evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
If the resident receives a type of vaccine that is preventive in nature but for which no Part B benefit category exists (e.g., diphtheria), then the vaccine would not be covered under either Parts A or B and, as a consequence, would become coverable under the Part D drug benefit.  This is because priority of payment between the various parts of the Medicare law basically proceeds in alphabetical order:  Part A is primary to Part B (see section 1833(d) of the Act), and both Parts A and B are primary to Part D (see section 1860D -2(e)(2)(B) of the Act).
(Medicare Claims Processing Manual)
Further, it is worth noting that unlike preventive services covered under Part B, those preventive vaccines covered under Part D are not subject to SNF CB, even when furnished to an SNFs Part A resident. This is because section 1862(a)(18) of the Act specifies that SNF CB applies to . . . covered skilled nursing facility services described in section 1888(e)(2)(A)(i) . . . . Section 1888(e)(2)(A)(i) of the Act, in turn, defines covered skilled nursing facility services specifically in terms of (I) Part  A SNF services, along with (II) those non- excluded services that (if not for the enactment of SNF CB) would be types of services . . . for which payment may be made under Part B  . . . (emphasis added).  Preventive and screening services as a class would not fall within the scope of clause (I) above because, as discussed previously, the diagnostic  and therapeutic services covered under the Part A SNF benefit (see 1862(a)(1)(A) of the Act) do not encompass preventive services (see 1862(a)(1)(B) of the Act) or screening  services (see 1862(a)(1)(F), (G), (H), (L), (M), and (N) of the Act). Similarly, those Part D preventive drugs (such as preventive vaccines) for which no  Part B benefit category exists would not fall within the scope of clause (II) above, because this clause encompasses services that, if not for the enactment of CB, would be separately coverable under Part  B.  Formerly, bone mass measurement (screening) was listed as a preventive service excluded from SNF consolidated billing.  This was incorrect.  Such services are diagnostic, not screening, procedures, and therefore are bundled into SNF PPS payment and subject to consolidated billing.  20.5 - Therapy Services  (Rev. 2573, Issued: 10- 26-12, Effective: 04 -01-13, Implementation: 04- 01-13)
(Medicare Claims Processing Manual)
Therapy services are edited as inclusions, rather than exclusions, to consolidated billing.  Physical therapy, speech- language pathology services, and occupational therapy are bundled into the SNFs global per diem payment for a residents covered Part A s tay. They are also subject to the SNF Part B consolidated billing requirement (for services furnished to SNF residents during noncovered  stays) and must be billed by the SNF alone for its Part B residents on a 22x type of bill.  As noted in section 10.3 of this chapter, therapy services furnished to SNF residents remain subject to consolidated billing even when performed by a type of practitioner, such as a physician, whose services would otherwise be excluded (see section 1888(e) (2)(A)(ii) of the Social Security Act and the regulations at 42 CFR 411.15(p)(1)(i)).  Further, while most services either clearly fall within the category of therapy or clearly fall outside of it,  there are a few services (such as certain debridement codes) which, based on the specific type of practitioner involved, are sometimes considered therapy services and other times not.  However, because the consolidated billing provision focuses on the nature of the therapy service itself (rather than the type of practitioner who happens to be performing it), these sometimes therapy codes are always  considered therapy services in the specific context of SNF consolidated billing.   This means that a practitioner who furnishes such a service to an SNF resident must always look to the SNF itself (rather than to Part B) for payment.
