evekhm/cms_iom_500 huggingface dataset:
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Step 3 -  If the hospital is a childrens hospital, a cancer hospital, a rural hospital with 100 or fewer beds, or a sole community hospital (including EACHs) with 100 or fewer beds, subtract the result of step 2 from the result of step 1 and pay .85 times this amount.  If the hospital is not one of the hospital types listed above, no payment is made.  Step 4 -  When the result of step 2 is greater than the result of step 1 for the final month of a providers cost report period, do nothing more.  When the result of step 2 is greater than the result of step 1 for any other month, store all step 1 and step 2 totals and include these totals with the totals for the next months TOP calculation.  70.7 - Transitional Outpatient Payments (TOPs) for CY 2010 through CY 2012  (Rev. 2531, 08- 24-12, Effective:10- 01-12, Implementation:10- 01-12)  Hold harmless transitional outpatient payments (TOPs) to small rural hospitals and rural sole community hospitals were scheduled to expire December 31, 2009. Section 3121 of the Affordable Care Act extended the hold harmless provision for small rural hospi tals with 100 or fewer beds through December 31, 2010, at 85 percent of the hold harmless amount.  Sole Community Hospitals (SCHs) and Essential Access Community Hospitals (EACHs) are no longer limited to those with 100 or fewer beds effective January 1, 2010 through December 31, 2010 and these providers will receive TOPs payments at 85 percent of the hold harmless amount until December 31, 2010.  Section 108 of the Medicare and Medicaid Extenders Act of 2010 (MEA) further extended the hold harmless provision for rural hospitals with 100 or fewer beds and to all SCHs (and EACHs) regardless of bed size through December 31, 2011 at 85 percent of the hold harmless amount.   Section 308 of the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA) as amended by section 3002 of the Middle Class Tax Relief and Jobs  Creation Act , extends the Outpatient Hold -Harmless provision, effective for dates of service on or after January 1, 2012, through December 31, 2012, to rural hospitals with 100 or fewer beds.
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Section 308 of the Temporary Payroll Tax Cut Continuation Act of 2011 also extended through February 29, 2012 the hold harmless provision for SCHs (and EACHs) without the bed size limitation.  However, section 3002 of the Middle Class Tax Relief and Jobs  Creation Act  extended through December 31, 2012, the hold harmless provision for SCHs (and EACHs) that have no more than 100 beds.  Cancer and children's hospitals are permanently held harmless under section 1833(t)(7)(D)(ii) of the Social Security Act.   Monthly TOPs calculations that contractors are required to calculate are described below.  This calculation is effective for services provided by SCH (and EACHs) with more than 100 beds between January 1, 2010 and February 29, 2012.  This calculation is ef fective for services provided by rural hospitals with 100 or fewer beds and SCHs (and EACHs) with 100 or fewer beds between January 1, 2010 and December 31, 2012.   Step 1 -  Compute the pre -BBA amount for each month by first multiplying the total charges for covered services for all OPPS services on claims paid during the month and reduce the total charges to cost by multiplying them by the outpatient cost -to-charge r atio and then multiplying this amount by the provider -specific payment -to-cost ratio (PSPCR).   Step 2 -  Add together the total Medicare program payments, unreduced coinsurance and deductible applied for all APCs, as well as all outlier payments (including reconciled outlier payments and the time value of money) and transitional pass -through payments  for drugs, biologicals and/or devices for those same claims paid during the month as those used in Step 1.  If the result is greater than the result of step 1, go to step 4.  No transitional payment is due this month.   Step 3 -  If the hospital is a childrens hospital, a rural hospital with 100 or fewer beds, or a sole community hospital (including EACHs), subtract the result of step 2 from the result of step 1 and pay .85 times this amount.  If the hospital is not one of the hospital types listed above, no payment is made.
