evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
In this chapter the terms provider and supplier are used as defined in 42 CFR 400.42 CFR   400.202 (Follow the link, choose the applicable year, select Title 42, then open Chapter IV .  You then must choose which part to open.  To get to 400.202 you select the first choice and download the pdf version.).     Provider means a hospital, a CAH, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, a home health agency, or a hospice that has in effect an agreement to participate in Medicare, or a clinic, a rehabilitation agency, or a publ ic health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech -language pathology services, or a community mental health center that has in effect a similar agreement but only to furnish partial hospitaliz ation or intensive outpatient  services.    Of these provider types only hospitals, CAHs, SNFs, and HHAs would be able to bill for DMEPOS; and for hospitals, CAHs, and SNFs usually only for outpatients.  Any exceptions to this rule are discussed in this chapter.     Supplier means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.    A DMEPOS supplier must meet certain requirements and enroll as described in Chapter 10 of the Program Integrity Manual.  A provider that enrolls as a supplier is considered a supplier for DMEPOS billing.  However, separate payment remains restricted to those items that are not considered included in a PPS rate.    Unless specified otherwise the instructions in this chapter apply to both providers and suppliers, and to the A/B MACs (A), (B), (HHH), and DME MACs that process their claims.
(Medicare Claims Processing Manual)
Unless specified otherwise the instructions in this chapter apply to both providers and suppliers, and to the A/B MACs (A), (B), (HHH), and DME MACs that process their claims.   10 - Where to Bill DMEPOS and PEN Items and Services  (Rev. 11414; Issued: 05 -12-22; Effective: 06 -13-22; Implementation: 06 -13-22) NOTE: CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document  the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase custom er satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.   For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.   For claims with dates of service prior to January 1, 2023  processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim.  This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned.
(Medicare Claims Processing Manual)
Skilled Nursing Facilities, CORFs, OPTs, and hospitals bill the A/B MAC Part A for prosthetic/orthotic devices, supplies, and covered outpatient DME and oxygen (refer to 40).  The HHAs should bill Durable Medical Equipment (DME) to the A/B MAC (HHH), or should meet the requirements of a DME supplier and bill the DME MAC.  This is the HHA's decision.  A/B MACs Part A other than A/B MACs (HHH) will receive claims only for the class "Prosthetic and Orthotic Devices."   Unless billing to the A/B MAC Part A is required as outlined in the preceding paragraph, claims for implanted DME, implanted prosthetic devices, replacement parts, accessories and supplies for the implanted DME shall be billed to the A/B MACs Part B and not the DME MAC.    Suppliers enrolled with the NSC as a DMEPOS supplier should enroll with and bill to the A/B MAC Part B for replacement parts, accessories and supplies for prosthetic implants and surgically implanted DME items that are not required to be billed to the A/B MAC Part A as stated above. Such suppliers should bill the A/B MAC Part B for these items only, unless the entity separately qualified as a supplier for items and/or services in another benefit category.   Suppliers that enroll with the NSC as a DMEPOS supplier shall bill the A/B MAC Part B using their NPI and shall not include their NSC number on the claim.
(Medicare Claims Processing Manual)
Suppliers that enroll with the NSC as a DMEPOS supplier shall bill the A/B MAC Part B using their NPI and shall not include their NSC number on the claim.   Under no circumstances should any entity that is enrolled as a DMEPOS supplier with the NSC, that is not the physician or provider that implants the device, bill the A/B MAC Part B for an implanted device. However, DMEPOS suppliers should bill for any of t he replacement parts, accessories or supplies for prosthetic implants and surgically implanted DME.   The claims filing jurisdiction for these items is determined by the suppliers location, in accordance with Pub. 100- 04, Medicare Claims Processing Manual, chapter 1, section 10. With respect to payment for these items, contractors are reminded of the long standing policy for payment of DMEPOS items, which specifies that payment for DMEPOS is based on the fee schedule amount for the State where the beneficiary maintains his/her permanent residence.    The Healthcare Common Procedure Coding System (HCPCS) codes that describe these categories of service are updated quarterly.  All  other  DMEPOS items are billed to the DME MAC.  See the Medicare Claims Processing Manual, Chapter 23, 20.3 for additional information.  A spreadsheet containing an updated list of HCPCS for which DME MACs have jurisdiction is updated as needed (typically quarterly) to reflect codes that have been added or discontinued (deleted). Any new HCPCS not included in this updated list a re A/B MAC jurisdiction only, and not DME MAC jurisdiction. The spreadsheet is  posted at the following website: https://www.cms.gov/Center/Provider -Type/Durable -Medical -Equipment -DME -Center.html under the heading of Coding.