(Medicare Claims Processing Manual)
SNF residents that fall below a Medicare skilled level of care may be moved out of the SNF or certified distinct part unit (DPU) to the Medicare non -certified area of the facility.  In doing so, the beneficiary is no longer subject to the SNF consolidated billing rule and therapy services may be billed directly to Medicare by the provider rendering the service or if billed by the SNF should be submitted on a 23x type of bill.  If the entire facility qualifies as a Medicare- certified SNF, all Part B therapie s must continue to be billed by the SNF on a 22x type of bill.  The CWF SNF CB therapy edit will be bypassed for 22x bill types that contain therapy services when those line item dates of service fall within a non-covered period reported on an inpatient 21x bill type.  For additional instructions, see Chapter 7, SNF Part B Billing, section 10.1.  In transmittals for A/B MAC (A) billing providing the annual update list of HCPCS codes affected by SNF consolidated billing, such services are referred to as Major Category V of SNF consolidated billing.  See section 10.1 above for the link to where transmittals providing curr ent lists of HCPCS codes used for Major Category V can be found.  20.6 - SNF CB Annual Update Process for A/B MACs (A)  (Rev. 3230, Issued: 04- 03-15, Effective: 06-15-15, Implementation: 06-15-15)
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Barring any delay in the Medicare Physician Fee Schedule, CMS will provide the new Annual Update code file to CWF by November 1. Should this date change, CWF will be notified through the appropriate mechanism. All future updates will be submitted via a Recurring Update Notification form. These Recurring Update Notifications also describe how the changes will be implemented.  The CWF contractor shall compare the new code list for Major Categories I through V to the codes in the current edits. Codes that appear on the new list, but not in the current edit, shall be added to the edit.  CMS will make a determination as to which codes should be deleted from which edits. This mechanism will allow for any changes in professional component/technical component designations to be correctly coded for edits and for deleted codes and codes no longer valid for Medicare purposes as of the end of the calendar year, to continue to pay correctly for prior dates of service.  CMS will respond to the list provided by the CWF contractor and provide the determination on the codes to the CWF contractor.  The CWF contractor will delete codes from the edits per the CMS determination.   A/B MACs (A) , a term used to indicate both Part A and Part B institutional services, shall continue to respond to rejects and unsolicited responses received from CWF per current methodology.  A/B MACs (A)  shall reopen and reprocess any claims brought to their attention for services that prior to this update were mistakenly considered to be subject to consolidated billing and therefore, not separately payable.  A/B MACs (A)  need not search claims history to identify these claims.  Prior to January 1 of each year, a new code file will be posted to the CMS Web site at: http://www.cms.hhs.gov/SNFConsolidatedBilling/.  Should this date change, A/B MACs (A) will be notified through the appropriate mechanism.  Coding changes throughout the year may also be made as necessary through a quarterly update process.  As soon as the new code file is posted to the CMS Web site, through their Web sites and list serves, A/B MACs (A)  shall notify providers of the availability of the new file.
(Medicare Claims Processing Manual)
30 - Billing SNF PPS Services (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  SNFs and hospital swing bed providers are required to report inpatient Part A PPS billing data as follows.  Refer to the Medicare Claims Processing Manual, Chapter 25, Completing and Processing the Form CMS -1450 Data Set, for a description of claim data elements.    In addition to the required fields identified in Chapter 25, SNFs must also report occurrence span code 70 to indicate the dates of a qualifying hospital stay of at least three consecutive days which qualifies the beneficiary for SNF services.    Separate bills are required for each Federal fiscal year for admissions that span the annual update effective date (October 1).    Use Type of Bill 21X for SNF inpatient services or 18X for hospital swing bed services.    Revenue Code 0022.  This code indicates that this claim is being paid under the SNF PPS.  This revenue code can appear on a claim as often as necessary to indicate different HIPPS Rate Code(s) and assessment periods.    Effective for claims with dates of service on or after January, 1 2011, there must be an occurrence code 50 (assessment date) for each assessment period represented on the claim with revenue code 0022.  The date of service reported with occurrence code 50 must contain the ARD.  An occurrence code 50 is not required with default HIPPS code AAAxx (where xx equals varying digits) or ZZZZZ October 1, 2019 and after.  In addition, for OMRA related AIs 05, 06, 0A, 0B, 0C, 12, 13, 14, 15, 16, 17, 1A, 1B, 1C, 24, 25, 26, 2A, 2B, 2C, 34, 35, 36, 3A, 3B, 3C, 44, 45, 46, 4A, 4B, 4C, 54, 55, 56, 5A, 5B, 5C where 2 HIPPS may be produced by one assessment, providers need only report one occurrence code 50 to cover both HIPPS codes.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).
