evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
50.3 - Transitional Pass Through Payments for Designated Devices  (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  Certain designated new devices are assigned to APCs and identified by the OCE as eligible for payment based on the reasonable cost of the new device reduced by the amount included in the APC for the procedure that reflects the packaged payment for devices used with the procedure. OCE will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible.  All related payment calculations will be returned on the same APC line and identified as a designated new device.   Refer to https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html  for the most current OPPS APC Offset File.   50.4  Changes to Pricer Logic Effective April 1, 2002  (Rev. 11941, Issued:04 -05-23, Effective: 04 -01-02, Implementation: 05- 05-23)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning April 1, 2002.  A. New OPPS wage indexes will be effective April 1, 2002.  These are the same wage indexes that were implemented on October 1, 2001, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule, and CMS is using the corrected wage indexes where applicable.   B. Inpatient hospitals considered reclassified on October 1, 2001, will be considered reclassified for OPPS on April 1, 2002.  C. Section 401 designations and floor MSA designations will be considered effective for OPPS on April 1, 2002.   D. New payment rates and coinsurance amounts were effective for OPPS on April 1, 2002, except those 55 APCs with coinsurance amounts limited to 55 percent of the payment rate, which were effective January 1, 2002.  The coinsurance limit equal to the inpatient  deductible of $812 remains effective January 1, 2002.  E. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.
(Medicare Claims Processing Manual)
61.2 - Edits for Claims on Which Specified Procedures are to be Reported With Device Codes and For Which Specific Devices are to be Reported With Procedure Codes  (Rev. 3685, Issued: 12- 22-16, Effective: 01 -01-17, Implementation: 01- 03-17)  The OCE will return to the provider any claim that reports a HCPCS code for a device -intensive procedure that does not also report at least one device HCPCS code required for that procedure.  If the claim is returned to the provider for failure to pass the  edit, the hospital will need to modify the claim by either correcting the procedure code or ensuring that one of the required device codes is on the claim before resubmission.  While all devices that have device HCPCS codes and that were used in a given p rocedure should be reported on the claim, only one of the possible device codes is required to be on the claim for payment to be made, unless otherwise specified.  The device edit does not apply to the specified procedure code if the provider reports one of the following modifiers with the procedure code:   52 - Reduced Services;  73 - Discontinued outpatient procedure prior to anesthesia administration; and 74 - Discontinued outpatient procedure after anesthesia administration.  Where a procedure that normally requires a device is interrupted, either before or after the administration of anesthesia if anesthesia is required or at any point if anesthesia is not required, and the device is not used, hospitals should report modifier 52, 73 or 74 as applicable.  The device edit is not applied in these cases.   The OCE will also return to the provider claims for which specified devices are billed without the procedure code that is necessary for the device to have therapeutic benefit to the patient.  If the claim is returned to the provider for failure to pass the edi t, the hospital will need to modify the claim by either correcting the device code or ensuring that one of the required procedure codes is on the claim before resubmission.      61.2.1  Bypass Edit Modifier CG for Claims on Which Specified Procedures are to be Reported With Device Codes                            (Rev.4513, Issued: 02- 04-2020, Effective: 01 -01- 2020, Implementation: 01- 06-2020)
(Medicare Claims Processing Manual)
For certain device -intensive procedures, providers may bypass the device edit requiring at least one device HCPCS code for the procedure. For situations where no device was performed with certain device -intensive procedures, providers may bypass the edit b y reporting modifier CG.   61.3 - Billing for Devices Furnished Without Cost to an OPPS Hospital or Beneficiary or for Which the Hospital Receives a Full or Partial Credit and Payment for OPPS Services Required to Furnish the Device  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  61.3.1 - Reporting and Charging Requirements When a Device is Furnished Without Cost to the Hospital Prior to January 1, 2014  (Rev. 2903, Issued: 03- 11-14, Effective: 04 -01-14, Implementation: 04- 07-14)  Effective January 1, 2007, the definition of modifier - FB is  Item Provided Without Cost to Provider, Supplier or Practitioner, or Credit Received for Replacement Device (Examples, but not Limited to:  Covered Under Warranty, Replaced Due to Defect, Free Samples).   