evekhm/cms_iom_500 huggingface dataset:
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To process a claim i n the unlikely event that two procedures appearing on the ASC code pair file with the same device are billed in the same encounter, contractors should check the claim and history for each code  pair on the ASC code pair file or look -up table, in the order they are listed in the file . If one pass through device could pair with multiple procedures on the look -up table, the contractor should apply the offset  to the first code pair it identifies by going through the look -up table sequentially, in the order that they appear. If there is more than 1 unit of a pass -through device on the claim, the contractor should take an offset for each code pair. No code pair should be offset more than once and the number of code pairs receiving an offset should be no more than the units of a pass-through device.  40.8 - Payment When a Device is Furnished With No Cost or With Full or Partial Credit Beginning January 1, 2008  (Rev. 11793; Issued:01- 19-23; Effective: 02- 21-23; Implementation: 02 -21-23)  Contractors pay ASCs a reduced amount for certain specified procedures when a specified device is furnished without cost or for which either a partial or full credit is received (e.g., device recall).  For specified pro cedure codes that include payment for a device, ASCs are required to include modifier FB on the procedure code when a specified device is furnished without cost or for which full credit is received.  If the ASC receives a partial credit of 50 percent or m ore of the cost of a specified device, the ASC is required to include modifier FC on the procedure code if the procedure is on the list of specified procedures to which the -FC reduction applies.  A single procedure code should not be submitted with both modifiers FB and - FC.  The pricing determination related to modifiers   FB and - FC is made prior to the application of multiple procedure payment reductions.  Contractors adjust beneficiary coinsurance to reflect the reduced payment amount.  Tables listing the procedures and devices to which the payment adjustments apply, and the full and partial adjustment amounts, are available on the CMS Web- site.
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In order to report that the receipt of a partial credit of 50 percent or more of the cost of a device, ASCs have the option of either:  1)  Submitting the claim for the procedure to their Medicare contractor after the procedures performance but prior to manufacturer acknowledgement of credit for a specified device, and subsequently contacting the contracto r regarding a claims adjustment once the credit determination is made; or 2) holding the claim for the procedure until a determination is made by the manufacturer on the partial credit and submitting the claim with modifier FC appended to the implantation  procedure HCPCS code if the partial credit is 50 percent or more of the cost of the device.  If choosing the first billing option, to request a claims adjustment once the credit determination is made, ASCs should keep in mind that the initial Medicare payment for the procedure involving the device is conditional and subject to adjustment.  40.9 - Payment and Coding for Presbyopia Correcting IOLs (P -C IOLs) and Astigmatism Correcting IOLs (A -C IOLs)  (Rev. 11793; Issued:01 -19-23; Effective: 02 -21-23; Impleme ntation: 02- 21-23)  CMS payment policies and recognition of P -C IOLs and A- C IOLs are contained in Transmittal 636 (CR3927) and Transmittal 1228 (CR5527) respectively.   Effective for dates of service on and after January 1, 2008, when inserting an approved A-C IOL in an ASC concurrent with cataract extraction, HCPCS code V2787 (Astigmatism -correcting function of intraocular lens) should be billed to report the non -covered charges for the A -C IOL functionality of the inserted intraocular lens.  Additionally,  note that HCPCS code V2788 (Presbyopia -correcting function of intraocular lens) is no longer valid to report non -covered charges associated with the A -C IOL.  However, this code continues to be valid to report non -covered charges for a P -C IOL.  The payme nt for the conventional lens portion of the A -C IOL and P -C IOL continues to be bundled with the ASC procedure payment.
