evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
52.80 -  Transplant of pancreas  52.82 -  Homotransplant of pancreas   If ICD -10 is applicable, the provider uses the following ICD -10-PCS codes:   0FYG0Z0 Transplantation of Pancreas, Allogeneic, Open Approach  0FYG0Z1 Transplantation of Pancreas, Syngeneic, Open Approach   Contractors who receive claims for PA that are not billed using the covered diagnosis/procedure codes listed above shall reject such claims. The MCE edits to ensure that the transplant is covered based on the diagnosis. The MCE also considers ICD -9-CM code s 52.80 and 52.82 and ICD-10-PCS codes 0FYG0Z0 and 0FYG0Z1 as limited coverage dependent upon whether the facility is approved to perform the transplant and is certified for the age of the patient.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 50  RARC: N/A  MSN: 15.4   Contractors shall hold the provider liable for denied\ rejected claims unless the hospital issues a Hospital Issued Notice of Non- coverage (HINN) or a physician issues an Advanced Beneficiary Notice (ABN) for Part -B for physician services.  D. - Charges for Pancreas Alone Acquisition Services   A separate organ acquisition cost center has been established for pancreas transplantation.  The Medicare cost report will include a separate line to account for pancreas transplantation costs.  The 42 CFR 412.2(e)(4)  was changed to include PA in the list of organ acquisition costs that are paid on a reasonable cost basis.   Acquisition costs for PA transplantation are billed in Revenue Code 081X.  The contractor removes acquisition charges prior to sending the claims to Pricer so such charges are not included in the outlier calculation.  90.6 - Intestinal and Multi- Visceral Transplants  (Rev. 10210, Issued: 07- 10-2020, Effective: 08 -10-2020, Implementation: 08- 10-2020)   A. - Background
(Medicare Claims Processing Manual)
A. - Background   Effective for services on or after April 1, 2001, Medicare covers intestinal and multi -visceral transplantation for the purpose of restoring intestinal function in patients with irreversible intestinal failure. Intestinal failure is defined as the loss of absorptive capacity of the small bowel secondary to severe primary gastrointestinal disease or surgically induced short bowel syndrome. Intestinal failure prevents oral nutrition and may be associated with both mortality and profound morbidity. Multi -Visceral transplantation includes organs in the digestive system (stomach, duodenum, liver, and intestine). See 260.5 of the National Coverage Determinations Manual for further infor mation.   B. - Approved Transplant Facilities   Medicare will cover intestinal transplantation if performed in an approved facility. The approved facilities are located at:  https://www.cms.gov/Medicare/Provider-Enrollment- and-Certification/CertificationandComplianc/downloads/ApprovedTransplantPrograms.pdf    C. - Billing   If ICD -9-CM is applicable, ICD-9-CM procedure code 46.97 is effective for discharges on or after April 1, 2001.  If ICD-10 is applicable, the ICD-10-PCS procedure codes are 0DY80Z0, 0DY80Z1, 0DYE0Z0, and 0DYE0Z1.  The Medicare Code Editor (MCE) lists these codes as limited coverage procedures.  The contractor shall override the MCE when this procedure code is listed and the coverage criteria are met in an approved transplant facility, and also determine if the facility is certified for adults and/or pediatr ic transplants dependent upon the patients age.