When a hospital furnishes a device received without cost or with full credit from a manufacturer, the hospital must append modifier - FB to the procedure code (not the device code) that reports the service provided to furnish the device.  The hospital must report a token charge for the device (less than $1.01) in the covered charge field.  This includes circumstances in which the cost of a replacement device is less than the cost of the device being replaced, such that the hospital incurs no net cost for the device being inserted.  For example, if a device that originally cost $20,000 fails and is replaced by a device that costs $16,000 and for which the manufacturer gives a credit of $16,000, there is no cost to the hospital for the device being inserted and the hospital would append modifier - FB to the procedure code and report a token char ge for the device.   61.3.2 - Reporting and Charging Requirements When the Hospital Receives Full Credit for the Replaced Device against the Cost of a More Expensive Replacement Device Prior to January 1, 2014  (Rev. 2903, Issued: 03- 11-14, Effective: 04 -01-14, Implementation: 04- 07-14)
(Medicare Claims Processing Manual)
When a hospital replaces a device with a more expensive device and receives a credit in the amount that the device being replaced would otherwise cost, the hospital must append modifier - FB to the procedure code (not on the device code) that reports the se rvice provided to replace the device.  The hospital must charge the difference between its usual charge for the device being implanted and its usual charge for the device for which it received credit.  This charge should be billed in the covered charge field.   Hospitals should not report modifier - FB when the hospital receives a partial credit for a replacement device when the amount of the credit is less than the amount that the device would otherwise cost the hospital.  For example, a device fails in the 6th month of a 1 year warranty and under the terms of the warranty, the hospital receives a credit of 50 percent of the cost of a replacement device.  The hospital should not append modifier - FB to the procedure code in which the device is implanted.  See the  Medicare Claims Processing Manual, Pub 100- 04, Chapter 4, 61.3.3 for billing instructions pertaining to partial credit situations.   61.3.3 - Reporting Requirements When the Hospital Receives Partial Credit for the Replacement Device Prior to January 1, 2014  (Rev. 2903, Issued: 03- 11-14, Effective: 04 -01-14, Implementation: 04- 07-14)  When a hospital receives a partial credit of 50 percent or more of the cost of a new replacement device due to warranty, recall, or field action, the hospital must append modifier - FC to the procedure code (not on the device code) that reports the service provided to replace the device.   61.3.4 - Medicare Payment Adjustment Prior to January 1, 2014  (Rev. 2903, Issued: 03- 11-14, Effective: 04 -01-14, Implementation: 04- 07-14)
(Medicare Claims Processing Manual)
CMS recognizes that showing a charge for a device that has been furnished without cost is not optimal, but showing a token charge in this circumstance will allow claims for reasonable and necessary services to be adjudicated.   61.3.6 - Medicare Payment Adjustment Beginning January 1, 2014 (Rev. 2903, Issued: 03- 11-14, Effective: 04 -01-14, Implementation: 04- 07-14)  Effective January 1, 2014, Medicare payment is reduced by the amount of the device credit for specified procedure codes reported with value code FD.  The payment deduction is limited to the full device offset when the FD value code appears on a claim.  Payment is only reduced for procedure codes that map to the Ambulatory Payment Classification groups (APCs) on the list of APCs subject to the adjustment that are reported with value code FD and that are present on claims with specified device HCPCS codes .  The OPPS Pricer deducts the lesser of the device credit or the full unadjusted device offset amount from the Medicare payment for a procedure code in an APC subject to the adjustment when billed with value code FD on the claim.  This deduction is made fr om the Medicare payment after the multiple procedure discounting and terminated procedure discounting factors are applied, units of service are accounted for, and after the APC payment has been wage adjusted.  When two or more procedures assigned to APCs subject to the adjustment are reported with value code FD the OPPS Pricer will apportion the device credit to the applicable line on the claim for each procedure assigned to an APC subject to the adjustment.  When value code FD is reported on a claim where multiple APCs would be subject to the adjustment, the OPPS Pricer apportions the device credit to each of those lines.  The percentage of the device credit apportioned to each applicable line is based on th e percentage that the unadjusted payment of each applicable line represents, relative to the total unadjusted payment for all applicable lines.   NOTE:  The tables of APCs and devices to which the offset reductions apply, and the full and partial offset amounts, are available on the CMS Web site at: www.cms.hhs.gov/HospitalOutpatientPPS/ .