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Effective for services on and after January 1, 2010, ASCs are to bill for insertion of a Category 3 new technology intraocular lens (NT IOL) that is also an approved A -C IOL or P-C IOL, concurrent with cataract extraction, using three separate codes.  ASCs shall use HCPCS code V2787 or V2788, as appropriate, to report charges associated with the non-covered functionality of the A -C IOL or P -C IOL, the appropriate HCPCS code 66982 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devic es or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage); 66983 (Intracapsular c ataract extraction with insertion of intraocular lens prosthesis (1 stage procedure)); or 66984 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspirati on or phacoemulsification)), to report the covered cataract extraction and insertion procedure; and Q1003 (New technology, intraocular lens, category 3 (reduced spherical aberration) as defined in Federal Register notice, Vol. 65, dated May 3, 2000) to report the covered NTIOL aspect of the lens on claims for insertion of an A -C IOL or P -C IOL that is also designated as an NTIOL.  Listings of the CMS -approved Category 3 NTIOLs, A -C IOLs, and P -C IOLs are available on the CMS Web -site.   40.10 - Removal of D evice Portion from Certain Discounted Device-Intensive Ambulatory Surgical Center (ASC) Procedures Prior to the Administration of Anesthesia (Rev. 11793; Issued:01- 19-23; Effective: 02 -21-23; Implementation: 02 -21-23)
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Effective for claims with dates of ser vice beginning January 1, 2016, contractors will identify and process device intensive procedures and services billed with the 73 modifier, by utilizing the program payment amount appearing in the FB Mod Reduced Price field on the ASCFS record layout as th e full program payment, with the device portion removed, prior to processing the 73 modifier payment calculations.  If there is no payment amount in the FB Mod Reduced Price field of the ASCFS, then the procedure is not device intensive and this new policy would not apply.   To process claims correctly, when device intensive procedures and services are billed with the 73 and FB/FC modifiers, the FB/FC modifier is ignored for this line item unused device, and the line item would continue to be processed as st ated above.   For ASCs subject to the Ambulatory Surgical Center Quality Reporting (ASCQR) Program payment reduction, contractors shall utilize the procedure payment amount located in the respective Penalty FB Mod Reduced Price field on the ASCFS in place of the payment amount in the FB Mod Reduced Price field or the Penalty Price field on the ASCFS in place of the payment amount in the Price field, as appropriate.   50 - ASC Procedures for Completing the ASC X12 837 Professional Claim Format or the Form CMS- 1500 (Rev. 11793; Issued:01- 19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  The Place of Service (POS) code is 24 for procedures performed in an ASC.  Prior to January 1, 2008, Type of Service (TOS) code is F (ASC Facility Usage for Surgical Services) is appropriate when modifier SG appears on an ASC claim.  Otherwise TOS 2 (surgery) for professional services rendered in an ASC is appropriate.  Beginning January 1, 2008, ASCs no longer are required to include the SG modifier on facility claims in Medicare.  The contractors shall assign TOS code F to codes billed by specialty 49 for Place of Service 24.   60 - Medicare Summary Notices (MSN), Claim Adjustment R eason Codes, Remittance Advice Remark Codes (RAs)  (Rev. 1325; Issued: 08- 29-07; Effective:  01 -01-08; Implementation:  01 -07-08)
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60.1 - Applicable Messages for NTIOLs  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02 -10-17)  Contractors shall return as unprocessable any claims for NTIOLs containing Q1003 alone or with a code other than one of the procedure codes listed in 40.3.    The contractor shall use the following remittance advice messages and associated codes when returning claim s under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 16  RARC: M67  MSN: N/A  Contractors shall deny payment for Q1003 if services are furnished in a facility other than a Medicare -approved ASC.   The contractor shall use the following remittance advice messages and associated codes when denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 58  RARC: N/A  MSN: 16.2  Contractors shall deny payment for Q1003 if billed by an entity other than a Medicare -approved ASC.    The contractor shall use the following remittance advice messages and associated codes when denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 170  RARC: N/A  MSN: 33.1  Contractors shall deny payment for Q1003 if submitted for payment past the discontinued date (after the 5 -year period, or after February 26, 2011).  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 27  RARC: N/A  MSN: 21.11  A/B MACs (B) shall deny payment for Q1003 if services are furnished in a facility other than a Medicare -approved ASC.    The contractor shall use the following remittance advice messages and associated codes when denying claims  under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.
