evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
See sections 250.12 through 250.12.4 for more inf ormation on PCIP payments to CAHs paid under the optional method.  Use the information in the Professional Component/Technical Component (PC/TC) indicator field of the CORF extract of the Medicare Physician Fee Schedule Supplementary File to identify profe ssional services eligible for HPSA and physician scarcity bonus payments.  The following are the rules to apply in determining whether to pay the bonus on services furnished within a geographic HPSA billed with a QB or QU modifier for dates of service prio r to January 01, 2006 or the AQ modifier for services on or after January 01, 2006, and/or whether to pay the bonus on services furnished within a Physician Scarcity Area with the AR modifier effective for dates of service January 01, 2005, through June 30, 2008.  (Field 20 on the full MPFS file layout)  PC/TC Indicator  Bonus Payment Policy  0 Physician services. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components.   ACTION: Pay the bonus  1 Globally billed. Only the professional component of this service qualifies for the bonus payment.  The bonus cannot be paid on the technical component of globally billed services.   ACTION: Return the service as unprocessable and notify the CAH that the professional component must be re -billed if it is performed within a qualifying bonus area. If the technical component is the only component of the service that was performed in the bonus area, there wouldnt be a qualifying service.  1 Professional Component (modifier 26).   ACTION: Pay the bonus.   PC/TC Indicator  Bonus Payment Policy  1 Technical Component (modifier TC).   ACTION: Do not pay the bonus.  2 Professional Component only.   ACTION: Pay the bonus.  3 Technical Component only.   ACTION: Do not pay the bonus.  4 Global test only. Only the professional component of this service qualifies for the bonus payment.   ACTION: Return the service as unprocessable. Instruct the provider to re-bill the service as separate professional and technical component procedure codes.  5 Incident to cod es.  ACTION: Do not pay the bonus.  6 Laboratory physician interpretation codes.   ACTION: Pay the bonus  7 Physical therapy service.   ACTION: Do not pay the bonus.  8 Physician interpretation codes.   ACTION: Pay the bonus.  9 Concept of PC/TC does not apply.   ACTION: Do not pay the bonus.
(Medicare Claims Processing Manual)
ACTION: Pay the bonus  7 Physical therapy service.   ACTION: Do not pay the bonus.  8 Physician interpretation codes.   ACTION: Pay the bonus.  9 Concept of PC/TC does not apply.   ACTION: Do not pay the bonus.   NOTE:  Codes that have a status of X on the CORF extract Medicare Physician Fee Schedule Database (MFSDB) have been assigned PC/TC indicator 9 and are not considered physician services for MFSDB payment purposes. T herefore, neither the HPSA bonus nor the physician bonus payment (5 percent) will be paid for these codes.   250.3 - Payment for Anesthesia in a Critical Access Hospital (CAH)  (Rev 41, 12- 08-03)  Payment for anesthesia services is based on the HCPCS FILE, the Anesthesia Conversion Factor File, and the CORF extract of the MPFS Summary File.    250.3.1 - Anesthesia File  (Rev. 41, 12-08-03) Conversion Factor File = MU00.@BF12390.MPFS.CY04.ANES.V1023   Record Layout for the Anesthesia Conversion Factor File Data Element Name  Picture  Location Length  A/B MAC (B) Number  X (5)  1-5 5 Locality Number  X (2)  13-14 2 Locality Name  X (30) 19-48 30 Anesthesia CF 2002 99V99 74-77 4  250.3.2 - Physician Rendering Anesthesia in a Hospital Outpatient Setting (Rev. 2452, Issued: 04 -26-12, Effective: 01-10-12, Implementation: 10-01-12)
(Medicare Claims Processing Manual)
250.3.2 - Physician Rendering Anesthesia in a Hospital Outpatient Setting (Rev. 2452, Issued: 04 -26-12, Effective: 01-10-12, Implementation: 10-01-12)  When a medically necessary anesthesia service is furnished within a HPSA area by a physician, a HPSA bonus is payable. In addition to using the PC/TC indicator on the CORF extract of the MPFS Summary File to identify HPSA services, pay physicians the HPSA bonus when CPT codes 00100 through 01999 are billed with the following modifiers: QY, QK, AA, or GC and QB or QU in revenue code 963. Modifier QB or QU must be submitted to receive payment of the HPSA bonus for claims with dates of service prior to Jan uary 01, 2006. Effective for claims with dates of service on or after January 01, 2006, the modifier AQ, physician providing a service in a health professional shortage area, may be required to receive the HPSA bonus. Refer to 250.2.2 of this chapter for more information on when modifier AQ is required.   