(Medicare Claims Processing Manual)
NOTE:  The tables of APCs and devices to which the offset reductions apply, and the full and partial offset amounts, are available on the CMS Web site at: www.cms.hhs.gov/HospitalOutpatientPPS/ .   61.4 - Billing and Payment for Brachytherapy Sources (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  61.4.1 - Billing for Brachytherapy Sources - General  (Rev. 2718, Issued: 06- 07-13, Effective: 07 -01-13, Implementation: 07- 01-13)  Brachytherapy sources (e.g., brachytherapy devices or seeds, solutions) are paid separately from the services to administer and deliver brachytherapy in the OPPS, per section 1833(t)(2)(H) of the Act, reflecting the number, isotope, and radioactive intensi ty of devices furnished, as well as stranded versus non- stranded configurations of sources.  Therefore, providers must bill for brachytherapy sources in addition to the brachytherapy services with which the sources are applied, in order to receive payment for the sources.  The separately payable sources are found in Addendum B of the most recent O PPS annual update published on the CMS web site.  New sources meeting the OPPS definition of a brachytherapy source may be added for payment beginning any quarter, and the new source codes and descriptors are announced in recurring update notifications.  Each unit of a billable source is identified by the unit measurement in the respective sources long descriptor.  Seed- like sources are generally billed and paid per source based on the number of units of the source HCPCS code reported, including the bil ling of the number of sources within a stranded configuration of sources.  Providers therefore must bill the number of units of a source used with the brachytherapy service rendered.   61.4.2 - Definition of Brachytherapy Source for Separate Payment   61.4.2 - Definition of Brachytherapy Source for Separate Payment   (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)
(Medicare Claims Processing Manual)
Brachytherapy sources eligible for separate billing and payment must be radioactive sources, meaning that the source contains a radioactive isotope.  Separate brachytherapy source payments reflect the number, isotope, and radioactive intensity of sources furnished to patients, as well as stranded and non- stranded configurations.  61.4.3 - Billing of Brachytherapy Sources Ordered for a Specific Patient  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  A hospital may report and charge Medicare and the Medicare beneficiary for all brachytherapy sources that are ordered by the physician for a specific patient, acquired by the hospital, and used in the care of the patient.  Specifically, brachytherapy sourc es prescribed by the physician in accordance with high quality clinical care, acquired by the hospital, and actually implanted in the patient may be reported and charged.  In the case where most, but not all, prescribed sources are implanted in the patient , CMS will consider the relatively few brachytherapy sources that were ordered but not implanted due to specific clinical considerations to be used in the care of the patient and billable to Medicare under the following circumstances.  The hospital may cha rge for all sources if they were specifically acquired by the hospital for the particular patient according to a physicians prescription for the sources that was consistent with standard clinical practice and high quality brachytherapy treatment, in order  to ensure that the clinically appropriate number of sources was available for the implantation procedure, and they were not implanted in any other patient.  Those sources that were not implanted must have been disposed of in accordance with all appropriat e requirements for their handling.  In general, the number of sources used in the care of the patient but not implanted would not be expected to constitute more than a small fraction of the sources actually implanted in the patient.  Under these circumstances, the beneficiary is liable for the copayment for all the sources billed to Medicare.   61.4.4 - Billing for Brachytherapy Source Supervision, Handling and Loading Costs  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  Providers should report charges related to supervision, handling, and loading of radiation sources, including brachytherapy sources, in one of two ways:
(Medicare Claims Processing Manual)
Providers should report charges related to supervision, handling, and loading of radiation sources, including brachytherapy sources, in one of two ways:   1. Report the charge separately using CPT code 77790 (Supervision, handling, loading of radiation source), in addition to reporting the associated HCPCS procedure code(s) for application of the radiation source;   2. Include the supervision, handling, and/or loading charges as part of the charge reported with the HCPCS procedure code(s) for application of the radiation source.  Do not bill a separate charge for brachytherapy source storage costs. These costs are treated as part of the department's overhead costs.   61.4.5 - Payment for New Brachytherapy Sources (Rev. 2718, Issued: 06- 07-13, Effective: 07 -01-13, Implementation: 07- 01-13)  Not otherwise specified (NOS) brachytherapy source codes are available for payment of new brachytherapy sources for which source codes have not yet been established: C2698 (Brachytherapy source, stranded, not otherwise specified, per source), and C2699 (Brachytherapy source, non- stranded, not otherwise specified, per source).  The payment rates for these NOS codes are based on a rate equal to the lowest stranded or non -stranded payment rate for such sources, respectively, on a per source basis (as opposed, for example, to per mCi).  Once CMS establishes a new HCPCS code for a new source, the new code will be assigned to its own APC, with the payment rate set based on consideration of external data and other relevant information, until claims data are availab le for the standard OPPS rate making methodology.  61.5 - Billing for Intracoronary Stent Placement  (Rev. 2611, Issued: 12- 14-12, Effective: 01 -01-13, Implementation, 01- 07-13)