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The contractor shall use the following remittance advice messages and associated codes when denying claims  under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 58  RARC: N/A  MSN: 16.2  60.2 - Applicable Messages for ASC 2008 Payment Changes Effective January 1, 2008  (Rev. 3650, Issued: 11- 10-16, Effective: 02 -10-17, Implementation: 02 -10-17)  Contractors shall deny services not included on the ASC facility payment files (ASCFS and ASC DRUG files) when billed by ASCs (specialty 49).   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 8  RARC: N95  MSN: 26.4  If there is no approved ASC surgical procedure on t he same date for the billing ASC in history, contractors shall return pass -through device claims/line items, brachytherapy claims/line items, drug code (including C9399) claims/line items, and any other ancillary service claims/line items such as radiology  procedure claim/line items on the ASCFS list or ASCDRUG list as unprocessable.   The contractor shall use the following remittance advice messages and associated codes when returning claims under this policy.  This CARC/RARC combination is compliant with C AQH CORE Business Scenario Three.   Group Code: CO  CARC: 16  RARC: M51  MSN: N/A  Contractors shall deny the technical component for all ancillary services on the ASCFS list billed by specialties other than 49 provided in an ASC setting (POS 24).  The contrac tor shall use the following remittance advice messages and associated codes when denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.
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Group Code: CO  CARC: 171  RARC: N/A  MSN: 16.2  Contractors shall deny globally billed  ancillary services on the ASCFS list if billed by specialties other than 49 provided in an ASC setting (POS 24).  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 4  RARC: N/A  MSN: 16.2  Contractors shall deny separately billed implantable devices.   The contractor shall use the followi ng remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four.  Group Code: CO  CARC: 97  RARC: M97  MSN: 16.32  If there is a related, approv ed surgical procedure for the billing ASC for the same date of service, also include the following MSN message: 16.8.  60.3  Applicable ASC Messages for Certain Payment Indicators Effective for Services Performed on or after January 1, 2009 (Rev. 11793; Issued:01 -19-23; Effective: 02 -21-23; Implementation: 02 -21-23)  Contractors shall deny services for HCPCS codes with payment indicators C5  (Inpatient surgical procedure under the OPPS; no payment made.), M6 (No payment made; paid under another fee schedul e), U5 (Surgical unlisted service excluded from ASC payment.  No payment made.), or X5 (Unsafe surgical procedure in ASC.  No payment made).   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying clai ms under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four.  Group Code: CO  CARC: 5  RARC: N/A  MSN: 16.32  Contractors shall deny services for CPT codes with payment indicators E5 (Surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made), or Y5 (Non -surgical procedure/item not valid for Medicare purposes because of coverage, regulation and/or statute; no payment made).
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The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: PR  CARC: 96  RARC: N425  MSN: 16.10  NOTE:   Contractors shall assign beneficiary liability for facility charges HCPCS codes billed with ASC payment indicators C5, E5, U5 and X5 .  Contractors return as unprocessable services for HCPCS codes with payment indicator D5 (Deleted/discontinued code; no p ayment made).   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 181  RARC: N56  MSN: N/A  Contractors shall deny services for HCPCS with payment indicators L1  (Influenza vaccine; pneumococcal vaccine, Covid -19 Vaccine, monoclonal antibody therapy product.  Packaged item/service; no separate payment made), NI (Packaged service/item; no separate payment made) or  S1 (Service not surgical in nature; and not a radiology service payable under the OPPS, drug/biological, or brachytherapy source.  Packaged item/service; no separate payment made).   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Four.  Group Code: CO  CARC: 97  RARC: N390  MSN: 16.32  Contractors shall return as unprocessable services for HCPCS with payment indicators B5 (Alternative code may be available; no payment made).  The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This  CARC/RARC combination is compliant with CAQH CORE Business Scenario Two.   Group Code: CO  CARC: 16  RARC: M51  MSN: N/A
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Group Code: CO  CARC: 16  RARC: M51  MSN: N/A  70 - Ambulatory Surgical Center (ASC) HCPCS Additions, Deletions, and Master Listing (Rev. 11793; Issued:01- 19-23; Effective: 02 -21-23; I mplementation: 02 -21-23)  Prior to January 1, 2018, the CMS Division of Data Systems (DDS) releases the ASC HCPCS, additions, deletions, and master listing files of ASC codes on a periodic basis.  Instructions on how to retrieve these files from the CMS ma inframe telecommunications system are also published on the same periodic basis.  The Office of Information Services (OIS) announces the dates that the files are available.  Beginning January 1, 2008, the CMS Division of Data Systems (DDS) releases the ASCF S, ASC Drug File, ASC Restated Drug Files, ASC PI file, and the ASC Code Pair file, as appropriate.  Instructions on how to retrieve these files from the CMS mainframe are communicated at the time that the files are released.  The ASC payment system quarte rly recurring update notifications also identify the files that are applicable to that quarters update of the payment system.