(Medicare Claims Processing Manual)
Step 4 -  When the result of step 2 is greater than the result of step 1 for the final month of a providers cost report period, do nothing more.  When the result of step 2 is greater than the result of step 1 for any other month, store all step 1 and step 2 totals and include these totals with the totals for the next months TOP calculation.   70.8 - TOPs Overpayments (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)  Because the revised TOP calculations are often implemented in the system after their effective date, overpayments or underpayments in interim TOPs to providers are expected.   Unless directed by CMS, retroactive calculations of monthly interim TOP amounts are not necessary because any difference in interim TOP payments and actual TOP amounts determined on the cost report will be taken into account in the cost report settlement process, including tentative settlements.   If mutually agreed upon by both the contractor and the provider, the contractor can pay less than 85 percent of the monthly TOP payment to that provider, to avoid significant overpayments throughout the year that must be paid back to the contractor at cost  report settlement.   Contractors should advise providers of the revised TOP calculations and other changes in OPPS using their normal communication protocols (Web site, regularly scheduled bulletins, electronic bulletin boards, or listserv).   80 - Shared system Requirements to Incorporate Provider -Specific Payment -to-Cost Ratios into the Calculation of Interim Transitional Outpatient Payments Under OPPS  (Rev. 1, 10- 03-03) A-01-44  80.1 - Background - Payment -to-Cost Ratios (Rev. 1060, Issued: 09 -18-06, Effective: 10 -01-06, Implementation: 10- 02-06)
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80.1 - Background - Payment -to-Cost Ratios (Rev. 1060, Issued: 09 -18-06, Effective: 10 -01-06, Implementation: 10- 02-06)  Under regulations at 42 CFR 419.70, hospitals and community mental health centers (CMHCs) that are subject to the OPPS may be eligible to receive a transitional corridor payment, frequently referred to as a TOP.  The purpose of the TOP is to restore some of the decrease in the payment that  a provider may experience under the OPPS.  Providers that are eligible for TOPs receive monthly interim payments.  However, the final TOP amount is calculated based on the providers settled cost report.  Final TOP payments for a calendar year are based o n the difference between what the provider was paid under the OPPS, and the providers pre -Balanced Budget Act (BBA) amount.  The pre -BBA amount is an estimate of what the provider would have been paid during the calendar year for the same services under  the system that was in effect prior to OPPS.  If the pre -BBA amount exceeds the actual OPPS payments a provider received during a calendar year, qualifying cancer centers and childrens hospitals are permanently held harmless, and will receive the entire amount of the difference between their OPPS payments and their pre -BBA amount.  Other hospitals and CMHCs may receive a portion of the difference as a TOP, depending on the rules listed above.   The pre -BBA amount is calculated by multiplying the providers PCR, based on the providers base year cost report, times the reasonable costs the provider incurred during a calendar year to furnish the services that were paid under the OPPS.  For most hospitals and CMHCs, the base year cost report used to calculate the payment -to-cost ratio is the cost report that ended during calendar year 1996.  However, if a hospital or CMHC did not file a cost report that ended in calendar year 1996, the payment -to cost  ratio will be calculated using the providers first cost report that ended after calendar year 1996 and before calendar year 2001.   80.2 - Using the Newly Calculated PCR for Determining Final TOP Amounts  (Rev. 1, 10- 03-03) A-01-44
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80.2 - Using the Newly Calculated PCR for Determining Final TOP Amounts  (Rev. 1, 10- 03-03) A-01-44  Final TOP amounts are determined for each calendar year, based on the calendar year or portion of a calendar year that falls within a providers cost reporting period.  The PCR is one factor used on Worksheet E, Part B, of the hospital cost report (Form CM S-2552 -  96), and Worksheet J -3 of the CMHC cost report (Form CMS -2088) in calculating the providers final TOP amount.  Once calculated, the providers PCR will be used to calculate the providers pre-  BBA amount for all calendar years for which the provider may be eligible for a TOP payment.  The PCR will not change each year.   80.3 - Using the Newly Calculated PCR for Determining Interim TOPs  (Rev. 1060, Issued: 09- 18-06, Effective: 10 -01-06, Implementation: 10- 02-06)  Providers that are eligible for TOPs receive monthly interim payments.  Initially, the calculation of the monthly payment used a national uniform PCR of 80 percent for all providers.  After A/B MACs (A) calculated a provider -specific PCR, no later than October 1, 2001, that PCR shall be used in calculating monthly interim payments to the provider.  The shared systems maintainers will populate the PCR field of the Provider Specific File (formerly cost- of-living adjustment field) to reflect the provider -speci fic PCR.
