evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Medicare contractors must calculate overall cost -to-charge ratios for hospitals paid under OPPS and for CMHCs using the providers most recent full year cost reporting period, whether tentatively settled or final settled, in accordance with the instruction s in 10.11.7, 10.11.7.1, 10.11.8, 10.11.8.1 or 10.11.9 as applicable. The contractor must calculate a provider overall CCR whenever a more recent full year cost report becomes available. If a CCR is calculated based on the tentatively settled cost report , the contractor must calculate another overall CCR when the cost report is final or when a cost report for a subsequent cost reporting period is tentatively settled, whichever occurs first. If a CCR is based on a final settled cost report, the contractor must calculate the CCR when a cost report for a subsequent cost reporting period is tentatively settled.  10.11.2 - Circumstances in Which CCRs are Used  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  The contractors must apply CCRs prospectively to calculate outlier payments (for hospitals paid under OPPS and CMHCs), Transitional Outpatient Payment System (TOPS) payments (for hospitals paid under OPPS), device pass -through payments (for hospitals paid under OPPS), and items and services paid at charges adjusted to cost (for hospitals paid under OPPS).   10.11.3 - Selection of the CCR to be Used  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01 -05-09)  Contractors will use the CCR calculated for the most recent period of time, whether based on a tentatively settled cost report or a final settled cost report.  For example, if the CCR being used is the tentatively settled CCR for FY 2008, and a tentatively settled CCR for FY 2009 is determined before the final settled CCR for FY 2008, then the contractor uses the CCR based on the tentatively settled 2009 cost report.   10.11.3.1 - CMS Specification of Alternative CCR (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)
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10.11.3.1 - CMS Specification of Alternative CCR (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Effective January 1, 2009, the central office may direct Medicare contractors to use an alternative CCR if CMS believes this will result in a more accurate CCR.  Also, if the Medicare contractor finds evidence that indicates that using data from the latest  settled or tentatively settled cost report would not result in the most accurate CCR, then the Medicare contractor shall notify the CMS central office and CMS regional office to seek approval to use a CCR -based on alternative data.  For example, CCRs may be revised more often if a change in a hospital or CMHCs operations occurs which materially affects a hospital or CMHCs costs and charges.  The central and regional offices must approve the Medicare contractors request before the Medicare contractor may  use a CCR- based on alternative data.  Revised CCRs are applied prospectively to all OPPS claims processed after the update.  Medicare contractors shall send notification to the central office via the following address and e -mail address:   CMS  C/O Division of Outpatient Care -  OPPS Outlier Team  7500 Security Blvd.  Mail Stop C4 -05-17 Baltimore, MD 21244 outliersopps@cms.hhs.gov  10.11.3.2 - Hospital or CMHC Request for Use of a Different CCR  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)
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10.11.3.2 - Hospital or CMHC Request for Use of a Different CCR  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Effective January 1, 2009, CMS (or the Medicare contractor) may specify an alternative CCR if it believes that the CCR being applied is inaccurate.  In addition, a hospital or CMHC has the opportunity to request that a different CCR be applied for outlier payment calculation in the event it believes the CCR being applied is inaccurate.  The hospital or CMHC is required to present substantial evidence supporting its request.  Such evidence should include documentation regarding its costs and charges that demonstrate  its claim that an alternative ratio is more accurate.  After the Medicare contractor has evaluated the evidence presented by the hospital or CMHC, the Medicare contractor notifies the CMS central office and CMS regional office of any such request.  The CM S central and regional offices approve or deny any request by the hospital (or CMHC) or Medicare contractor for use of a different CCR.  Medicare contractors shall send requests to the CMS central office using the address and e -mail address provided above.   10.11.3.3 - Notification to Hospitals Paid Under the OPPS of a Change in the CCR  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  The Medicare contractor shall notify a hospital or CMHC whenever it makes a change to its CCR.  When a CCR is changed as a result of a tentative settlement or a final settlement of the cost report, the change to the CCR can be included in the notice that i s issued to each provider after a tentative or final settlement is completed.  Medicare contractors can also issue separate notification to a hospital about a change to its CCR(s).   10.11.4 - Use of CCRs in Mergers, Acquisitions, Other Ownership Changes, or Errors Related to CCRs  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  The contractors use the CCR for the surviving provider in cases of provider merger, acquisition or other such changes.