(Medicare Claims Processing Manual)
For these procedures where the provider is approved as a transplant facility and certified for the adult and/or pediatric population, and the service is performed on or after the transplant approval date dependent on patients age, contractors shall use cl aims data to determine that the coverage criteria specified in Publication 100-03, Section 260.5 have been met.    If payment is appropriate (i.e., the facility is approved, the service is furnished on or after the approval date, and the beneficiary has a covered condition), the contractor sends the claim to Grouper and Pricer.  If ICD -9-CM is applicable, charges for ICD -9-CM procedure code 46.97, and, if ICD-10 is applicable, the ICD -10-PCS procedure codes 0DY80Z0, 0DY80Z1, 0DYE0Z0, or 0DYE0Z1 should be billed under revenue code 0360, Operating Room Services.  For discharge dates on or after October 1, 2001, acquisition charges are billed under revenue code 081X, Organ Acquisition. For discharge dates between April 1, 2001, and September 30, 2001, hospitals were to report the acquisition charges on the claim, but there was no interim pass -through payment made for these costs.  Bill the procedure used to obtain the donor's organ on the same claim, using appropriate ICD procedure codes.   The 11X bill type should be used when billing for intestinal transplants.  Immunosuppressive therapy for intestinal transplantation is covered and should be billed consistent with other organ transplants under the current rules.  If ICD -9-CM is applicable, there is no specific ICD-9-CM diagnosis code for intestinal failure. Diagnosis codes exist to capture the causes of intestinal failure. Some examples of intestinal failure include but are not limited to the following conditions a nd their associated ICD-9-CM codes:    Volvulus 560.2,   Volvulus gastroschisis 756.79, other [congenital] anomalies of abdominal wall,    Volvulus gastroschisis 569.89, other specified disorders of intestine,    Necrotizing enterocolitis 777.5, necrotizing enterocolitis in fetus or newborn,
(Medicare Claims Processing Manual)
 Volvulus gastroschisis 569.89, other specified disorders of intestine,    Necrotizing enterocolitis 777.5, necrotizing enterocolitis in fetus or newborn,   Necrotizing enterocolitis 014.8, other tuberculosis of intestines, peritoneum, and mesenteric,    Necrotizing enterocolitis and splanchnic vascular thrombosis 557.0, acute vascular insufficiency of intestine,    Inflammatory bowel disease 569.9, unspecified disorder of intestine,    Radiation enteritis 777.5, necrotizing enterocolitis in fetus or newborn, and    Radiation enteritis 558.1.  If ICD -10-CM is applicable, some diagnosis codes that may be used for intestinal failure are:    Volvulus K56.2,   Enteroptosis K63.4,   Other specified diseases of intestine K63.89,   Other specified diseases of the digestive system K92.89,   Postsurgical malabsorption, not elsewhere classified K91.2,    Other congenital malformations of abdominal wall Q79.59,   Necrotizing enterocolitis in newborn, unspecified P77.9,   Stage 1 necrotizing enterocolitis in newborn P77.1,   Stage 2 necrotizing enterocolitis in newborn P77.2, and   Stage 3 necrotizing enterocolitis in newborn P77.3.  D. - Acquisition Costs   A separate organ acquisition cost center was established for acquisition costs incurred on or after October 1, 2001.  Therefore, acquisition charges billed on revenue code 081x are removed from the claims total covered charges so as to not be included in the IPPS outlier calculation.  The Medicare Cost Report will include a separate line to account for these transplantation costs.  For intestinal and multi- visceral transplants performed between April 1, 2001, and October 1, 2001, the DRG payment was payment in full for all hospital services related to this procedure.   E. - Medicare Summary Notices (MSN), Remittance Advice Messages, and Notice of Utilization Notices (NOU)
(Medicare Claims Processing Manual)
E. - Medicare Summary Notices (MSN), Remittance Advice Messages, and Notice of Utilization Notices (NOU)   If an intestinal transplant is billed by an unapproved facility after April 1, 2001, the contractor shall deny the claim.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 171  RARC: N/A  MSN: 21.6 or 21.18 or 16.2  100 - Billing Instructions for Specific Situations  (Rev. 1, 10- 01-03)  100.1 - Billing for Abortion Services  (Rev. 3481, Issued: 03- 18-16. Effective: 06 -20-16, Implementation: 06 -20-16)  Effective October 1, 1998, abortions are not covered under the Medicare program except for instances where the pregnancy is a result of an act of rape or incest; or the woman suffers from a physical disorder, physical injury, or physical illness, including a life endangering physic al condition caused by the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed.   