evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
50.3 - Transitional Pass Through Payments for Designated Devices  (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  Certain designated new devices are assigned to APCs and identified by the OCE as eligible for payment based on the reasonable cost of the new device reduced by the amount included in the APC for the procedure that reflects the packaged payment for devices used with the procedure. OCE will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible.  All related payment calculations will be returned on the same APC line and identified as a designated new device.   Refer to https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html  for the most current OPPS APC Offset File.   50.4  Changes to Pricer Logic Effective April 1, 2002  (Rev. 11941, Issued:04 -05-23, Effective: 04 -01-02, Implementation: 05- 05-23)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning April 1, 2002.  A. New OPPS wage indexes will be effective April 1, 2002.  These are the same wage indexes that were implemented on October 1, 2001, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule, and CMS is using the corrected wage indexes where applicable.  B. Inpatient hospitals considered reclassified on October 1, 2001, will be considered reclassified for OPPS on April 1, 2002.  C. Section 401 designations and floor MSA designations will be considered effective for OPPS on April 1, 2002.   D. New payment rates and coinsurance amounts were effective for OPPS on April 1, 2002, except those 55 APCs with coinsurance amounts limited to 55 percent of the payment rate, which were effective January 1, 2002.  The coinsurance limit equal to the inpatient  deductible of $812 remains effective January 1, 2002.  E. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.
(Medicare Claims Processing Manual)
E. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.   F. If a claim has more than 1 service with a status indicator (SI) of S or T and any lines with SI of S or T have less than $1.01 as charges, charges for all S and/or T lines will be summed and the charges will then be divided up proportionately to the payment rate for each S or T line.  The new charge amount will be used in place of the submitted charge amount in the line item outlier calculation.   EXAMPLE:   SI Charges  Payment Rate New Charges Amount  S $19,999 $6,000 $12,000 T $1 $3,000 $6,000 S $0 $1,000 $2,000  $20,000 $10,000 $20,000  Because total charges here are $20,000 and the first SI of S gets 6,000 of 10,000 total payment, the new charge for that line is 6,000/10,000 * $20,000 = $12,000.  G. All charges on lines with a SI of N (bundled services) on the claim will be summed and the charges will then be divided up proportionately to the payment rate for each S, T, V or X line.  This proportional amount will be added to the new charges amount from item F above or, if that doesn't apply, they will be added to the actual submitted charges for each S, T, V or X before making a line item outlier calculation.   H. Outliers will be calculated at a line item level.  No outlier payment will be calculated for SIs of G, K, N or H, although charges for packaged services (SI=N) will be used in calculating outlier payments for other services as described in G. above.  Price r will use submitted charges as modified by items F and G above.  The CMS changed the factor multiplied times the total claim payments from 2.5 to 3.5 and factor used to multiply the difference between claim payments and costs from .75 to .50.  Pricer will  keep the cost to charge ratio adjustment factor at .981956.  Pricer will sum all line item outlier amounts and output them as a single total claim outlier amount, just as it outputs the outlier amount that contractors are to place in value code 17.
(Medicare Claims Processing Manual)
I. Any claim with one or more APCs that match those listed in Table 1 of the March 1, 2002,  Federal Register will have all applicable APC offset amounts summed and wage adjusted.  The total wage adjusted offset amount will be subtracted proportionately from the charges reduced to costs for any SI H devices that have a HCPCS code beginning with a C, i.e., C1713 through C2631.  J. A pro rata reduction of 63.6 percent applies to all SI G and/or H payments.  For H, devices, the offset (or reduction) is applied to the final payment amount after  all device offset amounts (see item I  above) have been taken.  For SI G, pass thru drugs, CMS determines the pass -through amount (PTA) by subtracting 5 times the minimum coinsurance from the Medicare payment amount.  The CMS will multiply .364 times the PTA and add that amount to 5 times the minimum coinsurance to get the new Medicare payment amount.   K. The provider specific file for SNFs and HHAs that may be reimbursed for splints, casts and/or antigens under OPPS should have a cost to charge ratio of 0.000 (or 0.001 if the shared system will not allow 0.000.  Pricer will not pay outliers for these servi ces.  L. Pricer Drug Copayment Changes   M. APC  N. Drug Name  O. Corrected Copayment  P. 726 Q. Dexrazoxane  R. $27.85 S. 1607 T. Eptifibatide  U. $1.62  50.5 - Changes to Pricer Logic Effective April 1, 2002  (Rev.  11941, Issued:04- 05-23, Effective: 04 -01-02, Implementation: 05- 05-23)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning April 1, 2002.  V. New OPPS wage indexes will be effective April 1, 2002.  These are the same wage indexes that were implemented on October 1, 2001, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule, and CMS is using the corrected wage indexes where applicable.