The modifiers signify that a physician performed an anesthesia service.  Using the Anesthesia File (See Section above) the physician service will be 115 percent times the payment amount to be paid to a CAH on Method II payment plus 10 percent HPSA bonus payment.   Anesthesiology modifiers:   AA = anesthesia services performed personally by anesthesiologist.  GC =service performed, in part, by a resident under the direction of a teaching physician.  QK = me dical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals.  QY = medical direction of one CRNA by an anesthesiologist.   Modifiers AA and GC result in physician payment at 100% of the allowed amount. Modifiers QK and QY result in physician payment at 50% of the allowed amount.    Data elements needed to calculate payment:    HCPCS plus Modifier,   Base Units,   Time units, based on standard 15 minute intervals,   Locality specific anesthesia Conversion factor, and   Allowed amount minus applicable deductions and coinsurance amount.   Formula 1: Calculate payment for a physician performing anesthesia alone
(Medicare Claims Processing Manual)
Formula 1: Calculate payment for a physician performing anesthesia alone   HCPCS = xxxxx  Modifier = AA  Base Units = 4  Anesthesia Time is 60 minutes. Anesthesia time units = 4 (60/15)  Sum of Base Units plus Time Units = 4 + 4 = 8  Locality specific Anesthesia conversion factor = $17.00 (varies by localities)  Coinsurance = 20%   Example 1:   Physician personally performs the anesthesia case   Base Units plus time units -  4+4=8  Total uni ts multiplied by the anesthesia conversion factor times .80  8 x $17= ($136.00 -  (deductible*) x .80 = $108.80  Payment amount times 115 percent for the CAH method II payment.  $108.80 x 1.15 = $125.12 (Payment amount)  $125.12 x .10 = $12.51 (HPSA bonus payment)  *Assume the Part B deductible has already been met for the calendar year   Formula 2:  Calculate the payment for the physicians medical direction service when the physician directs two concurrent cases involving CRNAs. The medical direction allow ance is 50% of the allowance for the anesthesia service personally performed by the physician.   HCPCS = xxxxx  Modifier = QK  Base Units = 4  Time Units 60/15=4  Sum of base units plus time units = 8  Locality specific anesthesia conversion factor = $17(v aries by localities)  Coinsurance = 20 %   (Allowed amount adjusted for applicable deductions and coinsurance and to reflect payment percentage for medical direction).    Example 2:   Physician medically directs two concurrent cases involving CRNAs Base units plus time -  4+4=8  Total units multiplied by the anesthesia conversion factor times. 50 equal allowed amount minus any remaining deductible  8 x $17 = $136 x .50 = $68.00 - (deduc tible*) = $68.00  Allowed amount Times 80 percent times 1.15  $68.00 x .80 = $54.40 x 1.15 = 62.56 (Payment amount)  $62.56 x .10 = $6.26 (HPSA bonus payment)  *Assume the deductible has already been met for the calendar year.   NOTE:   For specific guidanc e on payment for Anesthesia and Teaching Services please review the following sections:   -
(Medicare Claims Processing Manual)
NOTE:   For specific guidanc e on payment for Anesthesia and Teaching Services please review the following sections:   -   Payment for Anesthesiology Services Pub.100- 04, Chapter 12, Section 50   - Teaching Physician Services Pub.100 -04, Chapter 12, Section 100.1.2 (4) Anesthesia.   250.3.3 - Anesthesia and CRNA Services in a Critical Access Hospital (CAH)  (Rev. 616, Issued: 07- 22-05, Effective: 10- 01-02, Implementation: 01- 03-06)  250.3.3.1 - Payment for CRNA Pass -Through Services  (Rev.4295, Issued: 05- 03-19, Effective: 08- 27-19, Implementation: 08 -27-19)  CAHs are eligible to receive CRNA pass -through payments (pass -through exemption) for both inpatient and outpatient services if they meet criteria discussed at 42 CFR  412.113(c) of the regulations. CRNA pass -through payments and the Method II election for outpatient CAH services are applied as described below. Note that for CAHs that have a CRNA pass -through exemption, all CRNA services provided to CAH swing- bed patients must be included on the CAH swing -bed bill. (See MCPM, C h. 3, 60 and 100.2 for more information)   If a CAH meets the criteria for a pass -through exemption and is interested in selecting Method II for its physicians and/or other practitioners , it can choose Method II for all outpatient professionals except the C RNA, and still retain the approved CRNA pass -through exemption for both inpatient and outpatient CRNA professional services .