(Medicare Claims Processing Manual)
61.5 - Billing for Intracoronary Stent Placement  (Rev. 2611, Issued: 12- 14-12, Effective: 01 -01-13, Implementation, 01- 07-13)  Since CY 2003, under the OPPS, we assign coronary stent placement procedures to separate APCs based on the use of nondrug- eluting or drug- eluting stents (APC 0104 (Transcatheter Placement of Intracoronary Stents) or APC 0656 (Transcatheter Placement of Int racoronary Drug- Eluting Stents), respectively).  In order to effectuate this policy, we created HCPCS G -codes G0290 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method;  single vessel) and G0291 (Transcatheter placement of a drug eluting intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; each additional vessel) for drug -eluting intracoronary stent placement procedures that pa rallel existing CPT codes 92980 (Transcatheter placement of an intracoronary stent(s), percutaneous, with or without other therapeutic intervention, any method; single vessel) and 92981 (Transcatheter placement of an intracoronary stent(s), percutaneous, w ith or without other therapeutic intervention, any method; each additional vessel), which are used to describe nondrug- eluting intracoronary stent placement procedures. For CY 2012 and years prior, CPT codes 92980 and 92981 have been assigned to APC 0104, while HCPCS codes G0290 and G0291 have been assigned to APC 0656.  Effective January 1, 2013, the AMAs CPT Editorial Panel is deleting CPT codes 92980 and 92981 and replacing them with the following new CPT codes:    CPT code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)
(Medicare Claims Processing Manual)
 CPT code 92928 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch)    CPT code 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));    CPT code 92933 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch);    CPT code 92934 (Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure));    CPT code 92937 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed;  single vessel);    CPT code 92938 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performe d; each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));    CPT code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);
(Medicare Claims Processing Manual)
 HCPCS code C9604 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug- eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel);    HCPCS code C9605 (Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug- eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed;  each additional branch subtended by the bypass graft (List separately in addition to code for primary procedure));    HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel);    HCPCS code C9607 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty; single ves sel); and    HCPCS code C9608 (Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drug- eluting intracoronary stent, atherectomy and angioplasty;  each addi tional coronary artery, coronary artery branch, or bypass graft (List separately in addition to code for primary procedure)).
(Medicare Claims Processing Manual)
Step 4 -  If the hospital is a childrens hospital, a small rural hospital with not more than 100 beds or a cancer hospital, subtract the result of step 2 from the result of step 1 and pay .85 times this amount.  Do not perform steps 5- 8.  Step 5 -  If the result of step 3 is equal to or greater than .9 but less than 1.0, subtract the result of step 2 from the result of step 1, and multiply the difference by .8 and pay .85 times this amount.   Step 6 -  If the result of step 3 is equal to or greater than .8 but less than .9, subtract .7 times the result of step 2 from .71 times the result of step 1, and pay .85 times this amount.  Step 7 -  If the result of step 3 is equal to or greater than .7 but less than .8, subtract .6 times the result of step 2 from .63 times the result of step 1, and pay .85 times this amount.  Step 8 -  If the result of step 3 is less than .7, multiply the result of step 1 by .21 and pay .85 times this amount.  Step 9 -  When the result of step 2 is greater than the result of step 1 for the final month of a providers cost report period, do nothing more.  When the result of step 2 is greater than the result of step 1 for any other month, store all step 1 and step 2 totals and include these totals with the totals for the next months TOP calculation.  70.2 - Transitional Outpatient Payments (TOPs) for CY 2002 (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  For services provided during calendar years 2002, TOPs were gradually reduced for all providers except those hospitals that receive hold harmless TOPs (cancer hospitals, childrens hospitals, and rural hospitals having 100 or fewer beds).  To avoid TOP overpayments, contractors were instructed to revise t he monthly interim TOP calculations to reflect the new calculation.   Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effective for services provided between January 1, 2002, and December 31, 2002.