evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
20.2.2 - Therapy Editing (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  On claims submitted by providers using the institutional claim format, CWF enforces consolidated billing for outpatient therapies by recognizing as therapies all services billed under revenue codes 042x, 043x, 044x.  These revenue codes are subject to cons olidated billing when submitted on types of bill 013x, 023x, 034x, 074x, 075x or 085x.  Consolidated billing edits do not apply on TOB 034x when the HHA is billing for disposable negative pressure wound therapy services during an HH period of care.   On claims submitted by practitioners using the professional claim format, CWF enforces consolidated billing for outpatient therapies using a list of HCPCS codes which represent therapy services.   Therapy services on professional claims are not subject to the home health consolidated billing methodology when performed by a physician.  Therefore, CWF bypasses the therapy edit if the HCPCS code is a therapy code subject to home health consolidated billing but the specialty code on the claim indicates a physician.   The following specialty codes indicate a physician for purposes of this edit:
(Medicare Claims Processing Manual)
The following specialty codes indicate a physician for purposes of this edit:   Code   Physician Specialty  01  General Practice  02  General Surgery  03  Allergy/Immunology  04  Otolaryngology  05  Anesthesiology  06  Cardiology  07  Dermatology  08  Family Practice  09  Interventional Pain Management  10  Gastroenterology  11  Internal Medicine  12  Osteopathic Manipulative Therapy  13  Neurology  14  Neurosurgery  16  Obstetrics/Gynecology  18  Ophthalmology  19  Oral Surgery (dentists only)  20  Orthopedic Surgery  22  Pathology  24  Plastic and Reconstructive Surgery  25  Physical Medicine and Rehabilitation  26  Psychiatry  28  Colorectal Surgery (formerly proctology)  29  Pulmonary Disease  Code   Physician Specialty  30  Diagnostic Radiology  33  Thoracic Surgery  34  Urology  35  Chiropractic  36  Nuclear Medicine  37  Pediatric Medicine  38  Geriatric Medicine  39  Nephrology  40  Hand Surgery  41  Optometry  44  Infectious Disease  46  Endocrinology  48  Podiatry  66  Rheumatology  70 Single or Multispecialty Clinic or Group Practice  72  Pain Management  76  Peripheral Vascular Disease  77  Vascular Surgery  78  Cardiac Surgery  79  Addiction Medicine  81  Critical Care (Intensivists)  82  Hematology  83  Hematology/Oncology  84  Preventive Medicine  85  Maxillofacial Surgery  86  Neuropsychiatry  90  Medical Oncology  91  Surgical Oncology  92  Radiation Oncology  93  Emergency Medicine  94  Interventional Radiology  Code   Physician Specialty  98  Gynecological/Oncology  99  Unknown Physician Specialty   20.2.3 - Other Editing Related to Home Health Consolidated Billing  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  CWF edits to prevent duplicate billing across two providers.  Consequently, CWF must edit to ensure that all DME items billed by HHAs have a line -item date of service and HCPCS code, even though HH consolidated billing does not apply to DME by law.
(Medicare Claims Processing Manual)
If revenue code 0636 and the HCPCS code for an osteoporosis drug is billed on a TOB 034x claim during an open HH period of care, CWF ensures that the provider of the 034x claim is the same as the primary provider of the open period of care, since by law consolidated billing must also be applied to the osteoporosis drug even though this item is paid outside of the unit of payment.  HH consolidated billing will not affect billing of DME or services outside the home health benefit, even when these services are billed by HHAs.   20.2.4 - Only Notice of Admission (NOA) Received and Services Fall Within Admission Period  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  If only an NOA has been received and the incoming claim with services subject to consolidated billing contains dates of service within the HH admission period, CWF returns an alert to the Medicare contractor to notify them that the claim may be subject to consolidated billing.  The Medicare contractor processes the claim to payment, but passes on the alert to the provider on the remittance advice at the line level.   The contractor shall use the following remittance advice messages and associated codes when making payment under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.   Group Code: CO  CARC: N/A  RARC: N88  MSN: N/A  This indicates to providers that the services may be denied and claim payment may be recouped if later editing or another post -payment recovery process identifies the claim as subject to consolidated billing.   20.2.5 - No NOA Received and Therapy Services Rendered in the Home  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  There may be situations in which a beneficiary is under a home health plan of care, but CWF does not yet have a record of either an NOA or a home health claim for the period of care.  To help inform independent therapy providers billing professional claims  to Medicare contractors that the services they rendered in the home setting may be subject to consolidated billing, providers will receive notification on the remittance advice when Medicare pays them for the service.