(Medicare Claims Processing Manual)
Alternatively, a CAH, with an approved pass -through exemption, can choose to give up its pass -through exemption for both inpatient  and outpatient CRNA professional services in order to include its CRNA outpatient professional services under Method II. By choosing to include the CRNA under Method II for outpatient services, the CAH loses its CRNA pass- through exemption for not only the outpatient CRNA services, but also the inpatient CRNA services. In this case the CAH would have to  bill the A/B MAC (B) for the CRNA inpatient professional services. All A/B MAC (A) payments for CRNA services are subject to cost settlement.   Provider Billing Requirements for CRNA Pass -Through   TOBs = 11X and 18X   Revenue Code 037X for CRNA technical services Revenue Code 0964 for Professional services  Reimbursement  Revenue Code 37X, CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)   Revenue Code 0964, CRNA professional service = Cost Reimbursement (100 percent of reasonable cost) for both inpatient (including swing -bed) and outpatient   Deductible and coinsurance apply.   Provider Billing Requirements for CRNA Pass -Through   TOB = 85X   Revenue Code 037X for CRNA technical services Revenue Code 0964 for Professional services  Anesthesia HCPCS codes and for any HCPCS codes for services the CRNA is legally authorized to perform in the state in which the services are furnished.   The appropriate HCPCS should be included when required for the applicable TOB and or revenue code.   Reimbursement  Revenue Code 37X, CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)    Revenue Code 0964, CRNA professional service = Cost Reimbursement (100 percent of reasonable cost) for both inpatient (including swing -bed) and outpatient   Deductible and coinsurance apply.    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 t he services are furnished.                         .      250.3.3.2 - Payment for Anesthesia Services by a CRNA (Method II CAH only)  (Rev. 4157, Issued: 11- 02-18, Effective: 04- 01-19, Implementation: 04- 01-19)
(Medicare Claims Processing Manual)
Provider Billing Requirements for Method II CRNA -  Gave up Pass -Through Exemption (or never had exemption)   TOB = 85X   Revenue Code = 037X for CRNA technical service   Revenue Code = 0964 for CRNA professional service   HCPCS Code for services the CRNA is legally authorized to perform in the state in which the services are furnished   Reimbursement - For dates of service on or after July 1, 2007  Revenue Code 037X for CRNA technical service = Cost Reimbursement (101 percent of reasonable cost)   Revenue Code 0964 for CRNA professional service = Based on 100 percent of the allowed amount when not medically directed or 50 percent of the allowed amount when medically directed.   Providers bill a QZ modifier for non- medically directed CRNA services. Deductible and coinsurance apply.   How to calculate payment  for anesthesia claims based on the formula -  For dates of service on or after July 1, 2007  Identify anesthesia claims by HCPCS code range from 00100 through 01999 Non-medically directed CRNA    (Sum of base units plus time (anesthesia time divided by 15)) times conversion factor minus (deductible and coinsurance) times 1.15  Medically directed CRNA   (Sum of base units plus time (anesthesia time divided by 15)) times conversion factor times medically directed reduction (50 %) minus (deductible and coinsuranc e) times 1.15   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.  Reimbu rsement - For dates of service prior to July 1, 2007   Revenue Code 037X for CRNA technical service = cost reimbursement   Revenue Code 0964 for CRNA professional service = 115% times 80% (not medically directed) or 115% times 50% (medically directed) of al lowed amount (Use Anesthesia formula) for outpatient CRNA professional services.   Providers a QZ modifier for non -medically directed CRNA services. Deductible and coinsurance apply.   How to calculate payment for anesthesia claims based on the formula -  For dates of service prior to July 1, 2007
(Medicare Claims Processing Manual)
