30/2004 April 2004 Update of the Hospital Outpatient Prospective Payment System  04/05/2004 3154 R103CP
(Medicare Claims Processing Manual)
Area (CBSA) Data Elements to the Provider Specific Files  10/04/2004 3272 R132CP  03/30/2004 April 2004 Update of the Hospital Outpatient Prospective Payment System  04/05/2004 3154 R103CP  02/20/2004 Optional Method for Outpatient Services: Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional Services  07/01/2004 3114 R089CP  02/06/2004 The Elimination of the 90- Day Grace Period for HCPCS Codes  07/06/2004 3093 R063CP  01/16/2004 Special  Rules for Critical Access Hospital (CAH) Outpatient Billing  04/05/2004 3051  Rev #  Issue Date  Subject  Impl Date  CR#  R053CP  12/22/2003 Outpatient Code Editors 01/05/2004 3021 R046CP  12/19/2003 Outpatient Code Editors 01/05/2004 3021 R045CP  12/19/2003 Outpatient Provider Specific File  01/20/2004 2994 R041CP  12/08/2003 Special Rules for Critical Access Hospital Outpatient Billing  01/05/2004 2990 R036CP  11/28/2003 Add revenue code 068x 01/01/2004 2995 R026CP  11/04/2003 Lung Volume Reduction Surgery 01/05/2004 2688 R001CP  10/01/2003 Initial Publication of Manual NA NA Back to top of Chapter
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 5 - Part B Outpatient Rehabilitation  and CORF /OPT Services   Table of Contents  (Rev. 11129, 11- 22-21)  Transmittals for Chapter 5
(Medicare Claims Processing Manual)
10 - Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services -  General  10.1 -  New Payment Requirement for A/B MACs (A)  10.2 -  The Financial Limitation  Legislation  10.3 -  Application of Financial Limitations  10.3.1 -  Exceptions to Therapy Caps  General  10.3.2 -  Exceptions Process  10.3.3 -  Use of the KX Modifier  10.3.4 -  Manual Review Threshold  to Ensure Appropriate Therapy  10.3.5 -  Identifying the Certifying Physician  10.3.6 -  MSN Messages Regarding the Therapy Cap  10.4 -  Claims Processing Requirements for Financial Limitations  10.5 -  Notification for Beneficiaries Exceeding Financial Limitations  10.6 -  Functional Reporting 10.7 -  Multiple Procedure Payment Reductions for Outpatient Rehabilitation Services  20 - HCPCS Coding Requirement  20.1 -  Discipline Specific Outpatient Rehabilitation Modifiers -  All Claims  20.2 -  Reporting of Service Units With HCPCS  20.3 -  Determining What Time Counts Towards 15- Minute Timed Codes -  All Claims  20.4 -  Coding Guidance for Certain CPT Codes  All Claims  20.5 -  CORF/OPT Edit for Billing Inappropriate Supplies  30 - Special Claims Processing Rules for Outpatient Rehabilitation Claims - Form CMS -1500 30.1 -  Determining Payment Amounts  30.2 -  Applicable A/B MAC (B)  CWF Type of Servi ce Codes  40 - Special Claims Processing Rules for Institutional Outpatient Rehabilitation Claims  40.1 -  Determining Payment Amounts  - Institutional Claims  40.2 -  Applicable Types of Bill 40.3 -  Applicable Revenue Codes  40.4 -  Edit Requirements for Revenue Codes  40.5 -  Line Item Date of Service Reporting  40.6  Non -covered Charge Reporting 40.7 -  Billing for Biofeedback Training for the Treatment of Urinary Incontinence  40.8  Rebilling Therapy Services for Hospital Inpatients  50 - CWF and PS&R Requirements -  A/B  MAC (A)  100 -  Special Rules for Comprehensive Outpatient Rehabilitation Facilities (CORFs)  100.1 -  General  100.1.1 -  Allowable Revenue Codes on CORF 75X Bill Types  100.2 -  Obtaining Fee Schedule Amounts  100.3 -  Proper Reporting of Nursing Services by CORFs -  A/B MAC (A)  100.4 -  Outpatient Mental Health Treatment Limitation  100.5 -  Off- Site CORF Services  100.6 -  Notifying Patient of Service Denial
(Medicare Claims Processing Manual)
-  Proper Reporting of Nursing Services by CORFs -  A/B MAC (A)  100.4 -  Outpatient Mental Health Treatment Limitation  100.5 -  Off- Site CORF Services  100.6 -  Notifying Patient of Service Denial  100.7 -  Payment of Drugs, Biologicals, and Supplies in a CORF  100.8 -  Billing for DME, Prosthetic and Orthotic Devices, and Surgical Dressings 100.10 -  Group Therapy Services (Code 97150)  100.10.1 -  Therapy Students  100.11 -  Billing for Social Work and Psychological Services in a CORF  100.12 -  Billing for Respiratory Therapy Services in a CORF  Exhibit 1 -  Physician Fee Schedule Abstract File  Addendum A -  Chapter 5, Section 20.4  Coding Guidance for Certain CPT Codes  All Claims