(Medicare Claims Processing Manual)
 HCPCS/Rates field must contain a 5 -digit HIPPS Code.  The first three positions of the code contain the RUG group and the last two positions of the code contain a 2 -digit assessment indicator (AI) code.  See Chapter 6 of the MDS RAI manual for valid RUG codes and AI codes.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).    SNF and SB PPS providers must bill the HIPPS codes on the claim form in the order in which the beneficiary received that level of care.    Service Units must contain the number of covered days for each HIPPS rate code.   NOTE:  Fiscal Intermediary Shared System (FISS) requirement:   The sum of all covered units reported on all revenue code 0022 lines should be equal to the covered days field less the number of days reported in an OSC 77.  ( NOTE : The covered units field is utilized in FISS and has no mapping to the 837 or paper claim).   Total Charges should be zero for revenue code 0022.   When a HIPPS rate code of RUAxx, RUBxx, RUCxx, RULxx and/or RUXxx is present, a minimum of two rehabilitation therapy ancillary codes are required (revenue code 042x and/or, 043x and/or, 044x).  When a HIPPS rate code of RHAxx, RHBxx, RHCxx, RHLxx, RHXxx, RLAxx, RLBxx, RLXxx, RMAxx, RMBxx, RMCxx, RMLxx, RMXxx, RVAxx, RV Bxx, RVCxx, RVLxx, and/or RVXxx is present, a minimum of one rehabilitation therapy ancillary revenue code is required (revenue code 042x, 043x, or 044x.  Bills that are missing required rehabilitation therapy ancillary revenue codes are to be returned to the SNF for resubmission.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).    The accommodation revenue code 018x, leave of absence is reported when the beneficiary is on a leave of absence and is not present at the midnight census taking time.
(Medicare Claims Processing Manual)
 The accommodation revenue code 018x, leave of absence is reported when the beneficiary is on a leave of absence and is not present at the midnight census taking time.    Principal Diagnosis Code -  SNFs enter the ICD -CM code for the principal diagnosis in the appropriate form locator.  The code must be reported according to Official ICD -CM Guidelines for Coding and Reporting, as required by the Health Insurance Portability and Accountability Act (HIPAA), including any applicable guidelines regarding the use of V codes for ICD -9.  The code must be the full ICD-CM diagnosis code, including all five digits (for ICD -9) or all seven digits (for ICD -10) where applicable.    Other Diagnosis Codes Required -  The SNF enters the full ICD -CM codes for up to eight additional conditions in the appropriate form locator.  Medicare does not have any additional requirements regarding the reporting or sequence of the codes beyond those c ontained in the ICD -CM guidelines.  30.1 - Health Insurance Prospective Payment System (HIPPS) Rate Code  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  The HIPPS rate code consists of the three- character resource utilization group (RUG) code that is obtained from the Grouper software program followed by a 2- digit assessment indicator (AI) that specifies the type of assessment associated with the RUG code obtained from the Grouper. Providers may access the Resident Assessment Instrument (RAI) manual located at the following link for assessment- related issues: http://www.cms.gov/Medicare/Quality -Initiatives -Patient -Assessment -Instruments/NursingHomeQualityInits/index.html.  SNFs must use the version of the Grouper software program identified by CMS for national PPS as described in the Federal Register for that year.  The Grouper translates the data in the Long Term Care Resident Instrument into a case-mix group and assigns the correct RUG code. Effective for dates of service on or after October 1, 2010, the Grouper will automatically assign the 2 -digit AI.
(Medicare Claims Processing Manual)
Providers may access the following link for HIPPS code information: http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/02_HIPPSCodes.asp#TopOfPage   The above link includes documents that contain the complete list of RUG codes and AIs billed for Part A SNF stays.  Definitions and usage of each code are included.  In addition, a master file of all valid/termed HIPPS codes is provided.  The HIPPS rate code that appears on the claim must match the assessment that has been transmitted and accepted by the State in which the facility operates.  The SNF may bill the program only after:   An assessment has been completed and submitted to the State RAI Database;    A Final Validation Report indicating that the assessment has been accepted by the state; and    The covered day has actually been used.   SNFs that submit claims that have not completed this process will not be paid.  It is important to remember that the record will be accepted into the State RAI database, even if the calculated RUG code differs from the submitted values.  The error will be flagged on the final validation report by issuing a warning message and listing the correct RUG code.  When such discrepancies occur, the RUG code reported on the Final Validation Report shall be used for billing purposes.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).   30.2  Coding PPS Bills for Ancillary Services  (Rev. 3230, Issued: 04- 03-15, Effective: 06-15-15, Implementation: 06-15-15)  When coding PPS bills for ancillary services associated with a Part A inpatient stay, the traditional revenue codes will continue to be shown, e.g., 0250 - Pharmacy, 042x - Physical Therapy, in conjunction with the appropriate entries in Service Units and Total Charges.    SNFs are required to report the number of units based on the procedure or service.    For therapy services, that is revenue codes 042x, 043x, and 044x, units represent the number of calendar days of therapy provided.  For example, if the beneficiary received physical therapy, occupational therapy or speech -language pathology on May 1, that would be considered one calendar day and would be billed as one unit.
