evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 7 - SNF Part B Billing (Including Inpatient Part B and  Outpatient Fee Schedule)  Table of Contents                                                                                                                       (Rev. 10880, 08- 06-21)  Transmittals for Chapter 7  10 - Billing for Medical and Other Health Services  10.1 -  Billing for Inpatient SNF Services Paid Under Part B  10.1.1  Editing of Skilled Nursing Facilities Part B Inpatient Services  10.2  Billing for Outpatient SNF Services  10.3 -  Determining How Much to Charge Before Billing Is Submitted  10.4 -  Charges for Services Provided in Different Accounting Years  10.5 -  General Payment Rules and Application of Part B Deductible and Coinsurance  20 - Use of Healthcare Common  Procedure Coding System (HCPCS)  30 - Billing Formats  30.1 -  Frequency of Billing for Skilled Nursing Facilities (SNFs)  30.2 -  Guidelines for Submitting Corrected Bills  40 - Billing Part B Rehabilitation Services  40.1 -  Audiologic Tests  50 - Billing Part B Radiology Services and Other Diagnostic Procedures  50.1 -  Bone Mass Measurements  60 - Billing for Durable Medial Equipment (DME), Orthotic/Prosthetic Devices, and Supplies (including Surgical Dressings)  60.1 -  Billing  60.2 -  Determining Payment and Patient Liability  60.3 -  Billing for Enteral and Parenteral Nutritional Therapy as a Prosthetic Device  70 - Drugs  70.1 -  Immunosuppressive Drugs Furnished to Transplant Patients  80 - Screening and Preventive Services  80.1 -  Pneumococcal Pneumonia, Influenza Virus, and Hepatitis B Vaccines  80.2 -  Mammography Screening  80.2.1 -  Diagnostic and Screening Mammograms Performed With New Technologies  80.3 -  Screening Pap Smears  80.4 -  Screening Pelvic Examinations  80.5 -  Prostate Cancer Screening  80.6 -  Colorectal Cancer Screening  80.7 -  Glaucoma Screening  90 - Billing for Laboratory Tests Under Part B -  General  90.1 -  Glucose Monitoring 100 -  Epoetin (EPO)  110 -  Carrier Claims Processing fo r Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a Non -covered SNF Stay    10 - Billing for Medical and Other Health Services                               (Rev. 10880, Issued: 08- 06-21, Effective:  11-08-21, Implementation: 11- 08-21)
(Medicare Claims Processing Manual)
10 - Billing for Medical and Other Health Services                               (Rev. 10880, Issued: 08- 06-21, Effective:  11-08-21, Implementation: 11- 08-21)  See Business Requirements at https://www.cms.gov/Regulations -and-Guidance/Guidance/Transmittals/Downloads/R20CP.pdf.  There are three situations in which a SNF may submit a claim for Part B services.  These are identif ied in subsections A through C below.   No bill is required when:    The patient is not enrolled under Part B;    Payment was made or will be made by the Public Health Service, VA, or other governmental entity;    Workers' compensation has paid or will pay the bi ll; or    Payment was made by liability, no -fault insurance, group health plan, or a large group health plan.   A - Beneficiaries in a Part B Inpatient Stay (Part B Residents)   A Part B inpatient stay includes services furnished to inpatients whose benefit days are exhausted, or who are not entitled to have payment made for services under Part A.  A more detailed description of services covered for beneficiaries in a Part B stay is found at 10.1  Billing for Inpatient Services Paid Under Part B.   B - Outpatient Services   Covered Part B services rendered to beneficiaries who are not inpatients of a SNF are considered SNF outpatient services.  They include the services listed in 10.1 below as well as additional services described in the Medicare Benefit Policy Manual, Chapter 8, "Coverage of Extended Care (SNF) Services Under Hospital Insurance," 80 and Medicare Benefit Policy Manual, Chapter 6, "Hospital Services Covered Under Part B."  Detailed instructions for billing are located in 10.2  Billing for Outpatient SNF Services.   C - Beneficiaries in a Part A Covered Stay
(Medicare Claims Processing Manual)