(Medicare Claims Processing Manual)
The contractors use the CCR for the surviving provider in cases of provider merger, acquisition or other such changes.   Effective for hospitals experiencing a change of ownership after January 1, 2007, that have not accepted assignment of an existing hospital's provider agreement in accordance with 42 CFR 489.18, and do not yet have a Medicare cost report, the contractor may use the default S tatewide CCR to determine cost -based payments until the hospital has submitted its first Medicare cost report.  See 10.11.10 for the location of the Statewide CCRs and the upper limit above which the contractor must use the Statewide CC R.  For purposes of identifying a CCR for payment, Medicare contractors may apply a Statewide average to hospitals receiving a new provider number, such as hospitals converting from non-IPPS to IPPS status.  Also, for purposes of identifying a CCR for paym ent, hospitals receiving a new provider number may request use of a different CCR based on substantial evidence.  Use of an alternative CCR is subject to the approval of the CMS central and regional offices as discussed in 10.11.3.2.  For hospitals experi encing a change of ownership prior to January 1, 2007, the contractor should use the prior hospital's CCR.   In instances where errors related to CCRs and/or outlier payments are discovered, the Medicare contractor shall contact the CMS central office to seek further guidance.  Medicare contractors may contact the CMS central office via the address and e- mail address listed in 10.11.3.1 of this chapter.   If a cost report is reopened after final settlement and as a result of this reopening, there is a change to the CCR, Medicare contractors should contact the CMS regional and central office for further instructions.  Medicare contractors may contact the CMS  central office via the address and email address listed in 10.11.3.1.  10.11.5 - New Providers and Providers with Cost Report Periods Less Than a Full Year  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)
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The contractors must calculate a hospital CCR using the most recent full -year cost report if a hospital or CMHC has a short period cost report.  The contractors must use the Statewide CCR for all inclusive rate hospitals paid under OPPS, or when a new provider does not have a full years cost report and has no cost report history.   See 10.11.10 for the location of the Statewide CCRs.   10.11.6 - Substitution of Statewide CCRs for Extreme OPPS Hospital Specific CCRs  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  The contractors must use the applicable Statewide average urban or rural hospital default ratio if the CCR calculated for a hospital paid under OPPS is greater than the upper limit CCR in the file of overall OPPS hospital CCR limits on the CMS Web site.   In addition to the circumstances listed in 10.11.6, 10.11.5, and 10.11.4 of this chapter, a Medicare contractor also should use a Statewide average CCR if it is unable to determine an accurate overall ancillary CCR for a hospital for whom accurate data w ith which to calculate an operating CCR is not available.  Further, the policies of 10.11.3.1 and 10.11.3.2 can be applied as an alternative to the Statewide average.   See 10.11.10 for the location of the Statewide CCRs and the upper limit above which the contractor must use the Statewide CCR.   10.11.7 - Methodology for Calculation of Hospital Overall CCR for Hospitals That Do Not Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning Before  May 1, 2010, Under Cost Report Form 2552- 96 (Rev. 2296, Issued: 09- 02-11, Effective: 10 -01-11, Implementation: 10- 03-11)  10.11.7.1 - Methodology for Calculation of Hospital Overall CCR for Hospitals That Do Not Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning On or After May 1, 2010, Under Cost Report 2552 -10 (Rev. 2296, Issued: 09- 02-11, Effective: 10 -01-11, Implementation: 10- 03-11)
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In calculating the hospitals costs or charges, do not include departmental CCRs and charges for services that are not paid under the OPPS such as physical, occupational and speech language therapies, clinical diagnostic laboratory services, ambulance, rur al health clinic services, non -implantable DME, etc. See 10.11.10 for the location of the list of exact cost centers that shall be included in the calculation of the overall CCR.   Step 1 -  Determining Overall Costs:   Calculate costs for each cost center by multiplying the departmental CCR for each cost center (and subscripts thereof) that reflect services subject to the OPPS from Form CMS 2552- 10, Worksheet C, Part I, Column 9 by the Medicare outpatient charges for tha t cost center (and subscripts thereof) from Worksheet D, Part V, Columns 2, 3, and 4,. Sum the costs calculated for each cost center to arrive at Medicare outpatient cost of services subject to OPPS.   Step 2 -  Determining Overall Charges: Calculate charges by summing the Medicare outpatient charges from Form CMS 2552- 10, Worksheet D, Part V, Columns 2, 3, and 4, (and for each cost center (and subscripts thereof) that reflect services subject to the OPPS.   Step 3 -  Calculating the Overall CCR: Divide the costs from Step 1 by the charges from Step 2 to calculate the hospitals Medicare outpatient CCR.   10.11.8 - Methodology for Calculation of Hospital Overall CCR for Hospitals That Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning Before May 1, 2010, Under Cost Report Form 2552 -96 (Rev. 2296, Issued: 09- 02-11, Effective: 10 -01-11, Implementation: 10- 03-11)  10.11.8.1 - Methodology for Calculation of Hospital Overall CCR for Hospitals That Have Nursing and Paramedical Education Programs for Cost Reporting Periods Beginning On or After May 1, 2010, Under Cost Report 2552-10 (Rev. 2296, Issued: 09- 02-11, Effective: 10 -01-11, Implementation: 10- 03-11)
