evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Beginning January 1, 2005, a clotting factor furnishing fee is separately payable to entities that furnish clotting factor unless the costs associated with furnishing the clotting factor is paid through another payment system.   The clotting factor furnishing fee is updated each calendar year based on the percentage increase in the consumer price index (CPI) for medical care for the 12 -month period ending with June of the previous year. The clotting factor furnishing fees applicable for dates of service in each calendar year (CY) are listed below:   CY 2005 - $0.140 per unit  CY 2006 - $0.146 per unit  CY 2007 - $0.152 per unit  CY 2008 - $0.158 per unit  CY 2009 - $0.164 per unit  CY 2010 - $0.170 per unit  CY 2011 - $0.176 per unit  CY 2012 - $0.181 per unit  CY 2013 - $0.188 per unit  CY 2014 - $0.192 per unit  CY 2015 - $0.197 per unit  CY 2016 - $0.202 per unit  CY 2017 - $0.209 per unit  CY 2018 - $0.215 per unit  CY 2019 - $0.220 per unit  CY 2020 - $0.226 per unit  CY 2021 - $0.238 per unit  CY 2022 - $0.239 per unit  CY 2023 - $0.250 per unit  CY 2024 - $0.250 per unit   Annual updates to the clotting factor furnishing fee are  subsequently communicated by a Recurring Update Notification .    CMS includes this clotting factor furnishing fee in the nationally published payment limit for clotting factor billing codes. When the clotting factor is not included on the Average Sales Price (ASP) Medicare Part B Drug Pricing File or Not Otherwise Class ified (NOC) Pricing File, the contractor must make payment for the clotting factor as well as make payment for the furnishing fee.   80.5 - Self-Administered Drugs  (Rev. 1539:  Issued:  06- 20-08; Effective/Implementation Date:  07 -21-08)  See Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 50.2.
(Medicare Claims Processing Manual)
See Pub. 100- 02, Medicare Benefit Policy Manual, chapter 15, section 50.2.  80.6 - Intravenous Immune Globulin  (Rev. 3085, Issued: 10- 03-14, Effective: ICD -10: Upon Implementation of ICD -10; ASC X12: January 1, 2012, Implementation: ICD -10: Upon Implementation of ICD -10; ASC X12: November 4, 2014)   Beginning for dates of service on or after January 1, 2004, Medicare pays for intravenous immune globulin administered in the home.  (See the Medicare Benefit Policy Manual, Chapter 15 for coverage requirements.)  Contractors pay for the drug, but not the items or services related to the administration of the drug when administered in the home, if deemed medically appropriate.   Contractors may pay any entity licensed in the State to furnish intravenous immune globulin.  Payment will be furnished to the entity with the authority to furnish the drug. intravenous immune glogulin Beneficiaries are ineligible to receive payment for the drug.   Pharmacies and hospitals dispensing intravenous immune globulin for home use would bill the DME MAC.  If the beneficiary is receiving treatment in an outpatient hospital, the bill must be sent to the A/B MAC (A).  If the beneficiary is receiving treatment in a physicians office, the bill must be sent to the A/B MAC (B).  Home Health Agencies dispensing intravenous immune globulin would bill the A/B MAC (HHH).  Physicians furnishing intravenous immune globulin for the refilling of an external pump for home infusion would bill the DME MAC.  Effective January 1, 2006, Medicare makes an additional payment once per day per beneficiary for preadministration- related services whenever a beneficiary receives intravenous immune globulin.  80.7 - Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee  (Rev. 754, Issued: 11- 10-05, Effective: 01 -01-06, Implementation: 01- 03-06)
(Medicare Claims Processing Manual)
80.7 - Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee  (Rev. 754, Issued: 11- 10-05, Effective: 01 -01-06, Implementation: 01- 03-06)  Section 303(e) (2) of the MMA implements a supplying fee for immunosuppressive drugs, oral anti -cancer chemotherapeutic drugs, and oral anti -emetic drugs used as part of an anti -cancer chemotherapeutic regimen.  Effective January 1, 2005, Medicare paid a separately billable supplying fee of $24.00 to a pharmacy, dialysis facility in the State of  Washington or any hospital outpatient department not subject to the OPPS  for each supplied prescription of the above -mentioned drugs.  In addition, Medicare also paid a separately billable supplying fee of $50.00 for the initial supplied prescription of the immunosuppressive drugs during the first month following the patients  transplant.