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Transmittals Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R11927CP  03/24/2023  April 2023 Update of the Ambulatory Surgical Center [ASC] Payment System  04/03/2023  13143  R11903CP  03/16/2023  April 2023 Update of the Ambulatory Surgical Center [ASC] Payment System -- Rescinded and replaced by Transmittal  11927  04/03/2023  13143  R11793CP  01/19/2023  Internet -Only Manual [IOM] Updates for Ambulatory Surgical Centers [ASCs]  02/21/2023  13067  R3939CP  12/22/2017  January 2018 Update of the Ambulatory Surgical Center (ASC) Payment System  01/02/2018  10441  R3650CP  11/10/2016  Updates to Pub. 100- 04, Chapters 8, 13 and 14 to Correct Remittance Advice Messages 02/10/2016  9841 R3430CP  12/29/2015  January 2016 Update of the Ambulatory Surgical Center (ASC) Payment System  01/04/2016  9484 R3031CP  08/22/2014  Update to Pub. 100- 04, Chapter 14 to Provide Language -Only Changes for Updating ASC X12 09/23/2014  8768 R2020CP  08/06/2010  Clarification of Billing Requirement for Ancillary Services Performed in the Ambulatory Surgical Center (ASC) by Entities Other Than A SCs 09/07/2010  7078 R1865CP  12/01/2009  January 2010 Update of the Ambulatory Surgical Center (ASC) Payment System  01/04/2010  6746 R1698CP  03/13/2009  April 2009 Update to the ASC Payment System; Summary of Payment Policy Changes/Manual Revisions  04/06/2009  6424 R1669CP  01/13/2009  January 2009 Update of the Ambulatory Surgical Center (ASC) Payment System  01/05/2009  6323 Rev #  Issue Date  Subject  Impl Date  CR#  R1616CP  10/17/2008  Implementation of an ASC HCPCS Payment Indicator File  01/05/2009  6184 R1572CP  08/08/2008  New Requirement for Ordering/Referring Information on Ambulatory Surgical Center (ASC) Claims for Diagnostic Services
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Implementation of an ASC HCPCS Payment Indicator File  01/05/2009  6184 R1572CP  08/08/2008  New Requirement for Ordering/Referring Information on Ambulatory Surgical Center (ASC) Claims for Diagnostic Services  01/05/2009  6129 R1514CP  05/23/2008  ASC Manualization  06/23/2008  6031 R1325CP  08/29/2007  Testing and Implementation of 2008 Ambulatory Surgical Center (ASC) Payment System Changes  01/07/2008  5680 R1308CP  07/20/2007  Testing and Implementation of 2008 Ambulatory Surgical Center (ASC) Payment System Changes (Sensitive and Controversial)  Replaced by Transmittal 1325  01/07/2008  5680 R1160CP  01/19/2007  Colorectal Cancer Screening Flexible Sigmoidoscopy and Colonoscopy Coinsurance Payment Change  07/02/2007  5387 R975CP  06/09/2006  Ambulatory Surgical Center (ASC) Claims Processing Manual Clarification  06/05/2006  5026 R942CP  05/05/2006  Ambulatory Surgical Center (ASC) Claims Processing Manual Clarification  10/02/2006  5026 R914CP  04/21/2006  Additional $50 Payment for New Technology Intraocular Lenses Furnished In Ambulatory Surgical Centers  05/22/2006  4361 R639CP  08/05/2005  Cessation of Additional $50 Payment for New Technology Intraocular Lenses (NTIOLs)  10/03/2005  3901 R001CP  10/01/2003  Initial Publication of Manual  NA NA Back to top of Chapter
(Medicare Claims Processing Manual)
Medicare Claims Processing Manual  Chapter 17 - Drugs and Biologicals   Table of Contents  (Rev. 12201, 08- 10-23)   Transmittals for Chapter 17
(Medicare Claims Processing Manual)