C - Beneficiaries in a Part A Covered Stay   SNFs are required to consolidate billing to their intermediary for their covered Medicare inpatient service s.  However, certain services rendered to SNF inpatients are excluded from the SNF Prospective Payment System (PPS) reimbursement and are also excluded from consolidated billing by the SNF.  Those services must be billed to Part B by the rendering provider  and not by the SNF (except screening and preventive services as described in the next paragraph.)  A list of services excluded from consolidated billing is found in the Medicare Claims Processing Manual, Chapter 6, "SNF Inpatient Part A Billing," 20  20.4.   Screening and preventive services are not included in the SNF PPS amount but may be paid separately under Part B for Part A patients who also have Part B coverage.  Screening and preventive services are covered only under Part B.  Only the SNF may bi ll for screening and preventive services under Part B for its covered Part A inpatients.  Bill type 22X is used in billing screening and preventive services for beneficiaries in a covered Part A stay and for beneficiaries that are Part B residents.  TOB 23 x is used for SNF outpatients or for beneficiaries not in the SNF or DPU.  The SNF must provide the service or obtain it under arrangements.   Coverage, billing and payment guidelines are found in the Medicare Claims Processing Manual, Chapter 18, "Preventi ve and Screening Services;" Chapter 17, "Drugs and Biologicals;" and the Medicare Benefit Policy Manual, Chapter 15, "Covered Medical and Other Health Services," 50.4.4.2.   There are certain medical and other health services for which payment may not be m ade to a SNF.  Most of these are professional services performed by physicians and other practitioners.  These services are always billed to the Medicare Part B MAC .  Others are services that have been determined to require a hospital setting to assure ben eficiary safety.  Part A MAC shared systems receive an annual file listing these non -payable HCPCS in November, and, if necessary, a quarterly update via a one -time-only notification.
(Medicare Claims Processing Manual)
Physicians, non- physician practitioners, and suppliers billing the Part  B MAC , and providers billing the Part A MAC should consult the CMS Web site at http://www.cms.hhs.gov/SNFConsolidatedBilling/  for lists of separately billable services.    10.1 - Billing for Inpatient SNF Services Paid Under Part B  (Rev. 980, Issued: 06- 14-06, Effective: 10- 01-06, Implementation: 10- 02-06)  When the beneficiary in a Medicare- certified SNF is not entitled to Part A benefits, limited benefits are provided under Part B.  Reasons for not being entitled to have payment made under Part A are that :   The beneficiary does not have Medicare Part A Health Insurance;    The beneficiary is not in a Medicare- certified bed;    The inpatient stay is not at a covered level of care and no Part A program payment is possible; or    The inpatient stay is not covered because the beneficiary did not have a 3 -day qualifying stay.
(Medicare Claims Processing Manual)
 The inpatient stay is not at a covered level of care and no Part A program payment is possible; or    The inpatient stay is not covered because the beneficiary did not have a 3 -day qualifying stay.   When no Part A program payment is possible, some or all services may be medically necessary and can be covered as ancillary services under Part B.  The following services may be billed by the S NF or the rendering provider or supplier under an arrangement with the SNF:   Diagnostic x -ray tests, diagnostic laboratory tests, and other diagnostic tests;   X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;   Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations;   Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or all or part of the funct ion of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices;   Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements require d because of breakage, wear, loss, or a change in the patients physical condition;   Outpatient physical therapy, outpatient speech- language pathology services, and outpatient occupational therapy (see Pub. 100 -02 Medicare Benefit Policy Manual, chapter 15, Covered Medical and Other Health Services, 220 and 230.  Screening mammography services;   Screening pap smears;   Influenza, pneumococcal pneumonia, and hepatitis B vaccines;   Colorectal screening;   Bone mass measurements;   Diabetes self -management;   Prostate screening;   Ambulance services;   Hemophilia clotting factors for hemophilia patients competent to use these factors without supervision);   Immunosuppressive drugs;   Oral anti -cancer drugs;   Oral drug prescribed for use as an acute anti -emetic used as part of an  anti-cancer chemotherapeutic regimen; and   Epoetin Alfa (EPO).   See chapter 6 of Pub. 100- 02, Medicare Benefit Policy Manual for a discussion of the circumstances under which the above services may be covered as Part B Inpatient services.