(Medicare Claims Processing Manual)
Medicare systems processing professional claims will provide this notification when the place of service on the claim is 12 home, the HCPCS code is a therapy code subject to home health consolidated billing and CWF has not returned a message indicating t he presence of an NOA.   30 - Common Working File (CWF) Requirements for the Home Health Prospective Payment System (HH PPS)  (Rev. 1, 10- 01-03) HH- 468, A3- 3640  30.1 - Eligibility Query to Determine Status (Rev. 10758; Issued: 05 -11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Under the HH PPS and home health consolidated billing one HHA is considered the primary home health agency in billing situations.  This primary agency is the only agency that may bill Medicare for home care for a given homebound beneficiary at a specific time.  When a homebound beneficiary seeks care from an HHA or from an institutional therapy provider subject to home health consolidated billing, the provider needs to determine if the beneficiary is already being served by an HHA -  an agency that then would be considered primary.   Providers may send an inquiry to determine the beneficiarys entitlement and eligibility status into the Common Working File or CWF, through their A/B MAC (A) or (HHH).  They must send the ASC X12 270 Health Care Eligibility Inquiry transaction set and wil l receive the ASC X12 271 Health Care Eligibility Response transaction set in response, in order to comply with the requirements of the Health Insurance Portability and Accountability Act.   A/B MACs (A) or (HHH) processing institutional claims will create an ELGH record from the 270 to request this data from CWF and will receive the ELGA record from CWF in response.  The A/B MAC (A) or (HHH) will create the 271 response or DDE screen from the  ELGA transaction record.
(Medicare Claims Processing Manual)
The response shows whether or not the beneficiary is currently in a home health admission period.  If the beneficiary is not already under care at another HHA, he/she can be admitted to the inquiring HHA, and that agency will become primary.  The beneficia ry can also be admitted even if an admission period is already open at another HHA if the beneficiary has chosen to transfer.   See chapter 31 for a description of the data elements and related requirements.  30.2 - CWF Response to Inquiry  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  CWF will return information on the two periods of care in the CWF episode file closest to the date the HHA or other provider entered in the applicable date field.  If a date is not specified, information on the two most recent periods of care will be returned.  See Chapter 31 for complete data sets returned to specific provider types.   30.3 - Timeliness and Limitations of CWF Responses  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Inquirers receive a response within a very short time frame.  However, these responses are not truly real time.  The CWF auxiliary file that retains admission period and period of care information is updated by, and is only as current as, each NOA or cla im batch run in CWF.  All processed NOAs and claims will update the file, even if claims are ultimately denied.  The CWF removes periods from the file only when:    HHAs cancel their own NOA for a period of care that includes no subsequent claims;   HHAs cancel their own claims for periods that were not initially created by an NOA; or    When a A/B MAC (HHH) processing HH claims cancels an NOA or a claim for specific reasons (i.e., fraud).