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W. Inpatient hospitals considered reclassified on October 1, 2001, will be considered reclassified for OPPS on April 1, 2002.  X. Section 401 designations and floor MSA designations will be considered effective for OPPS on April 1, 2002.   Y. New payment rates and coinsurance amounts were effective for OPPS on April 1, 2002, except those 55 APCs with coinsurance amounts limited to 55 percent of the payment rate, which were effective January 1, 2002.  The coinsurance limit equal to the inpatient  deductible of $812 remains effective January 1, 2002.  Z. APC 339, for Observation, will be priced at 1 unit no matter how many units are submitted.   AA.  If a claim has more than 1 service with a status indicator (SI) of S or T and any lines             with SI of S or T have less than $1.01 as charges, charges for all S and/or T lines will be summed and the charges will then be divided up proportionately t o the payment rate for each S or T line.  The new charge amount will be used in place of the submitted charge amount in the line item outlier calculation.  EXAMPLE:   SI Charges  Payment Rate New Charges Amount  S $19,999 $6,000 $12,000 T $1 $3,000 $6,000 S $0 $1,000 $2,000 SI Charges  Payment Rate New Charges Amount   $20,000 $10,000 $20,000  Because total charges here are $20,000 and the first SI of S gets 6,000 of 10,000 total payment, the new charge for that line is 6,000/10,000 * $20,000 = $12,000.  BB. All charges on lines with a SI of N (bundled services) on the claim will be summed and the charges will then be divided up proportionately to the payment rate for each S, T, V or X line.  This proportional amount will be added to the new charges amount from item F above or, if that doesn't apply, they will be added to the actual submitted charges for each S, T, V or X before making a line item outlier calculation.
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CC. Outliers will be calculated at a line item level.  No outlier payment will be calculated for SIs of G, K, N or H, although charges for packaged services (SI=N) will be used in calculating outlier payments for other services as described in G. above.  Pricer will use submitted charges as modified by items F and G above.  The CMS changed the factor multiplied times the total claim payments from 2.5 to 3.5 and factor used to multiply the difference between claim payments and costs from .75 to .50.  Pricer will keep the cost to charge ratio adjustment factor at .981956.  Pricer will sum all line item outlier amounts and output them as a single total claim outlier amount, just as it outputs the outlier amount that contractors are to place in value code 17.  DD. Any claim with one or more APCs that match those listed in Table 1 of the March 1, 2002,  Federal Register will have all applicable APC offset amounts summed and wage adjusted.  The total wage adjusted offset amount will be subtracted proportionately from the charges reduced to costs for any SI H devices that have a HCPCS code beginning with a C, i.e., C1713 through C2631.  EE.       A pro rata reduction  of 63.6 percent applies to all SI G and/or H payments.  For H, devices, the offset (or reduction) is applied to the final payment amount after all device offset amounts (see item I  above) have been taken.  For SI G, pass thru drugs, CMS determines the pass -through amount (PTA) by subtracting 5 times the minimum coinsurance from the Medicare payment amount.  The CMS will multiply .364 times the PTA and add that amount to 5 times the minimum coinsurance to get the new Medicare payment amount.   FF.      The provider specific file for SNFs and HHAs that may be reimbursed for splints, casts and/or antigens under OPPS should have a cost to charge ratio of 0.000 (or 0.001 if the shared system will not allow 0.000.  Pricer will not pay outliers for these servi ces.  GG. Pricer Drug Copayment Changes
(Medicare Claims Processing Manual)