(Medicare Claims Processing Manual)
See chapter 6 of Pub. 100- 02, Medicare Benefit Policy Manual for a discussion of the circumstances under which the above services may be covered as Part B Inpatient services.   Coverage rules f or these services are described in Pub. 100- 02, Medicare Benefit Policy Manual, Chapters 10, 14, or 15.  Specific billing instructions are found in the Medicare Claims Processing Manual, Chapters 13, 15, 16, 18, 20, or 23.  Outpatient physical therapy, out patient speech -language pathology services, and outpatient occupational therapy (see Chapter 10, 60) are billable services for SNF inpatients not in a Part A stay.  However, they must be billed by the SNF even when another entity renders the services under an arrangement with the SNF.   The determination of whether to use TOB 22x or 23x is a function of the type of facility in which the beneficiary resides.  If the facility is not Medicare -certified, it is not a SNF, although it may have a Medicare- certifi ed distinct part unit (DPU).  If the beneficiary is in a SNF or SNF DPU, Part B services must be billed on TOB 22x.  All services rendered to SNF patients residing in the non- Medicare -certified portion of an institution that is not primarily engaged in the  provision of skilled services must be billed on TOB 23x.  Beneficiaries residing in such portions of the facility are considered outpatients of the SNF for Medicare purposes.  If the entire facility qualifies as a Medic are- certified SNF, all Part B servi ces rendered to residents are billed on TOB 22x.  10.1.1 - Editing of Skilled Nursing Facilities Part B Inpatient Services  (Rev. 3481, Issued: 03- 18-16. Effective: 06- 20-16, Implementation: 06- 20-16)  Medicare pays under Part B for physicians services and  for non -physician medical and other health services listed below when furnished by a participating hospital to an inpatient of the SNF when patients are not eligible or entitled to Part A benefits or the patient has exhausted their Part A benefits.  The S SM shall edit to prevent payment on Type of Bill 22x for claims containing the revenue codes listed in the table below.
(Medicare Claims Processing Manual)
010x  011x  012x  013x  014x  015x  016x  017x  018x  019x  020x  021x  022x  023x  024x  0250  0251  0252  0253  0256  0257  0258  0259  0261  0269  0270  0273  0277  0279  029x  0339  036x  0370  0374  041x  045x  0472  0479  049x  050x  051x  052x  053x  0541  0542  0543  0544  0546  0547  0548  0549  055x  057x  058x  059x  060x  0630  0631  0632  0633  0637  064x  065x  066x  067x  068x  072x  0762  078x  079x  093x  0940  0941  0943  0944  0945  0946  0947  0949  095x  0960  0961  0962  0969  097x  098x  099x  100x  210x  310x        The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.   This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 96  RARC: M28  MSN: 21.21  10.2  Billing for Outpatient SNF Services  (Rev. 229, Issued 07- 20-04 Effective/Implementation 08- 19-04) SNF -529  Coverage is available for all of the services described in 10.1.  However, beneficiaries not in the Medicare -certified Distinct Part Unit (DPU) are not required to have therapy services (physical therapy, occupational therapy, and speech language pathology) billed by the SNF.  Therapy services need o nly be bundled to the SNF for those SNF residents in a Medicare- certified DPU.  For additional information see Chapter 6, SNF Inpatient Part A Billing, 20.5 Therapy Services.  10.3 - Determining How Much to Charge Before Billing Is Submitted  (Rev. 1, 10- 01-03) SNF -529.1
(Medicare Claims Processing Manual)
The SNF may be able to determine from the SNF's records, from a transferring hospital, or from the patient the extent to which the Part B cash deductible is met.  The SNF may charge the patient for the unmet deductible and coinsurance.  The SNF should subm it a bill even if no payment can be made because the unmet Part B cash deductible exceeds the covered charges.  In addition, a bill is required when the SNF becomes aware that no bill has been submitted for covered services even though the time limitation for filing has expired.   10.4 - Charges for Services Provided in Different Accounting Years  (Rev. 1, 10- 01-03) SNF -529.2   The SNF must not put charges for services provided in different accounting years on the same bill.  