(Medicare Claims Processing Manual)
Effective January 1, 2006, we are changing the supplying fee when multiple prescriptions are supplied in a 30- day period.  Medicare will pay $24 for the first prescription of the above -mentioned drugs supplied by a pharmacy in a 30- day period, and will pay $16 for each subsequent prescription, after the first one, supplied in that 30- day period.  A pharmacy will be limited to one $24 fee per 30- day period even if the pharmacy supplies more than one category of the abovementioned drugs (for example, an oral -anticancer drug and an oral anti -emetic drug) to a beneficiary.  If two different pharmacies supply the above -mentioned drugs to a beneficiary during a 30- day period, each pharmacy will be eligible for one $24 supplying fee for the first prescription suppl ied during that 30- day period, and a supplying fee of $16 for each subsequent prescription supplied in that 30-day period.  For a refill prescription, Medicare will allow payment of a $24 supplying fee to a particular supplier up to seven days before the e nd of the 30 -day period for which the last $24 supplying fee was paid to that supplier; however, each supplier will be limited to twelve $24 supplying fees per beneficiary per year.  Medicare will pay a supplying fee for each prescription, including prescriptions for different strengths of the same drug supplied on the same day (for example, a prescription for 100 mg tablets and 5 mg Tablets).  These changes do not alter the one -time $50 supplying fee for the first immunosuppressive prescription after a tra nsplant.
(Medicare Claims Processing Manual)
We are also changing the dispensing fee for inhalation drugs furnished through durable medical equipment.  Effective January 1, 2006, Medicare will pay an initial dispensing fee of $57 to a pharmacy for the initial 30- day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that time.  This initial 30 -day dispensing fee is a one -time fee applicable only to beneficiari es who are using inhalation drugs for the first time as a Medicare beneficiary.  Except in those circumstances where an initial 30 -day dispensing fee is applicable, Medicare will pay a dispensing fee of $33 to a pharmacy/supplier for each 30- day supply of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during the 30 day period.  Medicare will pay a dispensing fee of $66 to a pharmacy/supplier for each 90 -day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during the 90 days.  Only one 30- day dispensing fee will be payable per 30 -day period, and only one 90- day dispensing fee will be payable per 90-day period, regardless of the numbers of suppliers used during the respective periods.  A 30-day and 90- day supplying fee cannot be paid for drug supplied for the same month.  For a refill prescription, Medicare will allow payment of the dispensing fee no sooner than 7 days before the end of usage for the current 30- day or 90- day period for which a dispensing fee was previously paid.  Each inhalation drug supplier will be allowed no more than 12 months of dispensing fees per beneficiary per year.  Medicare will not pay separately for compounding drugs.  This cost  is in the dispensing fees.    Supply fees and dispensing fees must be billed on the same claim as the drug.  HCPCS Codes and Fees:   GO369, G0370, G0371, G0374 -  not recognized by Medicare as of 1/1/06.
(Medicare Claims Processing Manual)
HCPCS Codes and Fees:   GO369, G0370, G0371, G0374 -  not recognized by Medicare as of 1/1/06.   Q0510 -  First immunosuppressive prescription after a transplant , $50.00 fee   Q0511 -  Pharmacy supplying fee for immunosuppressive, oral -anti-cancer, and oral anti -emetic drugs, first prescription in a one month period.  Each pharmacy may receive this fee once in a 30 -day period.  Fee is $24.00.   Q0512 -  Pharmacy supplying fee for immunosuppressive, oral anti -cancer, and oral anti -emetic drugs -  each subsequent prescription in a 30- day period.  Fee is $16.00.  Q0513 -  Pharmacy dispensing fee for inhalation drug(s); per 30 -days.   Effective 1/1/06, Medicare will pay a dispensing fee of $33.00 to a pharmacy for a 30 -day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that period.  Payment will be made on the first claim received.   Q0514 -  Pharmacy dispensing fee for inhalation drugs(s); per 90 -days.  Effective 1/1/06, Medicare will pay a dispensing fee of $66.00 to a pharmacy for a 90 -day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that period.  Payment will be made on the first claim received.   G0333-  Pharmacy dispensing fee for initial inhalation drug(s); initial 30 day supply to a beneficiary.