A. - "G" Modifier   The "G7" modifier is defined as "the pregnancy resulted from rape or incest, or pregnancy certified by physician as life threatening."   Beginning July 1, 1999, providers should bill for abortion services using the new Modifier G7.  This modifier can be used on claims with dates of services October 1, 1998, and after.  CWF will be able to recognize the modifier beginning July 1, 1999.  B. - A/B MAC (A) Billing Instructions   1. Hospital Inpatient Billing   Hospitals use bill type 11X.  Medicare will pay only when one of the following condition codes is reported:   Condition  Code  Description  AA Abortion Performed due to Rape   Condition  Code  Description  AB Abortion Performed due to Incest  AD Abortion Performed due to life endangering physical condition   With one of the following:
(Medicare Claims Processing Manual)
Condition  Code  Description  AA Abortion Performed due to Rape   Condition  Code  Description  AB Abortion Performed due to Incest  AD Abortion Performed due to life endangering physical condition   With one of the following:   If ICD -9-CM Is Applicable:   an appropriate ICD principal diagnosis code that will group to DRG 770 (Abortion W D&C, Aspiration Curettage Or Hysterotomy) or   an appropriate ICD principal diagnosis code and one of the following ICD -9-CM operating room procedure that will group to DRG 779 (Abortion W/O D&C):69.01, 69.02, 69.51, 74.91.  If ICD -10-CM is applicable, one of the following ICD -10-PCS codes are used:   ICD-10-PCS code  Description  10A07ZZ  Abortion of Products of Conception, Via Natural or Artificial Opening  10A08ZZ  Abortion of Products of Conception, Via Natural or Artificial Opening Endoscopic  10D17ZZ  Extraction of Products of Conception, Retained, Via Natural or Artificial Opening  10D18ZZ  Extraction of Products of Conception, Retained, Via Natural or Artificial Opening Endoscopic  10A07ZZ  Abortion of Products of Conception, Via Natural or Artificial Opening  10A08ZZ  Abortion of Products of Conception, Via Natural or Artificial Opening Endoscopic  10A00ZZ  Abortion of Products of Conception, Open Approach  10A03ZZ  Abortion of Products of Conception, Percutaneous Approach  10A04ZZ  Abortion of Products of Conception, Percutaneous Endoscopic Approach   Providers must use ICD -9-CM codes 69.01 and 69.02 if ICD -9-CM is applicable, or, if ICD -10-CM is applicable,  the related 1CD -10-PCS codes to describe exactly the procedure or service performed.   The A/B MAC (A) must manually review claims with the above ICD -9-CM/ICD -10-PCS procedure codes to verify that all of the above conditions are met.  2. Outpatient Billing   Hospitals will use bill type 13X and 85X.  Medicare will pay only if one of the following CPT codes is used with the "G7" modifier.   59840  59851  59856  59841  59852  59857  59850  59855  59866   C. - Common Working File (CWF) Edits
(Medicare Claims Processing Manual)
59840  59851  59856  59841  59852  59857  59850  59855  59866   C. - Common Working File (CWF) Edits   For hospital outpatient claims, CWF will bypass its edits for a managed care beneficiary who is having an abortion outside their plan and the claim is submitted with the "G7" modifier and one of the above CPT codes.   For hospital inpatient claims, CWF will bypass its edits for a managed care beneficiary who is having an abortion outside their plan and the claim is submitted with one of the above inpatient procedure codes.  D. - Medicare Summary Notices (MSN)/Explanation of Your Medicare Benefits Remittance Advice Message  If a claim is submitted with one of the above CPT procedure codes but no "G7" modifier, the claim is denied.    The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: CO  CARC: 272  RARC: N/A  MSN: 21.21  100.2 - Payment for CRNA or AA Services (Rev. 4157, Issued: 11- 02-18, Effective: 04 -01-19, Implementation: 04- 01-19)  This section discusses reasonable cost -based payment for CRNA services (42 CFR  412.113(c)).  Note that effective January 1, 2013, qualifying rural hospitals and CAHs are eligible to receive CRNA pass -through payments for services that the CRNA is legally authorized to perform in the state in which the services are furnished.   Anesthesia services furnished on or after January 1, 1989, and before January 1, 1990, at a rural hospital or CAH by a qualified hospital employed or contracted CRNA or AA can be paid on a reasonable cost basis.  The A/B MAC (A) determines the hospital's qualification using the following criteria:    The hospital or CAH must be located in a rural area (as defined for PPS purposes) to be considered.
