evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Input records on claims must include all input items. Output records will contain all input and output items. The Medicare claims processing systems will move the following Pricer output items to the claim record. The return code will be placed in the claim header. The SNF -PAYMENT -RATE amount for each HIPPS code will be placed in the rate field of the appropriate revenue code 0022 line.  The Medicare claims processing systems will multiply the rate on each 0022 line by the number of units that correspond to each line.  The system will sum all 0022 lines and place this amount in the Provider Reimbursement field minus any coinsurance due from the patient.  For claims with dates of service on or after July 1, 2002, Pricer will compute payment only where the SNF -RTC is 00.   30.4.2  SNF PPS Rate Components (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  The SNF PPS rate for each RUG group consists of 3 components:  a nursing component, a therapy component and a non- case- mix adjusted component.  The following describes the rate components used for SNF PPS:    The nursing per diem amount is a standard amount which includes direct nursing care and the cost of non- therapy ancillary services required by Medicare beneficiaries.    The nursing index is based on the amount of staff time, weighted by salary levels, associated with each RUG group.  This index represents the amount of nursing time associated with caring for beneficiaries who qualify for the group.   The nursing per diem amount is case -mix adjusted by applying the nursing index.  The result is the nursing component for that RUG group.   The therapy per diem amount is a standard amount which includes physical, occupational, and speech- language therapy services provided to beneficiaries in a Part A stay.  Payment varies based on the actual therapy resource minutes received by the beneficiar y and reported on the MDS;    The therapy index is based on the amount of staff time, weighted by salary levels, associated with each RUG group.  This index represents the amount of rehabilitation treatment time associated with caring for beneficiaries who qualify for the group.
(Medicare Claims Processing Manual)
 The therapy index is based on the amount of staff time, weighted by salary levels, associated with each RUG group.  This index represents the amount of rehabilitation treatment time associated with caring for beneficiaries who qualify for the group.   If the RUG group is in the Rehabilitation plus Extensive Services or Rehabilitation category, the therapy per diem amount is case- mix adjusted by applying the therapy index.  The result is the therapy component for that Rehabilitation RUG group.   The non- case- mix therapy component is a standard amount to cover the cost of therapy assessments of beneficiaries who were determined not to need continued therapy services.   If the RUG group is not in the Rehabilitation plus Extensive Services or Rehabilitation category, this payment is added to the rate as therapy component for that RUG group.    The non- case- mix component is also a standard amount added to the rate for each RUG group to cover administrative and capital -related costs.   This standard amount is added to all RUG groups.  As of October 1, 2019, SNF PDPM changes are effective (see 120ff.).  30.4.3 - Decision Logic Used by the Pricer on Claims  (Rev. 4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)  A. Claims for services furnished prior to October 1, 2019, under RUG -IV  The SNF Pricer shall calculate the rate for each line item with revenue code 0022 on a SNF claim.  The SNF Pricer shall determine the rate using the following information:  - HIPPS-CODE on line item 0022; -CBSA  - Per diem amounts defined within the Pricers as types of rate based on the statement covers THRU -DATE:   Inpatient rate = Nursing case mix component  General service rate = Non -case-mix component  Therapy rate = Therapy non -case mix component
(Medicare Claims Processing Manual)
Inpatient rate = Nursing case mix component  General service rate = Non -case-mix component  Therapy rate = Therapy non -case mix component   Rehabilitation rate = Therapy case-mix component - Labor and non labor percentages based on the statement covers THRU-DATE;  - Wage index, SNF -FED BLEND year, and SNF -FACILITY RATE based on the statement covers THRU_DATE  - Rate adjustments applicable to the specific RUG code;  - Nursing index based on the RUG code; - Therapy index based on the rehabilitation RUG code;  On input records with TOB 21x (that is, all provider submitted claims and provider or A/B MAC (A) initiated adjustments), Pricer will perform the following calculations in numbered order for each RUG code:  (1) Multiply the