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10 - Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services - General  (Rev. 3454, Issued: 02- 04-16, Effective: 07- 01-16, Implementation: 07- 05-16)  Language in this section is defined or described in Pub. 100- 02, chapter 15, sections 220 and 230.  Section 1834(k)(5)  to the Social Security Act (the Act), requires that all claims for outpatient rehabilitation services and comprehensive outpatient rehabilitation facility (CORF) services, be reported using a uniform coding system.  The CMS chose HCPCS (Healthcare Common Procedure Coding System) as the coding system to be used for the reporting of these services.  This coding requirement is effective for all claims for outpatient rehabilitation services and CORF services submitted on or after April 1, 1998.  The Act also requires payment under a prospective payment system for outpatient rehabilitation services including CORF services.  Eff ective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for outpatient therapy services furnished by:    Comprehensive outpatient rehabilitation facilities (CORFs);    Outpati ent physical therapy providers (OPTs), also known as rehabilitation agencies;    Hospitals (to outpatients and inpatients who are not in a covered Part A stay);    Skilled nursing facilities (SNFs) (to residents not in a covered Part A stay and to nonresidents  who receive outpatient rehabilitation services from the SNF); and   Home health agencies (HHAs) (to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC)).
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 Home health agencies (HHAs) (to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC)).   NOTE:   No provider or supplier other tha n the SNF will be paid for therapy services during the time the beneficiary is in a covered SNF Part A stay.  For information regarding SNF consolidated billing see chapter 6, section 10 of this manual.  Similarly, under the HH prospective payment system, HHAs are responsible to provide, either directly or under arrangements, all outpatient rehabilitation therapy services to beneficiaries receiving services under a home health POC.  No other provider or supplier will be paid for these services during the ti me the beneficiary is in a covered Part A stay. For information regarding HH consolidated billing see chapter10, section 20 of this manual.   Section 143 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes  the Centers fo r Medicare & Medicaid Services (CMS) to enroll speech -language pathologists (SLP) as suppliers of Medicare services and for SLPs to   begin billing Medicare for outpatient speech -language pathology services furnished in private practice beginning July 1, 2009.  Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services.  Previously, the Medicare program could only pay SLP services if an institution, physician or nonphysician practitioner billed them.   In Chapter 23, as part of the CY 2009 Medicare Physician Fee Schedule Database, the descriptor for PC/TC indicator 7, as applied to certain HCPCS/CPT codes, is described as specific to the services of privately practicing therapists.  Payment may not be made if  the service is provided to either a hospital outpatient or a hospital inpatient by a physical therapist, occupational therapist, or speech- language pathologist in private practice.   The MPFS is used as a method of payment for outpatient rehabilitation ser vices furnished under arrangement with any of these providers.   In addition, the MPFS is used as the payment system for CORF services identified by the HCPCS codes in 20.  Assignment is mandatory.
(Medicare Claims Processing Manual)
In addition, the MPFS is used as the payment system for CORF services identified by the HCPCS codes in 20.  Assignment is mandatory.   Services that are paid subject to the MPFS are adjusted b ased on the applicable payment locality.  Rehabilitation agencies and CORFs with service locations in different payment localities shall follow the instructions for multiple service locations in chapter 1, section 170.1.1.  The Medicare allowed charge  for the services is the lower of the actual charge or the MPFS amount.  The Medicare payment for the services is 80 percent of the allowed charge after the Part B deductible is met.  Coinsurance is made at 20 percent of the lower of the actual charge or the MP FS amount.  The general coinsurance rule (20 percent of the actual charges) does not apply when making payment under the MPFS.  This is a final payment.  The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs) or hospitals in Maryland.  CAHs are to be paid on a reasonable cost basis. Maryland hospitals are paid under the Maryland All -Payer Model.   Contrac tors process outpatient rehabilitation claims from hospitals, including CAHs, SNFs, HHAs, CORFs, outpatient rehabilitation agencies, and outpatient physical therapy providers for which they have received a tie in notice from the Regional Office (RO).  Thes e provider types submit their claims to the contractors using the ASC X12 837 institutional claim format or the CMS -1450 paper form when permissible.  Contractors also process claims from physicians, certain nonphysician practitioners (NPPs),  therapists in private practices (TPPs), (which are limited to physical and occupational therapists, and speech- language pathologists in private practices), and physician- directed clinics that bill for services furnished incident to a physicians service (see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, for a definition of incident to).  These provider types submit their claims to the contractor using the ASC X 12 837 professional claim format or the CMS -1500 paper form when permissible.