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The shared systems maintainers will revise the monthly TOPs calculation to use the provider -specific PCR, taken from the Provider Specific File, in lieu of the national PCR of 80 percent.  If the value in the PCR field in the Provider Specific File is blank (i.e., the A/B MAC (A) has not yet calculated a provider -specific PCR), the A/B MAC (A) must immediately calculate a provider -specific PCR and cannot continue to use the national PCR of 80 percent.  The change to the provider -specific file and the change  in the calculation of TOPs payments were effective on July 1, 2001.  90 - Discontinuation of Value Code 05 Reporting  (Rev. 1777; Issued:  07- 24-09; Effective Date:  01-01-08; Implementation Date:  01-04-10)  Value code 05, Professional Component Included in Charges and Also Billed Separately to Carrier, was discontinued with the implementation of OPPS, including claims for Critical Access Hospitals and other hospitals not subject to OPPS.   100 - Medicare Summary Notice (MSN)  (Rev. 1, 10- 03-03)  Effective for claims with dates of service on or after August 1, 2000, A/B MACs (A) must modify the MSN for services provided by providers under OPPS to reflect the addition of an APC number.  This APC number should be placed next to the HCPCS code include d under the Services Provided column, and must be within a parenthesis.  The coinsurance column should reflect the coinsurance amount for which the beneficiary is responsible.  In addition, the back of the notice must be modified.  In place of the current language, the notice should reflect the following language:   THE AMOUNT YOU MAY BE BILLED for Part B services includes:   Annual deductible, the first $100 of Medicare Part B charges each year;   After the deductible has been met for the year, depending on services received, a coinsurance amount  (20 percent of the amount charged), or a fixed copayment  for each service; and   Charges for services or supplies that are not covered by Medicare.  You may not have to pay for certain denied services.  If so, a note on the front will tell you.  The Spanish version should read as follows:   La cantidad por la cual usted podra ser facturado incluye:
(Medicare Claims Processing Manual)
La cantidad por la cual usted podra ser facturado incluye:   Un deducible anual, los primeros $100 de Medicare Parte B de cargos aprobados cada ao, Despus de que haya cumplido con el deducible, dependiendo de los servicios recibidos, un coaseguro (20% de la cantidad cobrada), o un copago fijo por cada servicio ; y   Cargos por servicios/suministros que no estn cubiertos por Medicare.  Es posible que usted no tenga que pagar por ciertos cargos se servicios denegados.  De ser el caso, una NOTA en la parte del frente le indicar.   Also, A/B MACs (A) print the following message in the General Information Section:   If the coinsurance amount you paid is more than the amount shown on your notice, you are entitled to a refund.  Please contact your provider.   Spanish Version:   Si la cantidad de coaseguro que usted pag es mayor que la cantidad que muestra su notificacin, tiene derecho a un reembolso.  Por favor comunquese con su proveedor.   110 - Procedures for Submitting Late Charges Under OPPS  (Rev. 1, 10- 03-03) A-01-93
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110 - Procedures for Submitting Late Charges Under OPPS  (Rev. 1, 10- 03-03) A-01-93  Hospitals and CMHCs may not submit a late charge bill (code 5 in the third position of the bill type) for bill types 12X, 13X, 14X, and 76X effective for claims with dates of service on or after August 1, 2000.  They must submit an adjustment bill for any services required to be billed with HCPCS codes, units and line item dates of service.  A 7 in the third position of the bill type indicates an adjustment.  See Chapter 25 for additional instructions for reporting adjustments.  Separate bills containing only late charges will not be permitted for these bill types.  The submission of an adjustment bill, instead of a late charge bill, will ensure proper duplicate detection, bundling, correct application of coverage policies and proper editing by OCE and payment under OPPS.  120 - General Rules for Reporting Outpatient Hospital Services  (Rev. 3019, Issued: 08- 07-14, Effective: 01 -01-12, ICD -10: Upon Implementation of ICD-  10, Implementation: 09- 08-14, ICD -10: Upon Implementation of ICD - 10)   Hospitals use the electronic ASC X12 837 institutional claim transaction format or the hardcopy Form CMS -1450 to bill for covered outpatient services (type of bill 13X or 83X, and 85X).  The ASC X12 837 institutional claim transaction is required unless the hospital meets certain exception criteria.  These criteria are described in Chapter 24, 90- 90.5.4 of this manual.  See:   Medicare Benefit Policy Manual, Chapter 6, for definition of an outpatient;   Medicare Claims Processing Manual, Chapter 3, Inpatient Part A Hospital Billing, for outpatient services treated as inpatient services;   Medicare Claims Processing Manual Chapter 24, 90- 90.5.4 for when paper billing is permissible; and   Medicare Claims Processing Manual, Chapter 25, for general instructions for completing the hospital claim data set.