(Medicare Claims Processing Manual)
 SNFs are required to report the actual charge for each line item, in Total Charges.   30.3  Adjustment Requests  (Rev. 3230, Issued: 04- 03-15, Effective: 06 -15-15, Implementation: 06- 15-15)  Adjustment requests based on corrected assessments must be submitted within 120 days of the service through date.  The through date will be used to calculate the period during which adjustment requests may be submitted based on corrected RAI assessment s.  The through date indicates the last day of the billing period for which the HIPPS code is billed.  Adjustment requests based on corrected assessments must be submitted within 120 days of the through date on the bill.  For HIPPS changes resulting fr om an MDS correction, providers must append a condition code D2 on their adjustment claim.  An edit is in place to limit the time for submitting this type of adjustment request to 120 days from the service through date.   The CMS expects that most HIPPS code corrections will be made during the course of the beneficiarys Medicare Part A stay.  Therefore, providers that routinely submit corrections after the beneficiarys Part A stay has ended may be subject to focused medical review.   Adjustment requests to change a HIPPS code may not be submitted for any claim that has already been medically reviewed, such claims are identified in the FISS system by an indicator on the claim record.  This applies whether or not the medical review was performed either pre-  or post -payment.  All adjustment requests submitted are subject to medical review.  Information regarding medical review is located in the Medicare Program Integrity Manual.  30.4 - SNF PPS Pricer Software  (Rev. 3230, Issued: 04- 03-15, Effective: 06 -15-15, Implementation: 06- 15-15)  The Balanced Budget Act (BBA) of 1997 (Public Law 105- 33) mandated the implementation of a per diem prospective payment system (PPS) for skilled nursing facilities (SNFs), covering all costs (routine, ancillary, and capital) of covered SNF services furnish ed to beneficiaries under Part A of the Medicare program.
(Medicare Claims Processing Manual)
Effective for cost reporting periods beginning on or after July 1, 1998, all skilled nursing services billed on TOB 21x will be paid based on calculations made by the SNF Pricer. The SNF Pricer operates as a module within CMS claims processing systems.  T he SNF Pricer makes all payment calculations applicable under SNF PPS.  Medicare claims processing systems must send an input record for each HIPPS code reported on the claim to Pricer and Pricer will return an output record to the shared systems.  The Pri cer is available electronically to the shared systems and is updated at least annually. A PC version of the SNF Pricer Program can be found at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service- Payment/PCPricer/SNF.html  The following describes the elements of SNF PPS claims that are used in the SNF PPS Pricer and the logic that is used to make payment determinations.  No part of the Pricer logic is required to be incorporated into a SNFs billing system in order to bill M edicare. The following is presented for A/B MACs (A)  and as information for the SNFs, in order to help SNFs understand their SNF PPS payments and how they are determined.  30.4.1 - Input/Output Record Layout                                                       (Rev. 11109, Issued: 11-04- 21 Effective:10 -01-22, Implementation:01-03-22)  The SNF Pricer input/output file will be 300 bytes in length.  The required data and format are shown below.