At the end of the SNF's accounting  year, the SNF should submit a bill that contains the charges for all services furnished to the patient since the last bill through the end of the year.  The SNF should include bills in which the deductible covers all charges.  All services furnished in th e succeeding accounting year should be placed on a separate bill.  Complete all items on the subsequent bill.   10.5 - General Payment Rules and Application of Part B Deductible and Coinsurance  (Rev. 685, Issued: 09- 23-05, Effective: 12- 27-05, Implementatio n: 12 -27-05) SNF -529.3   Section 1888(e)(9) of the Social Security Act (the Act) requires that the payment amount for Part B SNF services shall be the amount prescribed in the otherwi se applicable fee schedule.  Thus, where a fee schedule exists for the type of service, the fee amount will be paid.  Where a fee does not exist on the Medicare Physician Fee Schedule (MPFS) the particular service is priced based on cost.  This is also true for all carrier -priced codes on the MPFS, but not for services paid on the Clinical Diagnostic Laboratory Fee Schedule.  All lab services missing fees are to be gap -filled.  Some specific services continue to be paid on a cost basis and are specificall y stated in the sections below where cost applies.
(Medicare Claims Processing Manual)
Where payment is made under a fee schedule, the beneficiary's deductible and coinsurance are based on the approved amount.  Where payment is made on a cost basis, deductible and coinsurance are based on c harges for the service.   20 - Use of Healthcare Common Procedure Coding System (HCPCS)  (Rev. 1, 10- 01-03) SNF -530, SNF -530.3   HCPCS is required for reporting all SNF services paid under Part B, whether paid by Medicare fee schedules or by some other mechanism.  A description of HCPCS codes is found in the Medicare Claims Processing Manual, Chapter 23.   The SNF should use the CPT -4 portion of HCPCS and/or Level II as directed by the manual sections applicable to the Part B service that is being billed.   Currently, HCPCS codes are not applicable on SNF Part A inpatient claims.   For Part B claims, there are separate codes for the technical component, professional component, and/or complete procedure.  Generally, SNFs bill for the technical component only, using the code that describes the procedure provided.   There may be specific rules for use of HCPCS codes for specific types of services (e.g., SNF's must bill global services for therapies).  These will be described in the manual sections for the applica ble service.   Revenue codes, HCPCS codes, line item dates of service, and units are required.  Charges must be reported by HCPCS code.  If the same revenue code applies to two or more HCPCS codes, the SNF should repeat the revenue code and show the line it em date of service, units and charge for each HCPCS code on a separate line.   30 - Billing Formats  (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09- 30-14)
(Medicare Claims Processing Manual)
The SNF must use the current ASC X12 837 institutional claim format or if permissible Form CMS -1450 to bill for covered Part B services.  Instructions for those formats are located in the Medicare Claims Processing Manual, Chapter 25, "Compl eting and Processing the CMS -1450 Data Set."   30.1 - Frequency of Billing for Skilled Nursing Facilities (SNFs)  (Rev. 1, 10- 01-03) SNF -561  SNFs must bill repetitive Part B services on a single individual monthly bill (or at the conclusion of treatment).  This avoids Medicare processing costs in holding such bills for monthly review and reduces bill processing costs for relatively small claims.  See the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements," 50.2.2, for additional ins tructions when billing repetitive services and billing repetitive services during an inpatient stay.   Other one -time Part B services must be billed upon completion of the services.   30.2 - Guidelines for Submitting Corrected Bills  (Rev. 1, 10- 01-03) SNF -562, SNF -562.A   When a SNF or intermediary discovers an error on an original bill, there are three methods for correcting the bill depending on the type of error.  