applicable urban or rural inpatient rate depending on CBSA by the nursing index;  (2) Multiply the applicable urban or rural rehab rate by the therapy index, add to (1);  (3) For the top 23 RUG categories, add the general service rate to the sum of (1) and (2) for the (non- wage-adjusted) total PPS rate and proceed to step (4); OR for the lower 43 RUG categories, add the general service rate to the therapy rate to the sum of (1) and (2) for the (non- wage - adjusted) total PPS rate and proceed to step (4);  (4) Multiply the sum of (3) by the labor percentage then multiply the product by the applicable wage index and round;  (5) Multiply the sum of (3) by the non- labor percentage and round;  (6) Add the product of (5) to the non-labor product in (4) for the (wage-adjusted) total PPS rate.   Conditional Steps completed if applicable after (6):  (6a) If ICD -10-CM diagnosis code B20 (or, for services furnished prior to October 1, 2015, ICD-9-CM diagnosis code 042) is present, multiply (6) by 2.28.  B. Claims for services furnished on or after October 1, 2019, under the SNF PDPM
(Medicare Claims Processing Manual)
The SNF PDPM Pricer shall calculate the rate for each line item with revenue code 0022 on a SNF claim.   The SNF PDPM Pricer shall determine the rate using the following information: SNF PRICER uses the REGION IND, HIPPS CODE, QRP -IND & AIDS ADD- ON-IND to CALCULATE THE HCPPS RATES.                          1.    CBSA   a.    URBAN = 5 numeric characters  b.    RURAL = 3 spaces & 2 digit state code c.    SPECIAL = APPLY SPECIAL WAGE INDEX "IN LIEU" OF CBSA WAGE INDEX                                                                   i.     SPECIAL = SNF- SPEC -WI-IND = '1' ON SNF-INPUT -RECORD and SNF -SPEC -WI-X = 5 numeric characters                                                                  ii.     CBSA -WIR -EFFDATE = '20051001'.   2.    HIPPS CODE - 5 CHARACTERS = 4 alpha/1 numeric character. [on line item 0022] Evaluate each of the 1st four characters to select component rates:  a.    Character # 1 = component rate for Physical Therapy (PT) & Occupational Therapy (OT). There are 16 PDPM Groups A thru P.  b.    Character # 2 = component rate for Speech Language Pathology  (SLP). There are 12 PDPM Groups A thru L. c.    Character # 3 = component rate for Nursing. There are 25 PDPM Groups A thru Y.  d.    Character # 4 = component for Non-Therapy Ancillary (NTA). There are 6 PDPM Groups A thru F.  e.    Character # 5 = component for Non-Case Mix (NCM) which do not impact the rates selected, but supply information about Assessment Level.                                                           i.     5-day assessment =   1                                                          ii.      IPA   = 0    3.    Non -Case- Mix component is fixed rate based on REGION -IND & QRP -IND [4 options  URBAN, RURAL, URBAN- QRP, & RURAL -QRP applied equally to each payment)                   4.    IF SNF -FED -BLEND =1      SET QRP IND TO Y  identifies that a reduced payment component rate should be selected.   5.    Variable Per Diem adjustment factor applies to PT/OT & NTA components only based on the day- in-stay;
(Medicare Claims Processing Manual)
5.    Variable Per Diem adjustment factor applies to PT/OT & NTA components only based on the day- in-stay;    6.    Nursing component is adjusted by factor of 1.18 when AIDS Add -On-Indicator is set to Y ( If input field SNF -PRIN -DIAG -CODE OR [SNF -OTHER -DIAG -CODE2 thru  SNF-OTHER -DIAG -CODE25] = 'B20   '.   7. NTA component is adjusted by reassigning a new component rate when AIDS Add -On-Indicator is set to Y (( If input field SNF -PRIN -DIAG -CODE OR [SNF -OTHER -DIAG -CODE2 thru  SNF-OTHER -DIAG -CODE25] = 'B20   '.  a. If reported NTA group is NF, reassigned NTA group is NC  b. If reported NTA group is NE, reassigned NTA group is NB  c. If reported NTA group is ND, reassigned NTA group is NA  d. If reported NTA group is NC, reassigned NTA group is NA  e. If reported NTA group is NB, reassigned NTA group is NA  f. If reported NTA group is NA, no reassignment is necessary (NA represents the highest per diem component rate).    8.       SNF -PDPM -UNITS   & VBP -MULTIPLIER cannot be = zero    9.    SNF -PDPM -PRIOR DAYS > 100 NF processing HALTS & an ERROR Code is placed in SNF -RTC      On input records with TOB 21x (that is, all provider submitted claims and provider or A/B MAC (A) initiated adjustments), Pricer will perform the following calculations in numbered order  for each SNF input character:    .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .      (1)     Capture/select the applicable rate components associated with each HIPPS CODE character from rate tables determined by the Region IND, QRP -IND and AID Add -On IND (applies to Nursing only).