(Medicare Claims Processing Manual)
File Position  Format  Title  Description  1-4 X(4)  MSA  Input item: The metropolitan statistical area (MSA) code.  Medicare claims processing systems pull this code from field 13 of the provider specific file.  5-9 X(5)  CBSA  Input item: Core -Based Statistical Area  10 X SPEC -WI-IND Input item (if applicable) :Special Wage Index Indicator  Valid Values: Y  (yes) or N (no) 11-16 X(6)  SPEC -WI Input item (if applicable): Special Wage Index  17-21 X(5)  HIPPS- CODE  Input Item: Health Insurance Prospective Payment System Code  Medicare claims processing systems must copy the HIPPS code reported File Position  Format  Title  Description  by the provider on each 0022 revenue code line  22-29 9(8) FROM -DATE  Input item: The statement covers period from date, copied from the claim form. Date format must be CCYYMMDD.  30-37 9(8) THRU- DATE  Input item: The statement covers period through date, copied from the claim form.  Date format must be CCYYMMDD.  38 X QRP -IND Input Item -Effective January 1, 2022 field renamed QRP -IND from FED -PPS- BLEND.  Input Item: Effective October 1, 2017, MACs shall populate the FED PPS BLEND IND field in the PSF with a "1" to indicate the SNF did not meet the quality reporting requirements.-  39-45 9(05)V9(02)  SNF-FACILITY RATE  Input item: Rate based on each SNFs historical costs (from (from A/B MAC (A) audited cost reports) including exception payments. NOTE :  All facilities have been paid at the full federal rate since FY 2002.  46-52 X(7)  SNF-PRIN -DIAG -CODE  Input item: The principle diagnosis code, copied from the claim form.  Must be three to seven positions left justified with no decimal points.  53-59 X(7)  SNF-OTHER -DIAG -CODE2  Input item: Additional Diagnosis Code, copied from the claim form, if present, must be three to seven positions left justified with no decimal points.  60-220 Defined above  Additional Diagnosis data  Input item: Up to twenty -three additional diagnosis codes accepted from claim. Copied from the claim form.  Must be three
(Medicare Claims Processing Manual)
form, if present, must be three to seven positions left justified with no decimal points.  60-220 Defined above  Additional Diagnosis data  Input item: Up to twenty -three additional diagnosis codes accepted from claim. Copied from the claim form.  Must be three to seven File Position  Format  Title  Description  positions left justified with no decimal points.  221-228 9(06)V9(02)  SNF-PAYMENT RATE  Output Item: The Calculated TOTAL amount received by the SNF based on the days received.  Effective FY 2018, this amount reflects VBP adjustment.  NOTE: Effective October 1, 2019, the previously calculated RUG per diem rate is replaced by the PDPM Calculated TOTAL amount received by the SNF.
(Medicare Claims Processing Manual)
229-230 9(2) SNF-RTC  Output item: A return code set by Pricer to define the payment circumstances of the claim or an error in input data. Payment return code:  00 HIPPS rate returned  Error return codes:  20 INVALID RATE COMPONENT  30 Bad CBSA code  40 Thru date < July 1, 1998 or Invalid  50 Invalid federal blend for that Year -NO LONGER IN USE  60 Invalid federal blend- NO LONGER IN USE  61 Federal blend = 0 and SNF  Thru date < January 1, 2000- NO LONGER IN USE   70     Invalid VBP Multiplier -        80     SNF -PDPM -UNITS =       ZERO         90      INVALID HIPPS CODE         01     CURRENT -DAYS > 100  File Position  Format  Title  Description  231-242 S9V9(11)  VBP -MULTIPLIER  Input item: Medicare systems move this information from field 52 of the provider specific file.  243-250 S9(06)V9(02)  VBP -PAY- DIFF  Output item: The total SNF VBP adjustment amount, determined by subtracting the SNF VBP adjustment total payment from the SNF PPS payment that would otherwise apply to the line. Added to the claim as a value code QV amount.  NOTE: Effective October 1, 2019, the previously calculated VBP difference per day is replaced by the TOTAL VBP difference amount.  251-252  9(02)  SNF-PDPM -UNITS  Input item: The number of service units reported by the SNF on the revenue code 0022 line that is being priced.  253-255  9(03)  SNF-PDPM -PRIOR -DAYS  Input item: When pricing the first revenue code 0022 line on a claim, this is the number of prior SNF days identified by FISS from claims history. On later dated revenue code 0022 lines, this is the days from claims history plus any units from any earlier dated.  256-300  X(45)  FILLER  Blank