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The HCPCS code is used to describe services where payment is under the Hospital OPPS or where payment is under a fee schedule or other outpatient payment methodology.  Line item dates of service are reported for every line where a HCPCS code is required under OPPS.  For providers paid via OPPS, A/B MACs (A) return to provider (RTP) bills where a line item date of service is not entered for each HCPCS code reported, or if the line item dates of service reported are outside of the statement -covers period.  This includes those claims where the from and through dates are equal.   NOTE:   Effective for dates of service on or after January 1, 2008, the A/B MAC (A) no longer processes claims on TOB 83X for ASCs.  All IHS ASC providers must submit their claims to the designated A/B MAC (B).   120.1 - Bill Types Subject to OPPS  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01 -02-24)    The following bill types are subject to OPPS:     All outpatient hospital Part B bills (bill types 12X, 13X with condition code 41 or 92; 14X and 13X without condition code 41 or 92) with the exception of bills from hospitals in Maryland, Indian Health Service, CAHs, hospitals located in Saipan, American Samoa, the Virgin Islands and Guam; and hospitals that provide Part B only services to their inpatients.  Effective 4/1/06 the 14X type of bill is for nonpatient laboratory specimens and is no longer applicable for partial hospitalization billing.     CMHC bills (bill type 76X with condition code 41 or 92);     CORF claims for hepatitis B vaccines (bill type 75X);     HHA claims for antigens, hepatitis B vaccines, splints and casts  (bill type 34X); and     For splints, casts and antigens when provided to hospice patients for treatment of a non -terminal illness by other than a hospital outpatient department.  This requires reporting of condition code 07.
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 For splints, casts and antigens when provided to hospice patients for treatment of a non -terminal illness by other than a hospital outpatient department.  This requires reporting of condition code 07.    As a result, A/B MACs (A) shall instruct CORFs, HHAs, and other providers to report HCPCS for these services, in order to assure payment under this system.  Payment will continue to be made for vaccines provide to hospice patients by the Medicare A/B MAC ( B).  The appropriate HCPCS codes are as follows:    Categories of Services Requiring HCPCS Codes  Category  HCPCS Codes  Angens  95144 -95149, 95165, 95170, 95180, and 95199  Vaccines  90657 -90659, 90732, 90744, 90746, 90747, 90748, G0008, G0009, and G0010  Splints  29105 -29131, 29505 -29515  Casts  29000 -29085, 29305, 29325 -29445, 29450, 29700 -29750, 29799    NOTE:   A/B MACs (HHH) shall advise their HHAs to report the above HCPCS codes with the exception of  vaccines under Revenue Code 0550 (Skilled Nursing).  The only time revenue code 0550 may be reported is when the HHA is billing for antigens, splints, or casts.  See Chapter 18 for the reporting of vaccines by HCPCS codes.   120.2 - Routing of Claims  (Rev. 1, 10- 03-03) A-02-00-026  Effective April 1, 2002, the following types of bills (TOBs) should be rerouted back to the OPPS OCE:
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Effective April 1, 2002, the following types of bills (TOBs) should be rerouted back to the OPPS OCE:   TOB  Description  22X Skilled Nursing Facility (SNF) Inpatient Part B  23X SNF/Outpatient  24X SNF Part B  32X Home Health Agency (HHA) visits under a Part B Plan of Treatment (POT)  33X HHA visits under a Part A (POT)  34X HHA visits under a POT  71X Rural Health Clinic  72X Hospital Based or Independent Renal Dialysis Center  73X Federally Qualified Health Center  74X Other Rehabilitation Facility  75X Comprehensive Outpatient Rehabilitation Facility (CORF)  81X Hospice (non -hospital based)  82X Hospice (hospital based)   Claims containing the above TOBs, other than 32X and 33X, with services that span beyond April 1, 2001, must be split prior to their submittal.  For example, if a claim contains services prior to and after April 1, 2002, the provider must submit two separa te claims.  One for the services prior to April 1, 2002, which will be routed to the non- OPPS OCE and another claim for the services April and later which will be routed to the OPPS OCE.  In the event the A/B MAC (A) receives a claim containing pre-  and post -April 1, 2002, dates of service, it returns it to the provider requesting that the claim be split as indicated above.   Claims containing the above TOBs with dates of service January 1, 2002, through March 31, 2002, should continue to be routed through the non- OPPS OCE.   NOTE:   TOBs (12X, 13X, 14X, and 85X) from Critical Access Hospitals, Maryland Hospitals, Indian Health Service Hospitals, U.S.  Virgin Island Hospitals, and those hospitals located in the Pacific (American Samoa, Guam, and Saipan) do not have to be rerouted since they are sent through the non- OPPS OCE.   140 - All-Inclusive Rate Hospitals  (Rev. 1, 10- 03-03) A-01-93, A -03-066