10 - Payment Rules for Drugs and Biologicals  20 - Payment Allowance Limit for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis  20.1 -  MMA Drug Pricing Average Sales Price  20.1.1 -  Online Pricing for Average Sales Price  20.1.2 -  Average Sales Price (ASP) Methodology  20.1.3 -  Exceptions to Average Sales Price (ASP) Payment Methodology 20.2 -  Single Drug Pricer (SDP)  20.3 -  Calculation of the Payment Allowance Limit for DME MAC Drugs  20.4 -  Calculation of the AWP  20.5 -  Detailed Procedures for Determining AWPs and the Drug Payment Allowance Limits  20.5.1 -  Background  20.5.2 -  Review of Sources for Medicare Covered Drugs and Biologicals  20.5.3 -  Use of Generics  20.5.4 -  Find the Strength and Dosage  20.5.5 -  Restrictions  20.5.6 -  Inherent Reasonableness for Drugs and Biologicals  20.5.7 -  Injection Services  20.5.8 -  Injections Furnished to ESRD Beneficiaries  20.5.9 -  Annual Update of AWP Payment Allowance Limit for Vaccines  30 - A/B MAC (B) Distribution of Limit Amounts  40 - Discarded Drugs and Biologicals  40.1 -  Discarded Erythropoietin Stimulating Agents for Home Dialysis  50 - Assignment Required for Drugs and Biologicals  60 - DMEPOS Suppliers Require a License to Dispense Drugs  60.1 -  Prescription Drugs Billed by Suppliers Not Licensed to Dispense Them  70 - Claims Processing Requirements -  General  70.1 -  Billing Drugs Electronically -  NCPDP  70.1.1 -  Reporting Modifiers in the Compound Drug Segment  70.1.2 -  Coordination of Benefits (COB)  70.1.3 -  Inbound NCPDP Claim  80 - Claims Processing for Special Drug Categories  80.1 -  Oral Cancer Drugs  80.1.1 -  HCPCS Service Coding for Oral Cancer Drugs  80.1.2 -  HCPCS and NDC Reporting for Prodrugs  80.1.3 -  Other Claims Processing Issues for Oral Cancer Drugs  80.1.4 -  MSN/Claim Adjustment Message Codes for Oral Cancer Drug Denials  80.2 -  Oral Anti -Emetic Drugs Used as Full Replacement for Intravenous Anti -Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen  80.2.1 -  HCPCS
(Medicare Claims Processing Manual)
Oral Cancer Drug Denials  80.2 -  Oral Anti -Emetic Drugs Used as Full Replacement for Intravenous Anti -Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen  80.2.1 -  HCPCS Codes for Oral Anti -Emetic Drugs  80.2.2 -  Claims Processing Jurisdiction for Oral Anti- Emetic Drugs  80.2.3 -  MSN Denial/Claim Adjustment and Remark Messages for Anti- Emetic Drugs  80.2.4 -  Billing and Payment Instructions for A/B MACs (A)  80.3 -  Billing for Immunosuppressive Drugs  80.3.1 -  Requirements for Billing A/B MAC (A) for Immunosuppressive Drugs  80.3.2 -  MSN/Remittance Messages for Immunosuppressive Drugs  80.3.3 -  Special Requirements for Immunosuppressive Drugs  80.4 -  Billing for Hemophilia Clotting Factors  80.4.1 -  Clotting Factor Furnishing Fee  80.5 -  Self-Administered Drugs  80.6 -  Intravenous Immune Globulin 80.7 -  Pharmacy Supplying Fee  and Inhalation Drug Dispensing Fee  80.8 -  Reporting of Hematocrit and/or Hemoglobin Levels  80.9 -  Required Modifiers for ESAs Administered to Non- ESRD Patients  80.10 -  Hospitals Billing for Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for Non- ESRD Patients  80.11 -  Requirements for Providing Route of Administration Codes for Erythropoiesis Stimulating Agents (ESAs)  80.12 -  Claims Processing Rules for ESAs Administered to Cancer Patients for Anti- Anemia Therapy  80.13 -  Supplier Payment Under Medicare Part B for Insulin Furnished Through