(Medicare Claims Processing Manual)
There are different fee rates for nonfacility and facility services.  Chapter 23 describes the differences in these two rates.  (See fields 28 and 29 of the record therein described).  Facility rates apply to professional services performed in a facility other than the professionals office.  Nonfacility rates apply when the service is performed in the professionals office.  The nonfacility rate (that is paid when the provider performs the services in its own facility) accommodates overhead and indirect expenses the provider incurs by operating its own facility.  Thus it is somewhat higher than the facility rate.   Contractors pay the nonfacility rate on institutional claims for services performed in the providers facility.  Contractors may pay professional claims using the  facility or nonfacility rate depending upon where the service is performed (place of service on the claim), and the provider specialty.   Contractors pay the codes in 20 under the MPFS on professional claims regardless of whether they may be considered rehabilitation services.  However, contractors must use this list for institutional claims to determine whether to pay under outpatient rehabilitation rules or whether payment rules for other types of service may apply, e.g., OPPS for hospitals, reasonable c osts for CAHs.   Note that because a service is considered an outpatient rehabilitation service does not automatically imply payment for that service.  Additional criteria, including coverage, plan of care and physician certification must also be met.  Thes e criteria are described in Pub. 100- 02, Medicare Benefit Policy Manual, chapters 1 and 15.   Payment for rehabilitation services provided to Part A inpatients of hospitals or SNFs is included in the respective PPS rate.  Also, for SNFs (but not hospitals), if the beneficiary has Part B, but not Part A coverage (e.g., Part A benefits are exhausted), the SNF must bill for any rehabilitation service.
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Payment for rehabilitation therapy services provided by home health agencies under a home health plan of care is included in the home health PPS rate.  HHAs may submit bill type 34X and be paid under the MPFS if there are no home health services billed under a home health plan of care at the same time, and there is a valid rehabilitation POC (e.g., the patient is not homebound).  An institutional employer (other than a SNF) of the TPPs,  or physician performing outpatient services, (e.g., hospital, CORF, etc.), or a clinic billing on behalf of the physician or therapist may bill the contractor on a professional clai m.  The MPFS is the basis of payment for outpatient rehabilitation services furnished by TPPs, physicians, and certain nonphysician practitioners or for diagnostic tests provided incident to the services of such physicians or nonphysician practitioners.  ( See Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, for a definition of incident to, therapist, therapy and related instructions.")  Such services are billed to the contractor on the professional claim format.  Assignment is mandatory.     The following table identifies the provider and supplier types, and identifies which claim format they may use to submit claims for outpatient therapy services to the contractor.   Provider/Supplier Service Type  Format  Bill Type  Comment  Inpatient SNF Part A  Institutional  21X Included in PPS  Inpatient hospital Part B  Institutional  12X Hospital may obtain services under arrangements and bill, or rendering provider may bill.  Inpatient SNF Part B (audiology tests are not included)  Institutional  22X SNF must provide and bill, or obtain under arrangements and bill. Outpatient hospital  Institutional  13X Hospital may provide and bill or obtain under arrangements and bill. Outpatient SNF  Institutional  23X SNF must provide and bill or obtain under arrangements and bill. HHA billing for services not rendered under a Part A or Part B home health plan of care, but rendered under a therapy plan of care.  Institutional  34X Service not under home health plan of care.  Outpatient physical therapy providers (OPTs), also known as rehabilitation agencies
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Institutional  74X Paid MPFS for outpatient rehabilitation services.  Comprehensive Outpatient Rehabilitation Facility (CORF)  Institutional  75X Paid MPFS for outpatient rehabilitation services and all other services except  drugs.  Drugs are paid 95% of the AWP.  Physician, NPPs, TPPs, (therapy services in hospital or SNF)  Professional  See Chapter 26 for place of service coding.  Payment may not be made for therapy services to Part A inpatients of hospitals or SNFs, or for Part B SNF residents.   NOTE:  Payment may be made to physicians and NPPs for their professional services defined as sometimes therapy (not part of a therapy plan) in certain situations; for example, when furnished to a beneficiary   Provider/Supplier Service Type  Format  Bill Type  Comment  registered as an outpat ient of a hospital.  Physician/NPP/TPPs office, or patients home  Professional  See Chapter 26 for place of service coding.  Paid via MPFS.  Critical Access Hospital - inpatient Part B  Institutional  12X Rehabilitation services are paid at cost.  Critical A ccess Hospital  outpatient Part B  Institutional  85X Rehabilitation services are paid at cost.   For a list of the outpatient rehabilitation HCPCS codes see 20.   If a contractor receives an institutional claim for one of these HCPCS codes with dates of service on or after July 1, 2003, that does not appear on the supplemental file it currently uses to pay the therapy claims, it contacts its professional claims area to obtain the non -facility price in order to pay the claim.   NOTE: The list of codes in 20 contains commonly utilized codes for outpatient rehabilitation services.  Contractors may consider other codes on institutional claims for payment under the MPFS as outpatient rehabilitation services to the extent that such codes are determined to be med ically reasonable and necessary and could be performed within the scope of practice of the therapist providing the service.   10.1 - New Payment Requirement for A/B MACs (A)  (Rev. 1, 10- 01-03)