(Medicare Claims Processing Manual)
(2)     Compute the PT -OT-FEE ROUNDED =     HIPPS- PT-RATE -COMP + HIPPS-OT-RATE -COMP.    (3)     Compute the PT -OT-PORTION ROUNDED =    PT -OT-FEE *  PT -OT-UTIL. (Utilization Days for PT -OT is determined by summing the PT -OT Variable Per Diem factors  for Total Days (CURRENT -DAYS + PRIOR -DAYS.)).    (4)     Compute the NTA -PORTION ROUNDED =  HIPPS- NTA- RATE -COMP * NTA- UTIL.   (Utilization Days for NTA category is determined by summing the NTA Variable Per Diem factors  for Total Days (CURRENT -DAYS + PRIOR -DAYS.).    (5)     Compute NURS -SLP-NCM -PORTION ROUNDED =     (HIPPS- NURSE -RATE -COMP +     HIPPS- SLP-RATE -COMP +    HIPPS- NCM -RATE -COMP) * CURRENT -DAYS (or SNF -PDPM -UNITS).                                                   (6)     Compute TOT -PDPM -CASEMIX -PERDIEM = (PT -OT-PORTION +     NTA-PORTION +    NURS -SLP- NCM -PORTION).     ALL 3 PORTIONS ARE ADDED TOGETHER TO GET THE  TOTAL CASE MIX PER DIEM.    (7)     Compute LABOR -PORTION ROUNDED =       (TOT -PDPM -CASEMIX -PERDIEM * PERCENT- 2020- LABOR).                                                           (8)     Compute LABOR -ADJUSTED ROUNDED =    (LABOR -PORTION * AREA-WAGE -INDEX).                                                                         (9)     Compute NON -LABOR -PORTION ROUNDED =    (TOT -PDPM -CASEMIX -PERDIEM * PERCENT- 2020- NLABOR)                                                           (10)  Compute TOTAL -LABOR -ADJ-RATE ROUNDED =    (LABOR -ADJUSTED + NON- LABOR -PORTION).     (11)  Compute TOTAL -CALC -PAYMENT -RATE ROUNDED = TOTAL -LABOR -ADJ-RATE.                                                                         (12)  Apply the VBP (Value Based Purchasing Factor).            Compute SNF -PAYMENT -RATE ROUNDED =   VBP -MULTIPLIER *   TOTAL-CALC -PAYMENT -RATE.                                                                     (13)  Obtain the VBP PAY Difference  Compute VBP -PAY- DIFF ROUNDED =   SNF -PAYMENT -RATE -  TOTAL -CALC -PAYMENT -RATE.
(Medicare Claims Processing Manual)
(13)  Obtain the VBP PAY Difference  Compute VBP -PAY- DIFF ROUNDED =   SNF -PAYMENT -RATE -  TOTAL -CALC -PAYMENT -RATE.   30.5 - Annual Updates to the SNF Pricer  (Rev. 10880, Issued: 08- 06-21, Effective: 11 -08-21, Implementation: 11- 08-21)  Rate and weight information used by the SNF Pricer is updated periodically, usually annually.  Updates occur each October, to reflect the fact that SNF PPS rates are effective for a Federal fiscal year.  Updates may also occur at other points in the year w hen required by legislation.  The following update items, when changed, are published in the Federal Register:"    The following components of the unadjusted Federal rates for both Rural and Urban areas:  o physical therapy,  o occupational therapy,  o speech -language pathology,  o nursing,  o non-therapy ancillary, and  o non-case-mix.   The case- mix indexes to be used for each case -mix group.   The factors to be applied in making the area wage adjustment.   Changes, if any, to the labor and non- labor percentages.   Whenever these update items change, Medicare also publishes a Recurring Update Notification to inform providers and A/B MACs (A) about the changes.  These Recurring Update Notifications also describe how the changes will be implemented through the SNF Pric er.  40 - Special Inpatient Billing Instructions  (Rev. 1733; Issued: 05- 08-09; Effective Date:  10 -01-06; Implementation Date:  04-27-09) The SNFs bill upon the following:   Discharge;   Benefit exhaustion; (Note: Submit both full and partial benefits exhaust claims monthly)   A decrease in level of care to less than skilled care; or   Monthly (and if necessary, monthly thereafter).  Each bill must include all diagnoses applicable to the admission.  However, SNFs do not include charges that were billed on an earlier bill.  The from date must be the day after the through date on the prior bill.  40.1 - Submit Bills in Sequence  (Rev. 1, 10- 01-03) SNF -517.13, A3- 3603.2
(Medicare Claims Processing Manual)