(Medicare Claims Processing Manual)
G0333-  Pharmacy dispensing fee for initial inhalation drug(s); initial 30 day supply to a beneficiary.   Effective January 1, 2006, Medicare will pay an initial dispensing fee of $57.00 to a pharmacy for the initial 30- day period of inhalation drugs furnished through DME regardless of the number of shipments or drugs dispensed during that time and regardless of the number of pharmacies used by a beneficiary during that time.  This initial 30- day dispensing fee is a one -time fee applicable only to beneficiaries who are using inhalation drugs for the first time as a Medicare beneficiary.   Based on the code descriptions above, a supplying fee and a dispensing fee is not appropriate for one drug.  The supplying fee is for immunosuppressives, oral anti -cancer drugs and oral anti -emetic drugs.  The dispensing fee is for inhalation drugs only.  A supplier cannot be paid for more than one of the following -- an initial dispensing fee  (G0333), a 30 -day dispensing fee (Q0513), or a 90 -day dispensing fee (Q0514) -  for a beneficiary for the same period.   80.8 - Reporting of Hematocrit and/or Hemoglobin Levels  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  Effective January 1, 2008, the following claims must report the most recent hematocrit or hemoglobin reading:   1.  All claims billing for the administration of an ESA (HCPCS J0881, J0882, J0885, J0886 and Q4081).  2.  All claims for the administration of a Part B anti -anemia drug (other than ESAs) used in the treatment of cancer that are not self -administered.   For institutional claims the hemoglobin reading is reported with a value code 48 and a hematocrit reading is reported with the value code 49.  Claims not reporting a value code 48 or 49 will be returned to the provider.
(Medicare Claims Processing Manual)
For institutional claims the hemoglobin reading is reported with a value code 48 and a hematocrit reading is reported with the value code 49.  Claims not reporting a value code 48 or 49 will be returned to the provider.   For professional paper claims, test results are reported in item 19 of the Form CMS -1500 claim form.  For electronic claims (ASC X12 837 professional claim format), providers report the hemoglobin or hematocrit readings in Loop 2400 MEA segment.  The speci fics are MEA01=TR (for test results), MEA02=R1 (for hemoglobin) or R2 (for hematocrit), and MEA03=the test results.   Effective for dates of service on and after January 1, 2008, contractors will return paper and electronic professional claims when the most recent hemoglobin or hematocrit test results are not reported.   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 Two.  Group Code: CO  CARC: 16  RARC: N764  MSN: N/A  80.9 - Required Modifiers for ESAs Administered to Non -ESRD Patients  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  Effective January 1, 2008, all non- ESRD claims billing HCPCS J0881 and J0885 must begin reporting one of the following modifiers:   EA: ESA, anemia, chemo -induced   EB: ESA, anemia, radio -induced  EC: ESA, anemia, non- chemo/radio  Institutional claims that do not report one of the above modifiers will be returned to the provider.   Professional claims that are billed without the required modifiers will be returned as unprocessable.