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10.1 - New Payment Requirement for A/B MACs (A)  (Rev. 1, 10- 01-03)  Effective with claims with dates of service on or after July 1, 2003, OPTs/outpatient rehabilitation facilities (ORFs), (74X and 75X bill type) are required to report all their services utilizing HCPCS.  A/B MACs (A) are required to make payment for these services under the MPFS unless the item or service is currently being paid under the orthotic fee schedule or the item is a drug, biological, supply or vaccine (see below for an explanation of these services).   The CMS currently provides A/B MACs (A) with a CORF supplemental file that contains all physician fee schedule services and their related prices.  A/B MACs (A)  use this file to price and pay OPT claims.  The format of the record layout is provided in Attachment E of PM A -02-090, dated September 27, 2002.  This is located in Chapter 23, section 50.3 .  A/B MACs (A)  will be notified in a one -time instruction of updates to this file and when it will be ava ilable for retrieval.     If an A/B MAC (A)  receives a claim for one of the above HCPCS codes with dates of service on or after July 1, 2003, that does not appear on the CORF supplemental file it currently uses to pay the CORF claims, it contacts its local A/ B MAC (B) to obtain the price in order to pay the claim.  When requesting the pricing data, it advises the A/B MAC (B)  to provide it with the nonfacility fee.   10.2 -  The Financial Limitation Legislation  (Rev. 4214, Issued: 01- 25-19, Effective: 01- 01-19, I mplementation: 02 -26-19)  A.  Legislation on Limitations   The dollar amount of the limitations (caps) on outpatient therapy services is established by statute.  The updated amount of the caps is released annually via Recurring Update Notifications and posted on the CMS Website  www.cms.gov/TherapyServices, on contractor Websites, and on each beneficiarys Medicare Summary Notice.  Medicare contractors shall publish the financial limitation amount in educational articles.  It is also available at 1 -800-Medicare.
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Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105- 33) of 1997, which added 1834(k)(5) to the Act, required payment under a prospective payment system (PPS) for outpatie nt rehabilitation services (except those furnished by or under arrangements with a hospital).  Outpatient rehabilitation services include the following services:   Physical therapy   Speech -language pathology; and   Occupational therapy.   Section 4541(c) of the BBA required application of financial limitations to all outpatient rehabilitation services (except those furnished by or under arrangements with a hospital).  In 1999, an annual per beneficiary limit of $1,500 was applied, including  all outpatient physical therapy services and speech -language pathology services.  A separate limit applied to all occupational therapy services.  The limits were based on incurred expenses and included applicable deductible and coinsurance.  The BBA provi ded that the limits be indexed by the Medicare Economic Index (MEI) each year beginning in 2002.  Since the limitations apply to outpatient services, they do not apply to skilled nursing facility (SNF) residents in a covered Part A stay, including patients  occupying swing beds.  Rehabilitation services are included within the global Part A per diem payment that the SNF receives under the prospective payment system (PPS) for the covered stay.  Also, limitations do not apply to any therapy services covered under prospective payment systems for home health or inpatient hospitals, including critical access hospitals.   The limitation is based on therapy services the Medicare beneficiary receives, not the type of practitioner who provides the service.  Physical therapists, speech -language pathologists, and occupational therapists, as well as physicians and certain nonphysician practitioners, could render a therapy service.     B.  Moratoria and Exceptions for Therapy Claims   Since the creation of therapy caps, Congres s has enacted several moratoria.  The Deficit Reduction Act of 2005 directed CMS to develop exceptions to therapy caps for calendar year 2006 and the exceptions have been extended periodically.  The cap exception for therapy services billed by outpatient h ospitals was part of the original legislation and applies as long as caps are in effect.  Exceptions to caps based on the medical necessity of the service are in effect only when Congress legislates the exceptions.   C. Repeal of Original Legislation and Re placement with Thresholds to Ensure Appropriate Therapy .