40.1 - Submit Bills in Sequence  (Rev. 1, 10- 01-03) SNF -517.13, A3- 3603.2   The SNFs must submit bills in sequence for each beneficiary they service.  The A/B MAC (A) will return to the SNF a continuing stay bill if the prior bill has not been processed.  When the A/B MAC (A) receives an out -of-sequence claim for a continuous stay, it will search its history for the prior adjudicated claim.  If the prior bill has not been finalized, the A/B MAC (A) will return to the provider (RTP), the incoming bill, request that the prior bill be submitted first, and the returned bill only be submitted after the SNF receives notice of adjudication of the prior bill.  A typical error message follows:   Bills for a continuous stay or admission must be submitted in the same sequence in which services are furnished.  If the provider has not already done so, please submit the prior bill.  Then, resubmit this bill after you receive the remittance advice for t he prior bill.   If the prior bill was submitted, the SNF will hold the returned bill until it receives a remittance advice for the prior bill.   40.2 - Reprocessing Inpatient Bills in Sequence  (Rev. 2245, Issued: 06- 16-11, Effective: 08 -01-11, Implementation: 08- 01-11)
(Medicare Claims Processing Manual)
40.2 - Reprocessing Inpatient Bills in Sequence  (Rev. 2245, Issued: 06- 16-11, Effective: 08 -01-11, Implementation: 08- 01-11)  When a beneficiary experiences multiple admissions (to the same or different facilities) during a benefit period, claims are processed by CWF in the same order that they are received, regardless of the dates on which expenses were incurred.  This first -in-first-out method of processing requests for payment facilitates prompt handling of claims.  If a SNF, any beneficiary, or secondary insurer have increased liability as a result of CWFs first -in/first- out (FI/FO) processing, the SNF must notify the A/B MAC (A) to arrange reprocessing of all affected claims.  This approach  is not applicable if the liability stays the same, e.g., if the coinsurance or deductible amounts are applied on the second stay instead of the first, but there is no issue with regard to the effective date of supplementary coverage or if the beneficiary is responsible for payment of the first claim instead of the second.   The A/B MAC (A) will verify and cancel any bills posted out -of-sequence and request that any other A/B MAC (A) involved also cancel any affected bills.  The A/B MAC (A) will reprocess all bills in the benefit period in the sequence of the beneficiarys stays to properly allocate days where payment is made in full by Medicare and to identify those days where the beneficiary is required to pay coinsurance.   40.3 - Determining Part A Admission Date, Discharge Date, and Utilization Days  (Rev. 1, 10- 01-03) SNF -515.4, SNF -515.4   40.3.1 - Date of Admission  (Rev. 229, Issued 07- 20-04 Effective/Implementation 08 -19-04)
(Medicare Claims Processing Manual)
40.3.1 - Date of Admission  (Rev. 229, Issued 07- 20-04 Effective/Implementation 08 -19-04)  The beneficiary, entitled to Part A benefits, becomes a SNF resident for Part A PPS billing purposes when admitted to a Medicare certified SNF or DPU.  This could be a first time admission or a readmission following events described in 40.3.2.  Services on and after this day are included in the PPS rate and cannot be billed by other providers and suppliers unless excluded as described in this chapter.  40.3.2 - Patient Readmitted Within 30 Days After Discharge  (Rev.  10569, Issued: 01- 14-21, Effective: 04 -01-21, Implementation: 04- 05-21)
(Medicare Claims Processing Manual)
40.3.2 - Patient Readmitted Within 30 Days After Discharge  (Rev.  10569, Issued: 01- 14-21, Effective: 04 -01-21, Implementation: 04- 05-21)   A patient is deemed not to have been discharged if the time between SNF discharge and readmission to the same or another SNF is within 30 days. (See the Medicare Benefit Policy Manual, Chapter 8, Coverage of Extended Care Services (SNF) Under Hospital Insurance, 20.2.) However, if more than 30 days elapse after the patients discharge from a participating SNF or after his/her transfer to a nonparticipating part of the institution, the patient must again meet the 3 -day hospital stay requirement to become eligible for SNF benefits. When a discharge bill has been sent and the patient is readmitted to the SNF within 30 days, the SNF must submit another bill, which shows the current admission date and the following additional data.  The SNF must complete condition code 57 on the claim to indicate the patient previously received Medicare covered SNF care within 30 days of the current SNF admission.  The SNF must complete occurrence span code 70 to indicate the qualifying stay dates for a hospital stay of a t least 3 days which qualifies the patient for payment of the SNF level of care services billed on the claim. If a discharge bill has not been sent at the time of readmission, the SNF must submit an interim bill with occurrence code 74 to show the from/t hrough dates of the leave of absence (the period the patient was not in the facility) and the number of noncovered days. For claims that contain both covered days and noncovered days, and those noncovered days are the responsibility of the beneficiary (e.g., days submitted for noncovered level of care), the provider should append span code 76 to indicate the days the beneficiary is liable.   40.3.3 - Same Day Transfer  (Rev.  4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)