How to calculate payment for anesthesia claims based on the formula -  For dates of service prior to July 1, 2007  Add the anesthesia code base unit and time units. The time units are calculated by dividing actual anesthesia time (Units field on the UB92) by 15. Multiply the sum of base and time units by the locality specific  anesthesia conversion factor (file name below).   The Medicare program pays the CRNA 80% of this allowable charge when not medically directed. Deductible and coinsurance apply.   If the CRNA is medically directed, pay 50% of the allowable charge. Deductible and coinsurance apply.   Base Formula   Number of minutes divided by 15, plus the base units = Sum of base units and time  Sum of base units and time times the conversion factor = allowed amount   Source   Number of minutes = Number of units on the claim (Units field of the UB04) Base Units = Anesthesia HCPCS   Conversion Factor = File - MU00.@BF12390.MPFS.CYXX.ANES.V1023     250.4 - CAH Outpatient Services Part B Deductible and Coinsurance  (Rev. 1070, Issued: 09- 29-06, Effective: 01-01-07, Implementation: 01-02-07)  Payment for outpatient services of a CAH is subject to applicable Medicare Part B deductible and coinsurance amo unts unless waived based on statute.  For information on the application of deductible and coinsurance for screening and preventive services, see chapter 18 of Pub. 100- 04, Medicare Claims Processing Manual.   Payments for clinical diagnostic laboratory tests furnished to CAH outpatients on or after November 29, 1999, are made on a reasonable cost basis with no beneficiary cost- sharing - no coinsurance, deductible, copayment, or any other cost- sharing.    250.5 - Medicare Payment for Ambulance Services Fur nished by Certain CAHs (Rev. 4390, Issued: 10- 07-19, Effective: 10-01-19, Implementation: 10-07-19)
(Medicare Claims Processing Manual)
250.5 - Medicare Payment for Ambulance Services Fur nished by Certain CAHs (Rev. 4390, Issued: 10- 07-19, Effective: 10-01-19, Implementation: 10-07-19)  Medically necessary ambulance services furnished for dates of service on or after December 21, 2000 and prior to January 1, 2004, by a CAH or by an entity that is owned and operated by the CAH are paid based on 100 percent of the reasonable costs if the 35 mile rule for reasonable cost -based payment is met.   For dates of service on or after January 1, 2004, medically necessary ambulance services furnished by a CAH or by an entity that is owned and operated by the CAH are paid based on 101 percent of the reasonable costs if the 35 mile rule for reasonable cost- based payment is met.   For dates of service on or after December 21, 2000 and prior to October 1, 2011, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH or the entity.   For dates of service on or after October 1, 2011 and prior to October 1, 2019, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH.  Additionally, if there is no provider or supplier of ambulance services  located within a 35 mile drive of the CAH but there is an entity owned and operated by the CAH located more than a 35 mile drive from the CAH, that CAH -owned and operated entity can only be paid 101 percent of reasonable costs for its ambulance services if it is the closest provider or supplier of ambulance services to the CAH.
(Medicare Claims Processing Manual)
For dates of service on or after October 1, 2019, in order for the 35 mile rule to be met, the CAH or the entity that is owned and operated by the CAH, must be the only provider or supplier of ambulance services located within a 35 mile drive of the CAH, excluding ambulance providers or suppliers that are not legally authorized to furnish ambulance services to transp ort individuals either to or from the CAH. Additionally, if there is no provider or supplier of ambulance services located within a 35 mile drive of the CAH but there is an entity owned and operated by the CAH located more than a 35 mile drive from the CAH , that CAH -owned and operated entity can only be paid 101 percent of reasonable costs for its ambulance services if it is the closest provider or supplier of ambulance services to the CAH.   Section 205 of the Medicare, Medicaid, and SCHIP Benefits Improvem ent and Protection Act (BIPA) of 2000 exempts certain CAHs from the current Medicare ambulance cost per trip payment limit as well as from the ambulance fee schedule. Section 205(a) of BIPA states:   The Secretary shall pay the reasonable costs incurred in furnishing ambulance services if such services are furnished (A) by a CAH (as defined in 1861(mm)(1)) , or (B) by an entity that is owned and operated by a CAH, but only if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35 -mile drive of such CAH.  Those CAHs and CAH -owned and operated entities that meet the 35 mile rule for reasonable cost -based payment shall report condition code B2 (CAH ambulance attesta tion) on their bills.   When the 35 mile rule for reasonable cost -based payment is not met, the CAH ambulance service or the ambulance service furnished by the entity that is owned and operated by the CAH, is paid based on the ambulance fee schedule.  250.6 - Clinical Diagnostic Laboratory Tests Furnished by CAHs  (Rev. 1782; Issued:  07- 30-09; Effective Date:  07- 01-09; Implementation Date:  07 -06-09)  Medicare beneficiaries are not liable for any coinsurance, deductible, copayment, or other cost sharing amo unt for clinical diagnostic laboratory services furnished as a CAH outpatient service.