HH. APC  II. Drug Name  JJ. Corrected Copayment  KK. 726 LL. Dexrazoxane  MM. $27.85 NN. 1607 OO. Eptifibatide  PP. $1.62  50.6 - Changes to the OPPS Pricer Logic Effective January 1, 2003  (Rev. 1, 10- 03-03)  The following list contains a description of all OPPS Pricer logic changes that are effective beginning January 1, 2003.   A. New OPPS wage indexes will be effective January 1, 2003.  These are the same wage indexes that were implemented on October 1, 2002, for inpatient hospitals.  Some corrections have been made since the publication of the inpatient rule and CMS are using the corrected wage indexes where applicable.   B. Inpatient hospitals considered reclassified on October 1, 2002, will be considered reclassified for OPPS on January 1, 2003.   C. Section 301 designations and floor MSA designations will be considered effective for OPPS on January 1, 2003.  D. New payment rates and coinsurance amounts will be effective for OPPS on January 1, 2003.  Some APCs have coinsurance amounts limited to 55 percent of the payment rate effective January 1, 2003.  Some APCs have a coinsurance limit equal to the inpatient deductible of $840 effect ive January 1, 2003.  E. If a claim has more than 1 service with a status indicator (SI) of T (SI of S has been  removed from this rule) and any lines with SI T have less than $1.01 as charges, charges for all T lines will be summed and the charges will then be divided up proportionately to the payment rate for each T line.  The new charge amount will be used in plac e of the submitted charge amount in the line item outlier calculation.   EXAMPLE:   SI Charges  Payment Rate New Charges Amount  T $19,999 $6,000 $12,000 T $1 $3,000 $  6,000 SI Charges  Payment Rate New Charges Amount  T $0 $1,000 $  2,000  $20,000 $10,000 $20,000  Because total charges here are $20,000 and the first SI of T gets 6,000 of 10,000 total payment, the new charge for that line is 6,000/10,000 x $20,000 = $12,000.
(Medicare Claims Processing Manual)
F. For outliers, CMS will change the factor multiplied times the total line item payments from 3.5 to 2.75 and the factor used to multiply the difference between line item payments and costs from .50 to .45.  The CMS will eliminate the cost to charge ratio adjustment factor of .981956 from outlier and device calculations.  G. Any claim having one or more APCs that match those listed in the Device Offset Table (Table 11) published in the November 1, 2002,  Federal Register and a HCPCS code with status indicator (SI) H, will have all applicable APC offset amounts (multiplied by the number of units and the multiple procedure discount factor applicable to that line item) summed and wage adjusted.  If there are more units of APC s with offset amounts than there are units of SI H devices that have an active (non- deleted) device catego ry HCPCS code beginning with a C, i.e., those codes listed in section XXII B. of this PM, the total wage adjusted offset amount will be multiplied by the number of units of SI H devices that have a HCPCS code beginning with a C and then divided by the number of units of APCs with offset amounts.  The total wage adjusted offset amount will then be subtracted proportionately from the charges reduced to costs for any SI H devices that have a HCPCS code beginning with a C.   The pro rata reduction of 63.6 percent applicable to all SI G and/or H payments is eliminated.   50.7 - Changes to the OPPS Pricer Logic, Effective January 1, 2003 Through January 1, 2006  (Rev. 1882, Issued:  12- 21-09; Effective Date:  01 -01-10; Implementation Date:  01-04-10)  For January Pricers occurring between CY 2003 and 2006, you may find the updates outlined in the following CRs:   January 2004 -  CR 3007, http://www.cms.hhs.gov/Transmittals/Downloads/R32OTN.pdf  January 2005 -  CR 3586, http://www.cms.hhs.gov/transmittals/Downloads/R385CP.pdf  January 2006 -  CR 4250, http://www.cms.hhs.gov/transmittals/downloads/R804CP.pdf