(Medicare Claims Processing Manual)
 As of January 1, 1988, the hospital or CAH employed or contracted with a CRNA or AA.  The hospital or CAH may employ or contract with more than one CRNA or AA; however, the total number of hours of service furnished by the anesthetists may not exceed 2,080 hours per year.    The hospital or CAH must demonstrate that during the 1987 calendar year, its volume of surgical procedures (inpatient and outpatient) requiring anesthesia services did not exceed 250 procedures.    Each qualified CRNA or AA  employed or under contract with the hospital or CAH must agree in writing not to bill on a reasonable charge basis for his or her patient care to Medicare beneficiaries in that hospital or CAH.   In addition to the criteria described above, to maintain eligibility for reasonable cost -based payment for services furnished on or after January 1, 1990, a hospital or CAH must   provide data for its entire patient population to demonstrate that during ca lendar year 1987 and the year immediately preceding its election of reasonable cost payments, its volume of surgical procedures requiring anesthesia services did not exceed 500 procedures.  Effective October 1, 2002, the hospital or CAH must provide data f or its entire patient population to demonstrate that during calendar year 1987 and the year immediately preceding its election of reasonable cost payments, its volume of surgical procedures requiring anesthesia services did not exceed 800 procedures.   If a hospital or CAH did not qualify for reasonable cost -based payment for CRNA or AA services in calendar year 1989, it can qualify in subsequent years if it demonstrates to the Medicare Contractor prior to the start of the calendar year that it met these  criteria noted below:    The hospital or CAH must be located in a rural area (as defined for PPS purposes) to be considered.   As of January 1, 1988, the hospital or CAH employed or contracted with a CRNA or AA.  The hospital or CAH may employ or contract with more than one CRNA or AA; however, the total number of hours of service furnished by the anesthetists may not exceed 2,080 hours per year.    Each qualified CRNA or AA  employed or under contract with the hospital or CAH has agreed in writing not to bill on a reasonable charge basis for his or her patient care to Medicare beneficiaries in that hospital or CAH.
(Medicare Claims Processing Manual)
 Each qualified CRNA or AA  employed or under contract with the hospital or CAH has agreed in writing not to bill on a reasonable charge basis for his or her patient care to Medicare beneficiaries in that hospital or CAH.    The hospital or CAH must provide data for its entire patient population to demonstrate that during calendar year 1987 and the year immediately preceding its election of reasonable cost payments, its volume of surgical procedures (inpatient and outpatient) requiring anesthesia services did not exceed 500 procedures.  Effective October 1, 2002, the hospital or CAH must provide data for its entire patient population to demonstrate that during calendar year 1987 and the year immediately preceding its election of reasonable cost payments, its volume of surgical procedures (inpatient and outpatient) requiring anesthesia services did not exceed 800 procedures.   Effective for calendar years beginning January 1, 1991, the A/B MAC (A) determines the number of surgical procedures for the immediately preceding year by summing the number of surgical procedures for the 9- month period ending September 30, annualized for a 12-month period.  Effective December 2, 2010, in addition to a hospital or CAH that is located in a rural area (as defined for PPS purposes), a hospital or CAH may be eligible to be paid based on reasonable cost for CRNA or AA services, if the hospital or CAH has reclassifi ed as rural under 42 Code of Federal Regulations 412.103.  To prevent duplicate payments, the A/B MAC (A) informs A/B MACs (B) of the names of CRNAs or AAs, the hospitals and/or CAHs with which they have agreements, and the effective dates of the agreements.  If the CRNA or AA bills Part B for anesthesia services furnished after the hospital's and/or CAHs election of reasonable cost payments, the A/B MAC (B) must recover the overpayment from the CRNA or AA.  Since a swing -b ed is a bed that is available for use to provide acute inpatient care or SNF -level care and the CRNA/AA pass-t hrough provision applies to hospital inpatients, CRNA and AA services provided to hospital and CAH swing-bed patients under the pass-through provision must be included on the hospital or CAH swing-bed bill.