(Medicare Claims Processing Manual)
 When a A/B MAC (HHH) processing HH claims cancels an NOA or a claim for specific reasons (i.e., fraud).  In general, responses will be as current as the previous day.  Therefore, even when a response indicates a beneficiary is not currently in an admission period, the possibility exists that an NOA or claim could be in process, and the inquiring agency would still not be the primary HHA for a beneficiary for whom a clear inquiry was received.  In such cases, the inquiring agency will not learn that it is not the primary HHA immediately.   Also possible but even more rare, NOAs or claims from two different HHAs for the same beneficiary for the same date may be in the same batch sent to CWF.  In such cases, the claim process will result in one of the two transactions being processed first and thereby deciding which of the two agencies will be primary.  30.4 - Provider/Supplier Inquiries to MACs  Based on Eligibility Responses  (Rev. 1348, Issued: 10- 05-07, Effective: 01 -01-08, Implementation: 11- 05-07)  Institutional providers and/or suppliers may want to follow -up on information they receive, usually to contact the primary agency on file to bill under arrangement.  The provider or supplier may determine the HHAs A/B MAC (HHH) from the CMS Web site which has a list of A/B MACs (HHH) that process HH claims by State.  The provider or supplier also may ask its own MAC through existing provider inquiry channels.  That MAC will instruct the provider regarding which A/B MAC (HHH) that processes HH claims to contact to learn which HHA is involved.
(Medicare Claims Processing Manual)
A/B MACs (HHH) that process HH claims may provide information on either the provider or A/B MAC (HHH) that these providers may request.  Information released will be determined by each MAC, such as HHA name and address, but must be enough for the inquiring provider/supplier to contact either the primary HHA, if under that A/B MAC (HHH)s jurisdiction, or another A/B MAC (HHH), if the provider number is attached to another A/B MAC (HHH).  If an instance ever exists where a provider is an individual, such as a provider doing business using a Social Security Number as a tax identification number, information cannot be released, since it would violate the individuals right to privacy.   30.5 - National Home Health Prospective Payment Episode History File  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  CWF maintains a national history file for each beneficiary in order to enforce consolidated billing and perform HH PPS processing.  Even though under the PDGM, the HH unit of payment is a 30- day period of care, this file continues to be named the episode file in CWF.  Only MACs, not providers, may view this file.   The episode file, populated as soon as an admission period is opened for a beneficiary with an NOA, contains:    The beneficiary identifier;    Period Start and End Dates  - the start date is received on an NOA or claim, and the end date is initially calculated to be the 30th day after the start date, changed as necessary when the claim for the period is finalized;    The pertinent A/B MAC (HHH), CMS Certification Number and National Provider Identifier ;   The HRG Code -  the HIPPS code used to determine payment for the period of care;    Date of Earliest Billing Activity (DOEBA) and Date of Latest Billing Activity (DOLBA) line item dates of service of the first and last HH visits reported on the claim for the period of care;    Patient Status Indicator - the patient discharge status code on an HH PPS claim, indicating the status of the HH patient at the end of the period of care.
(Medicare Claims Processing Manual)
 Patient Status Indicator - the patient discharge status code on an HH PPS claim, indicating the status of the HH patient at the end of the period of care.     Cancellation Indicator  Indicates if the claim has been denied as fully non -covered by medical review.  In these cases, the indicator is a value of 2.  In all other cases, the value is 0.    NOA Indicator  Indicates the period was initially created by an NOA, not a claim.   If the NOA is submitted as a transfer, with condition code 47, this indicator is set to 2. For any other NOAs, this indicator is set to 1.  If a period is created by a continuing claim, this indicator is blank.   The episode file contains the 36 most recent periods of care for any beneficiary.  Periods that precede the most recent 36 will be dropped off the file and will not be retrievable online.   30.6 - Opening and Length of HH PPS Episodes /Periods of Care  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  Within CWF, the episode history auxiliary file is separate from the home health benefit period auxiliary file (labeled HHEH), which existed prior to HH PPS and is used to administer payment of HH services from the correct Medicare Trust Fund.  