(Medicare Claims Processing Manual)
Medicare beneficiaries are not liable for any coinsurance, deductible, copayment, or other cost sharing amo unt for clinical diagnostic laboratory services furnished as a CAH outpatient service.   For dates of service prior to July 1, 2009, payment for clinical diagnostic laboratory tests furnished by a CAH is made at 101 percent of reasonable cost only if the pa tient is an  outpatient of the CAH and is physically present in the CAH at the time the specimen is collected -  (Type of Bill (TOB), 85x).   For dates of service on or after July 1, 2009, an individual is no longer required to be physically present in a CAH at the time the specimen is collected.  However, the individual must be an outpatient of the CAH, as defined at 42 CFR 410.2 and be receiving services directly from the CAH.  In order for the individual to be receiving services directly from the CAH, the individual must either be receiving outpatient services in the CAH on the same day the specimen is collected, or the specimen must be collected by an employee of the CAH.   Tests for non- patients are billed on TOB 14x, and are paid under the lab fee schedul e.  250.7 - Payment for Outpatient Services Furnished by an Indian Health Service (IHS) or Tribal CAH  (Rev. 231, Issued 07- 23-04, Effective: 01- 01-04/Implementation: 01- 03-05)  The IHS or Tribal CAHs are paid for outpatient services based on a facility specific visit rate that is established on a yearly basis from prior year cost report information.  Payment for outpatient IHS or Tribal CAH services is paid at 80% of the facility specific outpatient visit rate for both facilities electing Standard Method (I ) and Optional Method (II) billing.  IHS or Tribal CAHs will follow the billing methodology for the billing method that is chosen.  Standard Method (I) is found in 250.1 and Optional Method (II) is found in 250.2 of this chapter.  Facilities billing unde r the Optional Method (II) will follow the methodology for HPSA and Scarcity payments as outlined in 250.2 of this chapter.  Outpatient services provided at IHS or Tribal CAHs should be billed on an 85X type of bill.
(Medicare Claims Processing Manual)
Effective for cost reporting periods beginning on or after January 1, 2004, payment for outpatient IHS or Tribal CAH outpatient services will be made at 101% of the facility specific outpatient visit rate less applicable Part B deductible and coinsurance amounts.   250.8 - Coding for Administering Drugs in a Method II CAH  (Rev. 803, Issued: 01- 03-06, Effective: 04- 03-06, Implementation: 04- 03-06)  This section provides billing guidance and payment instructions for hospitals when providing drugs and drug administration services in a Method II CAH.    250.8.1 - Coding for Low Osmolar Contrast Material (LOCM)  (Rev. 803, Issued: 01- 03-06, Effective: 04- 03-06, Implementation: 04- 03-06)  Method II CAHs bill the outpatient physician involvement (professional component) for the administration of Low Osmolar Contrast Material (LOCM) with revenue code 96X,  97X or 98X on type of bill (TOB) 85X.  Bills must include an appropriate outpatient hospital visit CPT code for evaluation and management (E & M).   The technical component for LO CM may be billed by both Method I and Method II CAHs with revenue code 636 and one of the following HCPCS codes as appropriate:   HCPCS Code  Descriptor  Q9945  Low osmolar contrast material (up to 149 mg/ml iodine concentration, per ml) Q9946  Low osmolar  contrast material (150 - 199 mg/ml iodine concentration, per ml) Q9947  Low osmolar contrast material (200 - 249 mg/ml iodine concentration, per ml) Q9948  Low osmolar contrast material (250 - 299 mg/ml iodine concentration, per ml) Q9949  Low osmolar  contrast material (300 - 349 mg/ml iodine concentration, per ml) Q9950  Low osmolar contrast material (350 - 399 mg/ml iodine concentration, per ml) Q9951  Low osmolar contrast material (400 or greater mg/ml iodine concentration, per ml)   250.8.2 - Coding for the Administration of Other Drugs and Biologicals  (Rev. 803, Issued: 01- 03-06, Effective: 04- 03-06, Implementation: 04- 03-06)