(Medicare Claims Processing Manual)
100.3 - Resident and Interns Not Under Approved Teaching Programs  (Rev. 1, 10-01-03)  A3-3669  A. - General   A provider's cost for the services furnished by residents and interns not under approved teaching programs (including physicians employed by the provider who are authorized to practice only in a provider setting) are covered under Part B.  (Part A covers only the costs of services performed for inpatients by residents and interns who are under approved teaching programs.) See the Medicare Benefit Policy Manual, Chapter 6 for further information on the coverage of these services.   The provider determines that part of the inpatient charges which represents the cost of the services of residents and interns who are not under approved teaching programs and bills these separately under Part B, using type of bill code 121 and revenue code 096X, 097X, or 098X as applicable.  B. - Provider Procedures   The cost of Part B residents' and interns' services to inpatients is calculated on a per diem basis by the hospital in consultation with its A/B MAC (A).  The A/B MAC (A) apportions the total cost of such services (including fringe benefits, etc.) between inpatient and outpatient services on the basis of the time spent on each.  It obtains the inpatient per diem figure by dividing the total annual inpatient cost for these services by the estimated annual number of inpatient days for all patients.  For the patients who are enrolled under Part B, regardless of whether Part A benefits are payable, the provider is reimbursed for 80 percent of the cost of providing these services.  The provider collects or bills the complementary insurer for 20 percent of the per diem rate for the services of residents and interns covered under Part B times the number of inpatient days provided.  The administrative cost of determining Part B deductible status involving the cost of query, response, recording, and accounting on an individual basis in the aggregate, exceeds the potential patient deductible obligation.  Therefore, as long as the patient is entitled to Part A benefits no determination of the patient's deductible liability need to be made for inpatient Part B interns' and residents' services.
(Medicare Claims Processing Manual)
Patients not enrolled under Part B are liable for the entire cost of intern and resident services.  The provider maintains a record of the inpatient days of these individuals so that this cost may be excluded from the amount of program obligation at the ti me of final cost settlement.   C. - A/B MAC (A) Procedures   Its A/B MAC (A) assists the provider in arriving at the inpatient per diem rate for the cost of services covered under Part B provided by residents and interns.  (See the Provider Reimbursement Manual, Part I, 2120 for apportioning costs between inpatient  and outpatient per diem and 2406 for establishing interim rates.) The normal interim reimbursement rate applied to other provider services applies to Part B residents' and interns' services.   100.4 - Billing for Services After Termination of Provider Agreement  (Rev. 1, 10- 01-03)  HO- 404, HH- 433  An agreement with a hospital is not time -limited and has no fixed expiration date.   A. - Part A Billing   A hospital whose provider agreement terminates (voluntarily or involuntarily), may be reimbursed for covered Part A inpatient services for up to 30 days for services furnished on or after the effective date of termination  for beneficiaries who were admitted prior to the termination date.   EXAMPLE:   Termination date:  6/30/01  Beneficiary admitted on or before 6/29/01  Payment can be made:  6/30/01, up to and including 7/29/01  B. - Assuring That Hospitals Continue to Bill for Covered Services   Upon cessation of a hospital's participation in the program, it supplies the Regional Office the names and HICNs of Medicare beneficiaries entitled to have payment made on their behalf, and continues to bill for covered services in accordance with subsecti on A.  It continues to submit "no- payment" death or discharge bills for Medicare beneficiaries admitted prior to the termination of the provider's agreement.  C. - Part B Billing
(Medicare Claims Processing Manual)
Following termination of its agreement, a hospital is considered to be a "nonparticipating hospital."  An inpatient of such a hospital who has Part B coverage, but for whom Part A benefits have been exhausted, or are otherwise not available, is entitled to  reimbursement for those services that are covered in a nonparticipating institution.  Services, if rendered, must be billed on Form CMS -1500 and sent to the A/B MAC (B).  If a hospital has been billing on the CMS -1554 for physician services, it continues to do so.  If a terminated hospital meets the necessary criteria, it may be certified to provide emergency services, and will be assigned an emergency provider number (E suffix).  This procedure is not automatic, however, and hospitals which are terminated for Life S afety Code violations may never be able to qualify as emergency providers.  Should a terminated hospital later qualify as an emergency provider, billings are handled by the designated emergency FI.   100.4.1 - Billing Procedures for a Provider Assigned Multiple Provider Numbers or a Change in Provider Number  (Rev. 267, Issued 07- 30-04, Effective: 10 -01-04, Implementation: 01- 03-05)  Where a multiple -facility provider is assigned separate provider numbers for each component facility or where a provider is assigned a different number, it is required to use the new number for all notices of admission, start of care notices, bills, etc., beginning with the date the new number is effective.  A. - Inpatient