(Medicare Claims Processing Manual)
Parenteral and enteral nutrition, and related accessories and supplies, are covered under the Medicare program as a prosthetic device.  See the Medicare Benefit Policy Manual, Chapter 15, for a description of the policy.  All Parenteral and Enteral (PEN) s ervices furnished under Part B are billed to the DME MAC.  If a provider ( see 01 ) provides PEN items under Part B it shall qualify for and receive a supplier number and bill as a supplier.  Note that some PEN items furnished to hospital and SNF inpatients are included in the Part A PPS rate and are not separately billable.  (If a serv ice is paid under Part A it should not also be paid under Part B.)    10.1 - Definitions  (Rev. 1, 10- 01-03) A3-3313.1, B3- 2100.1, HHA -220.1, HO -235.1, SNF -264.1  10.1.1 - Durable Medical Equipment (DME)  (Rev. 1, 10- 01-03)  DME is covered under Part B as a medical or other health service (1861(s)(6) of the Social Security Act [the Act]) and is equipment that:  a. Can withstand repeated use;  b. Is primarily and customarily used to serve a medical purpose;  c. Generally  is not useful to a person in the absence of an illness or injury; and  d. Is appropriate for use in the home.  All requirements of the definition must be met before an item can be considered to be durable medical equipment.  A SNF normally is not considered a beneficiary's home.  However, a  SNF can be considered a beneficiary's home for Method II home dialysis purposes.  See the Program Integrity Manual, Chapter 5, for guidelines on when a SNF may be considered a home.  For detailed coverage requirements (including definitions and discussion) associated with the following DME terms and circumstances see the Medicare Benefit Policy Manual, Chapter 15:
(Medicare Claims Processing Manual)
 "Durability"  "Medical Equipment"  "Equipment Presumptively Medical"  "Equipment Presumptively Nonmedical"   "Special Exception Items"  "Necessary and Reasonable"   "Necessity for the Equipment"   "Reasonableness of the Equipment"   "Payment Consistent With What is Necessary and Reasonable"   "Beneficiary's Home"   "Establishing the Period of Medical Necessity"   "Repairs, Maintenance, Replacement and Delivery"   "Leased Renal Dialysis Equipment"   "Coverage of Supplies and Accessories"   "Beneficiary Disposal of Equipment"   "New Supplier Effective Billing Date"   "Incurred Expense Date"   "Partial Months -Monthly Payment"   "Purchased Equipment Delivered Outside the U.S."   For coverage information on specific situations and items of DME, see the Medicare National Coverage Determinations Manual.   10.1.2 - Prosthetic Devices - Coverage Definition  (Rev. 1, 10- 01-03)  Prosthetic devices (other than dental) are covered under Part B as a medical or other health service (1861(s)(8) of the Act) and are devices that replace all or part of an internal body organ or replace all or part of the function of a permanently inopera tive or malfunctioning internal body organ.  R eplacements or repairs of such devices are covered when furnished incident to physicians' services or on a physician's orders.   For detailed coverage requirements (including definitions and discussion) associated with the following prosthetic device terms and circumstances see the Medicare Benefit Policy Manual, Chapter 15:    "Test of Permanence"   "Prosthetic Lenses"   "Intraocular Lenses (IOLs)"   "Supplies, Adjustments, Repairs and Replacements"   For coverage information on specific situations and prosthetic devices, see the Medicare National Coverage Determinations Manual.   10.1.3 - Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes) - Coverage Definition  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
These appliances are covered under Part B as a medical or other health service (1861(s)(9)  of the Act) when furnished incident to physicians' services or on a physician's order.  A brace includes rigid and semi -rigid devices that are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.   For detailed coverage requirements (including definitions and discussion) associated with the following terms and circumstances see the Medicare Benefit Policy Manual, Chapter 15:  "Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes"   "Adjustments and Replacement of Artificial Limbs"  For coverage information on specific situations, braces, trusses, and artificial limbs and eyes, see the Medicare National Coverage Determinations Manual.   10.1.4 - Payment Definition Variances (Rev. 1, 10- 01-03)  10.1.4.1 - Prosthetic Devices  (Rev. 1, 10- 01-03)  1834(h)(1)(G)  and (H)  of the Act, "Replacement of Prosthetic Devices and Parts," refers to prosthetic devices that are artificial limbs.  (Follow the link, scroll down to section (h) and look for the above title.)  (Section 1861(s) of the Act, which defines "medical and other health services," does not define artificial limbs as "prosthetic devices" ( 1861(s)(8)  follow the link, scroll down to section (s) and look for (8) prosthetic devices).  Rather, artificial limbs are included in the 1861(s)(9) category, "orthotics and prosthetics."  When discussing replacement, these instructions will use the term "prosthetic device" as intended by 1834(h)(1)(G), i.e., artificial limbs.  10.1.4.2 - Prosthetic and Orthotic Devices (P&O)  (Rev. 1, 10- 01-03)
(Medicare Claims Processing Manual)
Except as specifically noted (e.g., IOLs), when discussing payment and other policies, instructions in this chapter will use the terms "prosthetic and orthotic devices" and the abbreviation "P&O" interchangeably to refer to both 1861(s)(8) and (9)  (follow the link, scroll down to section (s) and look for both (8) and (9)) services.   10.2 - Coverage Table for DME Claims (Rev. 4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18) B3-2105   Reimbursement may be made for expenses incurred by a patient for the rental or purchase of durable medical equipment (DME) for use in his/her home provided that all the conditions in column A below have been met.  Column B indicates the action A/B MACs (A), (B), and (HHH), and DME MACs  will take to establish that the conditions have been met.