The SNF or intermediary may submit a late charge bill, an adjustment request, or maintain a lo g of charges.  Each of the methods and appropriate use are explained in the Medicare Claims Processing Manual, Chapter 1, "General Billing Requirements," 130.   40 - Billing Part B Rehabilitation Services  (Rev. 1, 10- 01-03) SNF -515.6   Part B rehabilitation services other than audiology services must be billed by the SNF for Part A inpatients, for Part B residents (those not in a covered Part A stay) and for outpatients.  Effective January 1, 1999, the MPFS is the payment basis for these  services.   The Medicare Claims Processing Manual, Chapter 5, "Part B Outpatient Rehabilitation and CORF Services," contains instructions for billing, payment, and applicable HCPCS codes.   40.1 - Audiologic Tests (Rev. 980, Issued: 06- 14-06, Effective: 10- 01-06, Implementation: 10- 02-06)
(Medicare Claims Processing Manual)
40.1 - Audiologic Tests (Rev. 980, Issued: 06- 14-06, Effective: 10- 01-06, Implementation: 10- 02-06)  Audiologic tests will generally be billed to the carrier by the provider of service.  For tests that include both a professional component and technical component, the SNF may elect to bill the technical component to th e intermediary, but is not required to bill the service.  See Pub 100- 02 chapter 15, section 80.3 for further information on audiology.   Payment to SNFs for audiologic tests are bundled into the PPS payment amount for beneficiaries in a covered SNF Part A stay, whether provided directly by the SNF or under arrangements by an independent provider based on a contract with the SNF.  Independent audiologists may bill the carrier directly for services rendered to beneficiaries not  in a SNF Part A covered stay.  For beneficiaries not in a covered Part A SNF stay, who are sometimes referred to as beneficiaries in a Part B SNF stay, audiologic tests are payable under Part B when billed by the SNF as type of bill 22X, or when billed directly to the carrier by the pro vider of the service.  Payment is based on the Medicare Physician Fee Schedule (MPFS), whether by the carrier or the intermediary.   Since audiologic tests are not  bundled with speech - language pathology services, payment is made to the provider of service or to the SNF where the services are provided under arrangements with the SNF for SNF outpatients.  50 - Billing Part B Radiology Services and Other Diagnostic Procedures  (Rev. 1, 10- 01-03)  Acceptable HCPCS codes for radiology and other diagnostic service s are taken primarily from the CPT -4 portion of HCPCS.  Payment is the lower of billed charges or the fee schedule amount.  In either case, any applicable deductible and coinsurance amounts are subtracted from the payment amount prior to payment.  Coinsura nce is calculated on the Medicare payment amount after the subtraction of any applicable deductible amount.
(Medicare Claims Processing Manual)
Additional instructions for coverage, billing, payment, and specific instructions for the services listed below are found in the Medicare Claims Pr ocessing Manual, Chapter 13, "Radiology Services":    Contrast material other than low osmolar contrast material (LOCM) for radiology;   LOCM;   Radiopharmaceuticals;   IV Persantine;   Transportation of equipment;   Position Emission Tomography (PET); and   Adenosine.   50.1 - Bone Mass Measurements  (Rev. 1, 10- 01-03) SNF -535.5   Sections 1861(s)(15)  and 1861(rr)(1)  of the Act (as added by 4106 of the Balanced Budget Act (BBA) of 1997) standardized Medicare coverage of medically necessary bone mass measurements by providing for uniform coverage under Medicare Part B.  This standardized coverage is effective for claims with dates of service furnished on or after July 1, 1998.  The Medicare Claims Processing Manual, Chapter 13, "Radiology Services," contains coverage, billing, and payment requirements for bone mass measurements.   60 - Billing for Durable Medial Equipment (DME) , Orthotic/Prosthetic Devices, and Supplies (including Surgical Dressings)  (Rev. 3053, Issued: 08- 28-14, Effective: ICD -10: Upon Implementation of ICD -10 ASC- X12: 01- 01-12, Implementation ICD -10: Upon Implementation of ICD -10; ASC X12: 09 -30-14)