(Medicare Claims Processing Manual)
40.3.3 - Same Day Transfer  (Rev.  4001, Issued: 03- 16-18, Effective: 06 -19-18, Implementation: 06- 19-18)  The day of admission counts as a utilization day, except in the situation where the patient was admitted with the expectation that he remain overnight but was transferred to another participating provider before the following midnight.  In this instance, the first provider completes the bill as follows:   Indicate 0 in Covered Days;    Insert condition code 40 to indicate the patient was transferred from one participating provider to another before the midnight immediately following the admission to the first provider; and,    Admission date, statement from and through dates are the same.   No payment is made to the originating participating provider.  Instead, the participating provider to which the patient was transferred counts the admission day as a utilization day that includes the day of admission and may bill the HIPPS default code.  If a patient is transferred from a Medicare participating facility to a nonparticipating facility the day of admission counts as a utilization day and the Medicare- participating facility may bill the HIPPS default code.   These general rules apply to transfers between SNFs and between a hospital and an SNF. However, under these same circumstances, if the two providers represent an institution composed of a participating hospital and a distinct part participating SNF, the fi rst provider cannot bill for accommodations, but may bill for ancillary charges.  40.3.4 - Situations that Require a Discharge or Leave of Absence  (Rev.  4001, Issued: 03- 16-18, Effective: 06-19-18, Implementation: 06-19-18)  Medicare systems are set up so that the SNF need not submit a discharge bill when the situation is that the beneficiary (who leaves the SNF and then returns before the following midnight) receives outpatient services from a Medicare participating hospital, CAH, or other appropriate provider during his/her absence.  Edits allow hospitals and CAHs to bill for these services for a beneficiary in a Part A PPS stay.  Receipt of outpatient services from another provider does not normally result in a SNF discharge.
(Medicare Claims Processing Manual)
Two situations force a discharge from a SNF:  1) the beneficiarys admission as an inpatient to a Medicare participating hospital or CAH, or 2) the beneficiarys transfer to another SNF for inpatient services.  A beneficiary cannot be an inpatient in more than one facility at a time.  Consequently, the SNF must  submit a discharge bill if either of these events occur.   If the patient is readmitted to the SNF, the SNF should submit a new bill (TOB 211 or 212) with a new admission date.  See 40.3.2, Patient Readmitted Within 30 days After Discharge, for further instructions.  Bills for excluded services (identified in 20 of this chapter) rendered by participating hospitals, CAHs, or other appropriate providers may be paid to the rendering provider in addition to the Part A PPS payment made to the SNF.  Other outpatient services furnished to a resident in a Part A PPS stay  by another provider/supplier must be billed by the SNF.  Home health or outpatient services provided during a leave of absence do not affect the leave and no discharge bill is required.  Home health services are not payable unless the patient is confined to his home, and under Medicare regulations, a SNF cannot qualify as a home.  Where the beneficiary receives services from a home health agency, the home health agency is responsible for billin g.  If the beneficiary is formally discharged or otherwise departs for reasons other than described above but then, is readmitted or returns before the following midnight, he is not considered discharged.  The SNF is responsible for billing for services during the period of absence, unless such services are otherwise excluded from Part A PPS payment or are excluded from Medicare coverage (see 10.1).  NOTE:   This instruction only applies to Medicare fee- for-service beneficiaries in a participating SNF.   40.3.5 - Determine Utilization on Day of Discharge, Death, or Day Beginning a Leave of Absence  (Rev.  4001, Issued: 03- 16-18, Effective: 06-19-18, Implementation: 06-19-18) SNF -517.6.B, A3-3103.4