(Medicare Claims Processing Manual)
A - Conditions  B - Review Action  l. Payment may be made for the following:  1. Payment may be made for following:  (a) Items of DME that are medically necessary  (a) The HCPCS file shows coverage status of items.  If item is not listed in the HCPCS file, the MAC will develop LMRP  to determine whether the item is covered.  (b) Separate charges for repair, maintenance and delivery  (b) Repairs - only if DME is being purchased or is already owned by patient and repair is necessary to make the equipment serviceable.  Medicare pays the least expensive alternative.  (See special exception in Chapter 15 of the Medicare Benefit Policy Manual for repair of dialysis delivery system.)  NOTE : See Chapter 15 of the Medicare Benefit Policy Manual for handling claims suggesting deliberate or malicious damage or destruction.  Maintenance - only if the equipment is being purchased, or is already owned by the patient, and if the maintenance is extensive amounting to repairs, i.e., requiring the services of skilled technicians.  (MACs deny claims for routine maintenance and periodic servicing, e.g., testing, cleaning, checking, oiling, etc.)  (See special exception in Chapter 15 of the Medicare Benefit Policy Manual for maintenance of dialysis delivery system.)  Delivery -  of rented or purchased equipment is covered, but the related payment is included in the fee schedule for the item.  Additional payment may be made at the discretion of the MAC in special circumstances (see Chapter 15  of the Medicare Benefit Policy Manual)  (c) Separate charges for disposable supplies, e.g., oxygen, if essential to the effective use of medically necessary (c) Claim must indicate that:   The patient has the DME for which the supply is intended;  A - Conditions  B - Review Action  durable medical equipment.  Separate charges for replacement of essential accessories such as hoses, tubes, mouthpieces, etc., only if the beneficiary owns or is purchasing durable medical equipment (BPM, Chapter 15, 110).  (Medications used in connection with durable medical equipment are covered under certain conditions -  see Chapter 15 of the Medicare Benefit Policy Manual)   The DME continues to be medically necessary; and   The items are readily identifiable as the type customarily used with such equipment. NOTE:  If the quantity of accessories and/or supplies included in a claim seems excessive or if claims for such items are received from the
(Medicare Claims Processing Manual)
be medically necessary; and   The items are readily identifiable as the type customarily used with such equipment. NOTE:  If the quantity of accessories and/or supplies included in a claim seems excessive or if claims for such items are received from the same claimant with undue frequency, see C hapter 5 of the Medicare Program Integrity Manual.  2. DME must be for use in patient's residence other than a health care institution.  (BPM, Chapter 15, 110.1.D & PIM, C hapter 5, 1)  2. Payment cannot be made for equipment for use in a n institution classified as:  a. A participating hospital,  b. An emergency hospital,  c. Meets 1861(e)(1)  of the Act,  d. A participating SNF or  e. Meets 1819(a)(1)  of the Act.  If an institution that includes a Medicare -participating distinct part SNF also has a nonparticipating portion that does not meet 1819(a)(1), the patient may be considered in his/her residence if he/she was physically located in such nonparticipating portion during the use period.  DMEPOS (DME, P&O, and supplies) items provided to hospice patients are generally included in the payment for hospice services.  Items of DMEPOS are covered by Medicare and paid in addition to the hospice payment only when those items or supplies are provid ed to the patient for treatment of a condition or illness not related to the patient's terminal illness.  3. Physician's prescription required.   A supplier must maintain and, upon request, make available to the MAC, the detailed written order (or, when required, the Certificate of Medical Necessity (CMN)) from the treating physician.  See the Medicare Program Integrity Manual, Chapter 5.