All HH PPS claims update bot h these files.  NOAs only update the episode history file.   The initial 30 -day period of care is created on this file based on the NOA. The start date of this period of care is also used to indicate the start date of an HH admission period.  The HH admission period is a claims processing concept used to correctly e nforce primary HHA assignment and HH consolidated billing.   Medicare systems determine a claim to fall within an HH admission period if it is within an admission period start and end date OR if it is on or after the start date of a period that remains open. Medicare systems determine the span of an admission period from HHEH period information as follows:
(Medicare Claims Processing Manual)
Admission Period Start Date: The HHEH Period Start Date when the NOA indicator is 1 or 2.  Admission Period End Date:    The HHEH Period End Date when the patient status on latest HHEH period in a series of contiguous periods indicates a discharge (the code is other than 30), or   The HHEH Start Date of a subsequent HHEH period when the NOA indicator on the subsequent period is 1 or 2. If an NOA with a different provider number falls within an admission period and does not report a transfer using condition code 47, the NOA will be returned to the provider because the HHA is not the primary HHA for that beneficiary.   If a claim subject t o HH consolidated billing falls within an admission period, but does not fall within dates that reflect an HH claim has been paid, the claim will receive an alert as described in section 20.2.5.   The initial 30 -day period of care created by the NOA is updated by the claim for that period.  All subsequent periods of care in the admission will be created by the subsequent claims.   Multiple periods can be open for the same beneficiary at the same time.  The same HHA may require multiple periods be opened for the same beneficiary because of an unexpected readmission after discharge.  Multiple periods may also occur between different p roviders if a transfer situation exists.  CWF will post NOAs received with appropriate transfer and readmit indicators to facilitate the creation of multiple periods.    Same day transfers are permitted, such that a period of care for one agency can end on the same date as a period of care was opened by another agency for the same beneficiary.  Both HHAs services for this date will be approved for payment, without regard for whether the same HH disciplines (e.g. skilled nursing, physical therapy, etc.) from both HHAs provided services.   When periods of care are created from NOAs, CWF calculates a period end date that does not exceed the start date plus 29 days.  CWF will assure no period exceeds the maximum length under any circumstance, and will auto- adjust the period end date to shorten the period if needed based on subsequent NOA or claim submissions (i.e., shortened by transfer).
(Medicare Claims Processing Manual)
30.7 - RESERVED   (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  30.8 - RESERVED  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  30.9 - Coordination of HH PPS Claims Episodes With Inpatient Claim Types (Rev. 4312, Issued: 05- 23-19, Effective: 01 -01-20, Implementation: 08- 16-19)  Beneficiaries cannot be institutionalized and receive home health care simultaneously.  Therefore claims for institutional inpatient services (inpatient hospital, skilled nursing facility (SNF) and swing bed claims), have priority in Medicare claims editin g over claims for home health services.   If an HH PPS claim is received, and CWF finds dates of service on the HH claim that falls within the dates of an inpatient, SNF or swing bed claim (not including the dates of admission and discharge and the dates of any leave of absence), Medicare systems will reject the HH claim.  The HHA may submit a new claim removing any dates of service within the inpatient stay that were billed in error.   If the HH PPS claim is received first and the inpatient hospital, SNF or swing bed claim comes in later, but contains dates of service duplicating dates of service on the HH PPS claim, Medicare systems will adjust the previously paid HH PPS claim to non -cover the duplicated dates of service.   30.10  RESERVED  (Rev. 4312, Issued: 05- 23-19, Effective: 01 -01-20, Implementation: 08- 16-19)  30.11 - Exhibit: Chart Summarizing the Effects of NOA/Claim Actions on the HH PPS Episode File  (Rev. 10758; Issued: 05- 11-21; Effective: 01 -01-22; Implementation: 08 -11-21)  The following chart summarizes basic effects of HH PPS claims processing on the episode record.  Even though under the PDGM, the HH unit of payment is a 30- day period of care, this file continues to be named the episode file in CWF and references to episode record below refer to periods of care.