(Medicare Claims Processing Manual)
Do not include departmental CCRs and charges for services not subject to the OPPS (such as physical, occupational and speech language therapies, clinical diagnostic laboratory services, ambulance, rural health clinic services, non- implantable DME, etc.) in calculating the hospitals costs or charges.  See 10.11.10 for the location of the list of the exact cost centers that should be included in the overall CCR.   Step 1 -- Determining costs for each department:   From Worksheet B, Part 1 -  Column 26, deduct the nursing and paramedical education costs found on the applicable line in Columns - 20, and 23 of Worksheet B, Part I to calculate a cost for each cost center.   Exception: The costs for 9200 are not calculated on this worksheet. For cost center 9200,  Observation Beds (Non -Distinct Part), use the cost reported on Worksheet D -1, Part IV, line 89, and deduct the nursing and paramedical education costs found on Works heet D -1, Part IV, line 93 and subscripts, column 5. See Step 3 below.   Step 2 -  Determining charges for each department: From worksheet C, Part 1 -  Column 8 (sum of columns 6 and 7), identify total charges.  Step 3 -  Determining the CCRs for each department without nursing and paramedical education costs: For each line, divide the costs from Step1 by the charges from Step 2 to acquire CCRs for each line, without inclusion of nursing and paramedical education costs. Exception: For cost center 9200,  Observation Beds (Non- Distinct Part), use the cost reported on Worksheet D -1, Part IV, line 89, and deduct the nursing and paramedical education costs found on Worksheet D -1, Part IV, line 93 and subscripts, column 5.   Step 4 -  Determining Overall Costs: Multiply the CCR in step 3 by the Medicare outpatient charges for that cost center (and subscripts thereof) from Worksheet D Part V, Columns 2, 3, and 4,. Sum the costs calculated for each cost center to arrive at Medica re outpatient cost of services subject to OPPS.
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Step 5 -  Determining Overall Charges: Calculate charges by summing the Medicare outpatient charges from Form CMS 2552- 10, Worksheet D, Part V, Columns 2, 3, and 4, for each cost center (and subscripts thereof) that reflect service subject to the OPPS.   Step 6 -  Calculating the Overall CCR: Divide the costs from Step 4 by the charges from step 5 to calculate the hospitals Medicare outpatient CCR.   10.11.9 - Methodology for Calculation of CCR for CMHCs  (Rev. 10869; Issued: 07- 14-21; Effective: 08 -13-21; Implementation: 08 -13-21)  Calculate the CMHCs CCR using the providers most recent full year cost report, Form CMS 2088- 92, and Medicare cost and charges from Worksheet C, Page 2. Divide costs from line 39.01, Column 3 by charges from line 39.02, Column 3 to calculate the CCR.  Calculate the CMHCs CCR using the providers most recent full year cost report, Form CMS 2088- 17, and Medicare cost and charges from Worksheet C.  Divide costs from line 50, Column 5, by charges from line 50, Column 4, to calculate the CCR .  If the CCR is above 1.0 enter the appropriate Statewide average urban or rural hospital default ratio that is in the OPSF for the CMHC.  There is no lower limit for CMHC CCRs.  Use the CCR you calculate and do not substitute the Statewide average urban or rural hospital default ratio in cases where the CCR is below 1.0.  Note that CCR reporting requirements in 10.11 apply to both hospitals paid under OPPS and to CMHCs.  10.11.10 - Location of Statewide CCRs, Tolerances for Use of Statewide CCRs in Lieu of Calculated CCRs and Cost Centers to be Used in the Calculation of CCRs (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)
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The file of OPPS hospital upper limit CCRs and the file of Statewide CCRs are located on the CMS Web site at www.cms.hhs.gov/HospitalOutpatientPPS/  under Annual Policy Files.  A spreadsheet listing the Statewide CCRs also  can be found in the file containing the preamble tables that appears in the most recent OPPS/ASC final rule.  The contractors must always use the most recent Statewide CCR.   The file of standard and nonstandard cost centers to be used in the calculation of hospital outpatient CCRs is also found on the CMS Web site at www.cms.hhs.gov/HospitalOutpatientPPS/  under Revenue Code to Cost Center Crosswalk.   10.11.11 - Reporting of CCRs for Hospitals Paid Under OPPS and for CMHCs  (Rev.  2111, Issued: 12- 03-10, Effective: 04 -01-11, Implementation: 04- 04-11 )  The contractors shall report the OPPS hospital overall or CMHC CCR they calculate, or the Statewide CCR they select, for each provider to the Outpatient Provider Specific File (OPSF; see  50.1 of this chapter) within 30 days after the date of the calculation or selection of the Statewide CCR for the provider.  If a cost report reopening results in adjustments that would change the CCR that is currently in effect, the contractor shall calcul ate and enter the CCR in the OPSF within 30 days of the date that the reopening is finalized.  In such an instance, contractors must create an additional record in the OPSF for the provider.  The contractor entries in the OPSF shall include the effective date of the CCR being entered.  Entries in the OPSF shall not replace  a pre- existing entry for the provider. The only instances a Medicare contractor retroactively changes a field in the PSF is to update the CCR when using the FISS Lump Sum Utility for outlier reconciliation or otherwise specified by the CMS Regional Office  or Central Office.   10.12 - Payment Window for Outpatient Services Treated as Inpatient Services  (Rev. 3238, Issued: 04-22-15,  Effective: 04 -01-15 Implementation: 04- 06-15)