(Medicare Claims Processing Manual)
10.3 - Beneficiaries Previously Enrolled in Managed Care Who Return to Traditional Fee for Service (FFS)  (Rev. 1, 10- 01-03) B3-9051  When a beneficiary who was previously enrolled in a Medicare HMO/Managed Care program returns to traditional FFS, he or she is subject to all benefits, rules, requirements and coverage criteria as a beneficiary who has always been enrolled in FFS.  When a beneficiary returns to FFS, it is as though he or she has become eligible for Medicare for the first time.  Therefore, if a beneficiary received any items or services from their HMO or Managed Care plan, they may continue to receive such items and services  only if they would be entitled to them under Medicare FFS coverage criteria and documentation requirements.   For example, if a beneficiary received a manual wheelchair under a HMO/Managed Care plan, he or she would need to meet Medicare coverage criteria and documentation requirements for manual wheelchairs.  He or she would have to obtain a Certificate of Medical Necessity (CMN), and would begin an entirely new rental period, just as a beneficiary enrolled in FFS, to obtain a manual wheelchair for the first time.  There is an exception to this rule if a beneficiary was previously enrolled in FFS and received a capped rental item, then enrolled in an HMO, stayed with the HMO for 60 or fewer days, then returned to FFS.  For purposes of this instruction, CMS has interpreted an end to medical necessity to include enrollment in an HMO for 60 or more days.   Another partial exception to this rule involves home oxygen claims.  If a beneficiary has been receiving oxygen while under a Medicare HMO, the supplier must obtain an initial CMN and submit it to the DME MAC at the time that FFS coverage begins.  However,  the beneficiary does not have to obtain the blood gas study on the CMN within 30 days prior to the Initial Certification date on the CMN, but the test must be the most recent study the patient obtained while in the HMO, under the guidelines specified in D ME MAC policy.  It is important to note that, just because a beneficiary qualified for oxygen under a Medicare HMO, it does not necessarily follow that he/she will qualify for oxygen under FFS.
(Medicare Claims Processing Manual)
Another partial exception to this rule involves home oxygen claims.  If a beneficiary has been receiving oxygen while under a Medicare HMO, the supplier must obtain an initial CMN and submit it to the DME MAC at the time that FFS coverage begins.  However,  the beneficiary does not have to obtain the blood gas study on the CMN within 30 days prior to the Initial Certification date on the CMN, but the test must be the most recent study the patient obtained while in the HMO, under the guidelines specified in D ME MAC policy.  It is important to note that, just because a beneficiary qualified for oxygen under a Medicare HMO, it does not necessarily follow that he/she will qualify for oxygen under FFS.   These instructions apply whether a beneficiary voluntarily returns to FFS, or if he or she involuntarily returns to FFS because their HMO or Managed Care plan no longer participates in the Medicare + Choice (HMO) program.    20 - Calculation and Update of Payment Rates  (Rev. 1, 10- 01-03) B3-5017, PM B -01-54, 2002 PEN Fee Schedule   Section1834 of the Act requires the use of fee schedules under Medicare Part B for reimbursement of durable medical equipment (DME) and for prosthetic and orthotic devices, beginning January 1 1989.  Payment is limited to the lower of the actual charge for the equipment or the fee established.  Beginning with fee schedule year 1991, CMS calculates the updates for the fee schedules and national limitation amounts and provides the A/B MACs (A), (B), (HHH), and DME MACs with the revised payment amounts.  The CMS calculates most fee schedule amounts and provides them to the A/B MACs (A), (B), and (HHH), and DME MACs.  However, for some services CMS asks A/B MACs (B) to calculate local fee amounts and to provide them to CMS to include in calculation of national amounts.  These vary from update to updat e, and CMS issues special related instructions to A/B MACs (B) when appropriate.
(Medicare Claims Processing Manual)
Parenteral and enteral nutrition services paid  on and after January 1, 2002 are paid on a fee schedule.  This fee schedule also is furnished by CMS.  Prior to 2002, payment amounts for PEN were determined under reasonable charge rules, including the application of the lowest charge level (LCL) restrictions.  The CMS furnishes fee schedule updates (DMEPOS, PEN, etc.) at least 30 days prior to the scheduled implementation.  A/B MACs (A), and (HHH)  use the fee schedules to pay for covered items, within their claims processing jurisdictions, supplied by hospitals, home health agencies, and other providers.  A/B MACs (A) and (HHH)  consult with DME MACs and, where appropriate with A/B MACs (B), on filling gaps in fee schedules.   The CMS furnishes the fee amounts annually, or as updated if special updates should occur during the year, to A/B MACs (A), (B), (HHH), and DME MACs and the Railroad Retirement Board (RRB), Specialty MAC (SMAC), and to other interested parties (including the Pricing, Data Analysis and Coding Contractor (PDAC), RRB, Indian Health Service, and United Mine Workers).   20.1 - Update Frequency  (Rev. 1, 10- 01-03) AB-03-071, AB -03-100, CMS Web Site   The DMEPOS fee schedule is updated annually to apply update factors and quarterly to include new codes and correct errors.   The current update of the DMEPOS fee schedule is located at:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS -Fee-Schedule.html   The current quarterly update is also located at:  http://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/DMEPOSFeeSched/DMEPOS -Fee-Schedule.html  20.2 - Locality (Rev. 1, 10- 01-03) B3-5017.1