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50.8 - Annual Updates to the OPPS Pricer for Calendar Year (CY) 2007 and Later  (Rev. 1882, Issued:  12- 21-09; Effective Date:  01 -01-10; Implementation Date:  01-04-10)  Starting with the January 2007 update, all annual updates within the OPPS Pricer are explained within recurring update notifications located at the Hospital OPPS Transmittals  Web site found at:  http://www.cms.gov/Regulations -and-Guidance/Guidance/Transmittals/index.html.   60 - Billing for Devices Eligible for Transitional Pass- Through Payments and Items Classified in New Technology APCs (Rev. 3425, Issued: 12- 18-15, Effective: 01 -01-16, Implementation: 01- 04-16)  The list of devices eligible for transitional pass -through payments changes as new device categories are approved for pass -through payment status on an ongoing basis, and as device categories expire from transitional pass -through payment and their costs ar e included in APC rates for associated surgical procedures.  To view or download the latest complete list of currently payable and previously payable pass -through device categories, refer to https://www.cms.gov/Medicare/Medicare -Fee-for-Service -Payment/HospitalOutpatientPPS/passthrough_payment.html   Please note that this link may change depending on CMS Web design requirements.   Hospitals are required to report device category codes that have expired from pass -through payment on claims when such devices are used in conjunction with procedures billed and paid for under the OPPS.  In a Federal Register notice dated November 15, 2004 we summarized several provisions (69 FR 65762) related to the required reporting of HCPCS codes for devices.   The most recent information concerning applications requesting CMS to establish coding and payment and eligibility requirements for additional (new) device categories for pass -through payment is located on the CMS Web site at https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html .  This Web link may change from time to time, depending on CMS Web design requirements.
(Medicare Claims Processing Manual)
60.1 - Categories for Use in Coding Devices Eligible for Transitional Pass -Through Payments Under the Hospital OPPS  (Rev. 3685, Issued: 12- 22-16, Effective: 01 -01-17, Implementation: 01- 03-17)  The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 requires establishing categories for purposes of determining transitional pass -through payment for devices, effective April 1, 2001.  Each category is defined as a separate code in the C series or occasionally a code in another series (e.g., certain codes in the L series) of HCPCS.  C -codes are assigned by CMS for this purpose when other HCPCS codes for the eligible item do not exist.  Only devices specifically describe d by the long descriptions associated with the currently payable pass -through category codes are qualified for transitional pass -through payments.  The complete list of currently and previously payable pass -through category codes can be viewed and/or downloaded from the CMS Web site, currently at https://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/HospitalOutpatientPPS/passthrough_payment.html   Each item that qualifies for transitional pass -through payments fits in one of the device categories currently active for pass -through payments.  Devices may be billed using the currently active category codes for pass -through payments, as long as they:    Meet the definition of a device that qualifies for transitional pass -through payments and other requirements and definitions put forth below in 60.3.   Are described by the long descriptor associated with a currently active pass -through device category HCPCS code assigned by CMS and   Are described according to the definitions of terms and other general explanations issued by CMS to accompany coding assignments in program instructions.  The current definitions and explanations are located with the latest complete list of currently payab le and previously payable pass -through device categories, found at https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html .  Please note that this link may change depending on CMS Web design requirements.