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140 - All-Inclusive Rate Hospitals  (Rev. 1, 10- 03-03) A-01-93, A -03-066  All-inclusive rate hospitals are required to code with HCPCS the outpatient services they provide and bill charges at the HCPCS level.  In addition, they are required to follow bill reporting instructions contained in 30.  Unlike other hospitals, all -inclusive rate hospitals do not have outpatient departmental cost -to-charge ratios from prior year cost reports that may be used for calculating outlier payments, device pass -through payments, or interim transitional corridor  payments.  As a result, A/B MACs (A) use the statewide average urban or rural outpatient cost -to-charge ratio, as appropriate, for all -inclusive rate hospitals.  In the future, once cost and charge data for an all -inclusive rate hospital is available, the A/B MAC (A) will be able to apply a cost -to-charge ratio that is specific to the hospital.  141 - Maryland Waiver Hospitals (Rev. 771; Issued: 12- 02-05; Effective Date: 01 -03-06; Implementation Date: 01 -03-06)  In accordance with 1814 (b)(3) of the Act, services provided by hospitals in Maryland subject to the Health Services Cost Review Commission are paid according to the terms of the waiver, that is 94% of submitted charges subject to any unmet Part B deductible and coinsurance. Payment should not be made under a fee schedule or other payment method for outpatient items and services provided except the fol lowing situations:   Non-patient laboratory specimens are paid under the clinical diagnostic laboratory fee schedule (bill type 14X); and   Ambulance services which are subject to the ambulance fee schedule.   150 - Hospitals That Do Not Provide Outpatient Services  (Rev. 1, 10- 03-03) HO- 440.1, A -00-21, A -02-064
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Ambulance services which are subject to the ambulance fee schedule.   150 - Hospitals That Do Not Provide Outpatient Services  (Rev. 1, 10- 03-03) HO- 440.1, A -00-21, A -02-064  Covered Part B -only services furnished to inpatients when they are furnished by a hospital that does no Medicare billing for hospital outpatients services under Part B are excluded from OPPS.  The Part B -only services, which are payable for hospital inpati ents who have either exhausted their Part A benefits or who are not entitled to Part A benefits, are specified in Chapter 3.  These services include, but are not limited to, diagnostic tests; x-ray and radioactive isotope therapy; surgical dressings; limb braces and trusses; and artificial limbs and eyes.  Medicare payment for excluded Part B -only ser vices furnished by these hospitals is determined using the method under which the hospital was paid prior to OPPS.   Hospitals must notify their A/B MAC (A) if they do not submit claims for outpatient Part B services, so that their claims can be excluded from the OPPS.  The hospital must also notify the A/B MAC (A) if it begins to furnish Part B outpatient services.  OPP S will apply at that time unless other exclusions are applicable.   160 - Clinic and Emergency Visits  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  CMS has acknowledged from the beginning of the OPPS that CMS believes that CPT Evaluation and Management (E/M) codes were designed to reflect the activities of physicians and do not describe well the range and mix of services provided by hospitals during visits of clinic and emergency department patients.  While awaiting the development of a national set of facility -specific codes and guidelines, providers should continue to apply their current internal guidelines to the existing CPT codes.  Each hospitals  internal guidelines should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes.  Hospitals should ensure that their guidelines accurately reflect resource distinctions between the five levels of codes.   Effective January 1, 2007, CMS is distinguishing between two types of emergency departments: Type A emergency departments and Type B emergency departments.