(Medicare Claims Processing Manual)
Institutional claims that do not report one of the above modifiers will be returned to the provider.   Professional claims that are billed without the required modifiers will be returned as unprocessable.   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 Two.  Group Code: CO  CARC: 4  RARC: N/A   MSN: N/A  ESAs administered for more than one of the indicated therapies are billed as separate line items (i.e., ESAs for chemo- induced anemia (EA modifier) are reported as separate line items (e.g., J0881EA); ESAs for radio- induced anemia (EB modifier) are reported as separate line items (e.g., J0885EB); ESAs for non- chemo/radio induced anemia (EC modifier) are reported as separate line items (e.g., J0881EC).  Only one of the three ESA modifiers may be reported at the line item level.    To return HCPCS J0881 or J0885 billed with more than one ESA modifier at the line item level, 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 Two.   Group Code: CO  CARC: 16  RARC: N63  MSN: N/A  80.10 - Hospitals Billing for Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for Non -ESRD Patients  (Rev. 1412, Issued: 01- 11-08, Effective: 01 -01-08, Implementation: 04- 07-08)
(Medicare Claims Processing Manual)
NOTE:  For EPO and Aranesp billing instructions for beneficiaries with ESRD, see the Claims Processing Manual, Chapter 8, sections 60.4 and 60.7.  For patients with chronic renal failure who are not yet on a regular course of dialysis, EPO and Aranesp administered in a hospital and billed as an outpatient service on type of bill 13x or inpatient Part B bill type 12x are paid under the Outpatient Pros pective Payment System (OPPS).  Non- OPPS hospitals are paid on reasonable charges.   Hospitals report charges under revenue code 0636.  For EPO, hospitals report charges under revenue code 0636 with HCPCS code J0885 effective January 1, 2006.  Aranesp is reported with HCPCS code J0881 effective January 1, 2006.  80.11 - Requirement for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)  (Rev. 1212; Issued:  03- 30-07; Effective:  01 -01-07; Implementation:  06 -29-07)  Patients with end stage renal disease (ESRD) receiving administrations of erythropoiesis stimulating agents (ESA), such as epoetin alfa (EPO) and Darbepoetin alfa (Aranesp) for the treatment of anemia may receive intravenous administration or subcutaneous administrations of the ESA.   Effective for claims submitted on or after February 1, 2007 with dates of services on or after January 1, 2007, all providers billing for injections of ESA for ESRD beneficiaries are encouraged to include the modifier JA on the claim to indicate an intrave nous administration or modifier JB to indicate a subcutaneous administration.  All providers billing for injections of ESAs for ESRD beneficiaries will be required to include route of administration when claims processing system changes are completed.  Renal dialysis facilities claim including charges for administrations of the ESA by both methods must report separate lines to identify the number of administration provided using each method.  80.12 - Claims Processing Rules for ESAs Administered to Cancer  Patients for Anti -Anemia Therapy  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)
(Medicare Claims Processing Manual)
The national coverage determination (NCD) titled, The Use of ESAs in Cancer and Other Neoplastic Conditions lists coverage criteria for the use of ESAs in patients who have cancer and experience anemia as a result of chemotherapy or as a result of the cancer itself.  The full NCD can be viewed in Publication 100- 03 of the NCD Manual, section 110.21.  Effective for claims with dates of service on and after January 1, 2008, non- ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EC (ESA, anemia, non-chemo/radio) shall be denied when any one of the following diagnosis codes is present on the claim:  ICD- 9-CM Applicable   any anemia in cancer or cancer treatment patients due to folate deficiency (281.2),   B-12 deficiency (281.1, 281.3),  iron deficiency (280.0- 280.9),  hemolysis (282.0, 282.2, 282.9, 283.0, 283.2, 283.9- 283.10, 283.19), or   bleeding (280.0, 285.1),    anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML) (205.00- 205.21, 205.80- 205.91); or   erythroid cancers (207.00- 207.81).