(Medicare Claims Processing Manual)
If a device does not meet the description and other coding instructions for currently payable categories, even though it appears to meet the other requirements in this section, it may not be billed using one of the HCPCS codes for currently payable categor ies for transitional pass -through payments unless an applicable category is established by CMS, as discussed in section 60.3 below.  Transitional pass -through payment for a device is based on the charge on the individual providers bill, and the amount by which the hospitals charges for a device, adjusted to cost (the cost of the device), exceeds the portion of the otherwise applicable Medicare outpatient department fee schedule amount associated with the device.   The OCE software determines the reduction to cost and the deduction for similar devices.   The eligibility of a device category for transitional pass -through payments is temporary, lasting for at least 2 but no more than 3 years.  (The initial categories expired on January 1, 2003 or on January 1, 2004.  The underlying provision is permanent, an d categories established later have expired or will expire in successive years.)  At the time of expiration, APC payment rates are adjusted to reflect the costs of devices (and drugs and biologicals) that received transitional pass -through payments.  These  adjustments are based on claims data that reflect the use of transitional pass -through devices, drugs and biologicals in conjunction with the associated procedures.   60.2 - Roles of Hospitals, Manufacturers, and CMS for Billing for Transitional Pass-Through Items  (Rev. 1336; Issued:  09- 14-07; Effective/Implementation Dates:  10 -01-07)  In general, hospitals are ultimately responsible for the content of the bills they present to Medicare.  If hospitals have questions about appropriate coding that they cannot resolve on their own, the appropriate first step would be to review the HCPCS codes and/or the regulation governing payment for the year of service.  CMS does not have to have qualified a particular device for transitional pass -through payment before a hospital can bill for the device.  Hospitals are expected to make appropriate coding decisions based on these instructions and other information available to them.  Many device manufacturers routinely provide hospital customers with information about appropriate coding of their devices.  This may be helpful but does not supersede Federal requirements.
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60.3 - Devices Eligible for Transitional Pass-Through Payments  (Rev. 4494: Issued: 01- 15-20: Effective:01 -01-20: Implementation; 01 -06-20)
(Medicare Claims Processing Manual)
The definition of and criteria for devices eligible for establishment of new categories for transitional pass -through payments was discussed and defined in a final rule with comment period published in the Federal Register on November 1, 2002, (67 FR 66781).  Two of the criteria were also modified by means of a final rule with comment period published in the Federal Register on November 10, 2005 (70 FR 68628).  As of January 1, 2010, implantable biologicals that are surgically inserted or implanted (through a surgical incision or natural orifice) are being evaluated for device pass -through payment as modified by means of a final rule with comment period and published in the November 20, 2009 Federal Register (74 FR 60471).  As of January 1, 2015, skin substitutes are being evaluated for device pass -through payment as modified by means of a final rule with comment period and published in the November 10, 2015 Federal Register (79 FR 66885).  As of  January 1, 2016, the application process for device pa ss-through payments will add a rulemaking component to the existing quarterly process and a requirement will ensure that medical devices seeking pass -through payments are new, as modified by means of a final rule with comment period and published in the  November 13, 2015 Federal Register (80 FR 70417).  As of January 1, 2017, the pass -through payment time period has been refined by having the pass -through start date begin with the date of first payment and by allowing pass -through status to expire quart erly as modified by means of a final rule with comment period and published in the November 14, 2016 Federal Register (81 FR 79655 ).  Also, in calculating the pass -through payment, the Implantable Devices Charged to Patients Cost to Charge Ration (CCR)  will replace the hospital- specific CCR, when available and device offsets will be calculated from the HCPCS payment rate, instead of the APC payment rate (81 FR 79655 through 79656).  As of January 1, 2020, devices that have received FDA marketing authori zation and a Breakthrough Device designation from the FDA have an alternative pathway to qualify for device pass -through payment status, under which devices would not be evaluated in terms of the current substantial clinical improvement criterion for the purposes of determining device pass -through payment status. The
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a Breakthrough Device designation from the FDA have an alternative pathway to qualify for device pass -through payment status, under which devices would not be evaluated in terms of the current substantial clinical improvement criterion for the purposes of determining device pass -through payment status. The devices must still meet the other criteria for pass -through status.   The regulations regarding transitional pass -through payment for devices are compiled at 42 CFR 419.66.  Additionally, the eligibility criteria for CMS to establish a new category for pass -through payment are discussed on the CMS Web site at https://www.cms.gov/Medicare/Medicare -Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html