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10.12 - Payment Window for Outpatient Services Treated as Inpatient Services  (Rev. 3238, Issued: 04-22-15,  Effective: 04 -01-15 Implementation: 04- 06-15)  The policy for the payment window for outpatient services treated as inpatient services is discussed in chapter 3  40.3 of this manual.  The policy requires payment for certain outpatient services provided to a beneficiary on the date of an inpatient admi ssion or during the 3 calendar days (or 1 calendar day for a non- IPPS hospital) prior to the date of an inpatient admission to be bundled (i.e., included) with the Medicare Part A payment for the beneficiarys inpatient admission if those outpatient services are provided by the admitting hospital or an entity that is wholly owned or wholly operated by the admitting hospital.  The policy applies to all diagnostic outpatient services (includi ng non- patient laboratory tests) and non -diagnostic services (i.e., therapeutic) that are related to the inpatient stay.  Ambulance and maintenance renal dialysis services are not subject to the payment window.
(Medicare Claims Processing Manual)
All diagnostic services (including non- patient laboratory tests) provided to a Medicare beneficiary by a hospital (or an entity wholly owned or wholly operated by the hospital) on the date of the beneficiarys inpatient admission or during the 3 calendar days (or, in the case of a non -subsection (d) hospital, 1 calendar day) immediately preceding the date of admission are required to be included on the Part A bill for the inpatient stay.  Outpatient non- diagnostic services that are related to an inpatient admission must be bundled with the Part A billing for the inpatient stay.  An outpatient service is related to the admission if it is clinically associated with the reason for a patients inpatient admission.  In accordance with section 102 of Pub. L. 111- 192, for services furnished on or after June 25, 2010, all outpatient non- diagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are deemed related to the admission, and thus, must be billed to Part A with the inpatient stay.  Also, outpatient non- diagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second, and third calendar days for a subsection (d) hospital paid under the IPPS (first calendar da y for non- subsection (d) hospitals) preceding the date of a beneficiarys inpatient admission are deemed related to the admission, and thus, must be billed to Part A with the inpatient stay, unless the hospital attests to specific non -diagnostic services a s being unrelated to the hospital claim (that is, the preadmission non- diagnostic services are clinically distinct or independent from the reason for the beneficiarys admission).  Outpatient non- diagnostic services provided during the payment window that are unrelated to the admission, and are covered by Part B, may be separately billed to Part B.  The June 25, 2010 effective date of section 102 of Pub. L. 111- 192 applies to outpatient services provided on or after June 25, 2010.
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In the event that there is no Part A coverage for the inpatient stay, the hospital may bill Part B for the services provided to the beneficiary prior to the point of inpatient admission (i.e., the time of formal admission pursuant to the inpatient admissio n order) that would otherwise be included in the payment window for Part A payment, including services requiring an outpatient status.  Certain Part B inpatient services provided to the beneficiary after the point of inpatient admission (i.e., the time of formal admission pursuant to the inpatient admission order) may also be billed to Part B when Part A payment cannot be made.  See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10 Medical and Other Health Services Furnished to Inpatients of Part icipating Hospital" for a full description of this policy.   A hospital may attest to specific non -diagnostic services as being unrelated to the hospital Part A claim (that is, the preadmission non -diagnostic services are clinically distinct or independent from the reason for the beneficiarys admission) by adding a  condition code 51 (definition 51 -  Attestation of Unrelated Outpatient Non -diagnostic Services) to the separately billed outpatient non- diagnostic services claim.  Providers may submit outpatient claims with condition code 51 starting April 1, 2011, for  outpatient claims that have a date of service on or after June 25, 2010.  Outpatient claims with a date of service on or after June 25, 2010, that did not contain condition code 51 received prior to April 1, 2011, will need to be adjusted by the provider if they were rejected by FISS or CWF.   20 - Reporting Hospital Outpatient Services Using Healthcare Common Procedure Coding System (HCPCS)  (Rev. 1, 10- 03-03) A3-3626.4, HO -442.6  20.1 - General  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)