(Medicare Claims Processing Manual)
ICD- 10-CM Applicable   any anemia in cancer or cancer treatment patients due to folate deficiency - (D52.0, D52.1, D52.8, or D52.9),   B-12 deficiency - (D51.1, D51.2, D51.3, D51.8, D51.9, or D53.1),   iron deficiency -  (D50.0, D50.1, D50.8, and D50.9),  hemolysis -  (D55.0, D55.1, D58.0, D58.9, D59.0, D59.1, D59.2, D59 4, D59.5, D59.6, D59.8, or D59.9),   bleeding -  (D50.0, D62),   anemia associated with the treatment of acute and chronic myelogenous leukemias (CML, AML) - (C92.00, C92.01, C92.02, C92.10, C92.11, C92.12, C92.20, C92.21, C92.40, C92.41, C92.42, C92.50, C92.51, C92.52, C92.60, C92.61, C92.62, C92.90, C92.91, C92.A0, C92.A1, C92.A2, C92Z0, C92Z1, or C92Z2), or   erythroid cancers - (C94.00, C94.01, C94.02, C94.20, C94.21, C94.22, C94.30, C94.31, C94.80, C94.81, D45).
(Medicare Claims Processing Manual)
Effective for claims with dates of service on and after January 1, 2008, contractors shall deny non- ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EC (ESA, anemia, non- chemo/radio) for:    any anemia in cancer or cancer treatment patients due to bone marrow fibrosis,  anemia of cancer not related to cancer treatment,   prophylactic use to prevent chemotherapy -induced anemia,   prophylactic use to reduce tumor hypoxia,  patients with erythropoietin -type resistance due to neutralizing antibodies; and  anemia due to cancer treatment if patients have uncontrolled hypertension.   Effective for claims with dates of service on and after January 1, 2008, non- ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EB (ESA, anemia, radio-induced), shall be denied.  Effective for claims with dates of service on and after January 1, 2008, contractors shall deny non- ESRD ESA services for HCPCS J0881 or J0885 billed with modifier EA (ESA, anemia, chemo -induced) for anemia secondary to myelosuppressive anticancer chemothe rapy in solid tumors, multiple myeloma, lymphoma, and lymphocytic leukemia when a hemoglobin 10.0g/dL or greater or hematocrit 30.0% or greater is reported.   NOTE:   ESA treatment duration for each course of chemotherapy includes the 8 weeks following the final dose of myelosuppressive chemotherapy in a chemotherapy regime.    Effective for claims with dates of service on and after January 1, 2008, Medicare contractors shall have discretion to establish local coverage policies for those indications not included in NCD 110.21.  Denials of claims for ESAs are based on reasonable and necessary determinations established by NCD 110.21.  A provider may have the beneficiary sign an Advanced Beneficiary Notice, making the beneficiary liable for services not deemed reasonable and necess ary and thus not covered by Medicare.
(Medicare Claims Processing Manual)
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: PR or CO  CARC: 50  RARC: N/A  MSN: 15.20  Medicare contractors have the discretion to conduct medical review of claims and reverse the automated adjudication if the medical review results in a determination of clinical necessity.   80.13  Supplier Payment Under Medicare Part B for Insulin Furnished Through Durable Medical Equipment                                                      (Rev. 12013; Issued: 05- 02-23; Effective: 07 -01-23; Implementation: 07 -03-23)  For insulin administered through an item of DME see Pub. 100- 04 Chapter 20,  Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Section 140.1.1 for further instruction.   90 - Claims Processing Rules for Hospital Outpatient Billing and Payment  (Rev. 1, 10- 01-03)  90.1 - Blood/Blood Products and Drugs Classified in Separate APCs for Hospital Outpatients  (Rev. 496, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)  Proper Billing for Blood Products and Blood Storage and Processing  Refer to Pub.100- 04, Medicare Claims Processing Manual, Chapter 4, 231 regarding billing for blood and blood products under the Hospital Outpatient Prospective Payment System (OPPS).       90.2 - Drugs, Biologicals, and Radiopharmaceuticals  (Rev. 4204, Issued: 01- 17-19, Effective: 01 -01-19, Implementation: 01- 07-19)   A. General Billing and Coding for Hospital Outpatient Drugs, Biologicals, and Radiopharmaceuticals   Hospitals should report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used.  It is also of great importance that hospitals billing for these products make certain that the reported units of service of the reported HCPCS code are consistent with the quantity of a drug, biological, or radiopharmaceutical that was used in the care of the patient.