(Medicare Claims Processing Manual)
Transaction  How CWF Is Impacted  How Other Providers Are Impacted  NOA   Opens an episode record using NOA From date to set Period Start Date    CWF uses Start Date to calculate admission period    Period End Date is automatically calculated to extend through 30th day    DOEBA and DOLBA are left blank   NOA indicator is set to 1    Other NOAs submitted during this open admission period will be rejected unless an indicator of a transfer or discharge/readmission is present    Transaction  How CWF Is Impacted  How Other Providers Are Impacted  NOA with condition code 47   Opens an episode record using NOAs From date to set Period Start Date    Period End Date is automatically calculated to extend through 30th day    DOEBA and DOLBA are left blank   The Period End Date (if later than the NOA From date) is automatically changed to reflect the NOAs from date.    NOA indicator is set to 2     CWF uses the new Start Date as the end date of the previous admission period.     The Period End Date created by the NOA or claim of the HHA the beneficiary is transferring from is automatically changed to reflect the "from" date on the NOA submitted by the HHA the beneficiary is transferring to.  The HHA the beneficiary is transferring  from cannot bill for services past the date of transfer.    Another HHA cannot bill during this episode unless another transfer NOA is submitted.  NOA Cancellation by Provider  (TOB 032D)   The episode record is deleted from CWF   No episode record is present to prevent NOA submission by another provider, making that provider the primary HHA for the dates of the episode  Claim (full 30-day period, patient status 30)  30-day record  is completed    Period End Date remains at the 30th day   DOEBA is updated to reflect first visit date in period    DOLBA is updated to reflect last visit date in episode    CWF considers the admission period still open.    Other NOAs submitted during this open period will be rejected unless an indicator of a transfer or discharge/readmission is present   Transaction  How CWF Is Impacted  How Other Providers Are Impacted  Claim (discharge with goals met prior to Day 30)   30-day record  is completed    Period End Date remains at the 30th day;    DOEBA is updated to reflect first visit date in episode
(Medicare Claims Processing Manual)
 Period End Date remains at the 30th day;    DOEBA is updated to reflect first visit date in episode    DOLBA is updated to reflect last visit date in episode    CWF uses the Period End Date as the end date of the admission period also.    Other NOAs submitted with From dates before the end date of this period will be rejected unless an indicator of a transfer or discharge/readmission is present    Claim (transfer)   Episode record completed    Period End Date reflects claim Through date;    DOEBA is updated to reflect first visit date in episode    DOLBA is updated to reflect last visit date in episode    CWF uses the Period End Date as the end date of the admission period also.   An NOA will be accepted if the From date is on or after period Through date  Claim Adjustment   No impact unless adjustment changes patient status to transfer or service lines are added or removed to change the DOEBA or DOLBA date.   No impact  Transaction  How CWF Is Impacted  How Other Providers Are Impacted  Claim Cancellation   The period is deleted from CWF unless an NOA indicator of 1 or 2 is present.   If an NOA indicator is present, the HIPPS code and DOEBA/DOLBA dates are removed but the period remains in the file.   No impact    40 - Completion of Form CMS -1450 for Home Health Agency Billing  (Rev. 3021, Issued: 08- 08-14, Effective: 01 -01-12, Implementation: 09- 08-14)
(Medicare Claims Processing Manual)
40 - Completion of Form CMS -1450 for Home Health Agency Billing  (Rev. 3021, Issued: 08- 08-14, Effective: 01 -01-12, Implementation: 09- 08-14)  The Social Security Act at 1862 (a)(22) requires that all claims for Medicare payment must be submitted in an electronic form specified by the Secretary of Health and Human Services, unless an exception described at 1862 (h) applies.  The electronic form  required for billing home health services is the ASC X12 837 institutional claim transaction.  Since the data structure of the 837 transaction is difficult to express in narrative form and to provide assistance to small providers excepted from the electronic claim requirement, the instructions below are given relative to the data element names on the Form CMS -1450 hardcopy form.  Each data element name is shown in bold type.  Information regarding the form locator numbers that correspond to these data elem ent names is found in chapter 25.  Because claim formats serve the needs of many payers, some data elements may not be needed by a particular payer.  This section provides detailed information only for items required for Medicare home health claims.  Items not listed need not be completed although home health agencies may complete them when billing multiple payers.  In all cases, the provider is responsible for filing a timely claim for payment.  (See chapter 1.)   40.1 - Notice of Admission (NOA)                                                            (Rev. 12106; Issued: 06- 29-23, Effective: 01 - 01-24; Implementation:01 -02-24)