evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
B. Billing for Infusions and Injections   Beginning in CY 2007, hospitals were instructed to use the full set of drug administration CPT codes (90760- 90779; 96401- 96549), (96413 -96523 beginning in CY 2008) (96360-96549 beginning in CY 2009) when billing for drug administration services provided in the hospital outpatient department.  In addition, hospitals are to continue to bill HCPCS code C8957 (Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump) when appropriate.  Hospitals are expected to report all drug administration CPT codes in a manner consistent with their descriptors, CPT instructions, and correct coding principles.  Hospitals should note the conceptual changes between CY 2006 drug administration codes effective under the OPPS and the CPT codes in effect beginning January 1, 2007, in order to ensure accurate billing under the OPPS.  Hospitals should report all HCPCS codes that describe the drug administration services provided, regardless of whethe r or not those services are separately paid or their payment is packaged.   Medicares general policy regarding physician supervision within hospital outpatient departments meets the physician supervision requirements for use of CPT codes 90760-90779, 96401- 96549, (96413- 96523 beginning in CY 2008).  (Reference:  Pub.100- 02, Medicare Benefit Policy Manual, Chapter 6, 20.4.)   Drug administration services are to be reported with a line item date of service on the day they are provided.  In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounte r where observation services span more than 1 calendar day.  C. Payments For Drug Administration Services   For CY 2007, OPPS drug administration APCs were restructured, resulting in a six- level hierarchy where active HCPCS codes have been assigned according to their clinical coherence and resource use.  Contrary to the CY 2006 payment structure that bundled payment for several instances of a type of service (non -chemotherapy, chemotherapy by infusion, non- infusion chemotherapy) into a per -encounter APC payment, structure introduced in CY 2007 provides a separate APC payment for each reported unit of a separately  payable HCPCS code.
(Medicare Claims Processing Manual)
Hospitals should note that the transition to the full set of CPT drug administration codes provides for conceptual differences when reporting, such as those noted below.   In CY 2006, hospitals were instructed to bill for the first hour (and any additional hours) by each type of infusion service (non- chemotherapy, chemotherapy by infusion, non- infusion chemotherapy).  Beginning in CY 2007, the first hour concept no longer exists. CPT codes in CY 2007 and beyond allow for only one initial service per encounter, for each vascular access site, no matter how many types of infusion services are provided; however, hospitals will receive an APC payment for the initial service and se parate APC payment(s) for additional hours of infusion or other drug administration services provided that are separately payable.    In CY 2006, hospitals providing infusion services of different types (non-chemotherapy, chemotherapy by infusion, non- infusion chemotherapy) received payment for the associated per -encounter infusion APC even if these infusions occurred during the same tim e period.  Beginning in CY 2007, hospitals should report only one initial drug administration service, including infusion services, per encounter for each distinct vascular access site, with other services through the same vascular access site being report ed via the sequential, concurrent or additional hour codes.  Although new CPT guidance has been issued for reporting initial drug administration services, Medicare contractors shall continue to follow the guidance given in this manual.  (NOTE:  This list above provides a brief overview of a limited number of the conceptual changes between CY 2006 OPPS drug administration codes and CY 2007 OPPS drug administration codes -  this list is not comprehensive and does not include all items hospitals will need to consider during this transition)   For APC payment rates, refer to the most current quarterly version of Addendum B on the CMS Web site at http://www.cms.hhs.gov/HospitalOutpatientPPS/.   D. Infusions Started Outside the Hospital
(Medicare Claims Processing Manual)
Effective for services furnished on or after July 1, 2005, the I/OCE will return to providers any claim that reports a charge for blood or blood products using Revenue Code 038X without a separate line for processing and storage services using Revenue Code  0390, 0392, or 0399.  Moreover, in order to process to payment, both lines must report the same line item date of service, the same number of units, and the same HCPCS code accompanied by modifier BL.  Payment for blood and blood products is based on the Ambulatory Payment Classification (APC) Group to which its HCPCS code is assigned, multiplied by the number of units transfused.  Units of whole blood or packed red cells for which only processing and storage charges are reported are not subject to the blood deductible.  The Medicare blood deductible is applicable only if the OPPS provider purchases whole blood or packed red cells fr om a community blood blank or if the OPPS provider assesses a charge that reflects more than blood processing and storage for whole blood or packed red cells collected by its owns blood bank.  If the beneficiary has not already fulfilled the annual blood deductible or replaced the blood, OPPS payment will be made for processing and storage costs only.  The beneficiary is liable for the blood portion of the payment as the blood deductible.  In order to ensure correct application of the Medicare blood deductible, providers should report charges for whole units of packed red cells using Revenue Code 381 (Packed red cells), and should report charges for whole units of whole blood using Revenue Code  382 (Whole blood).  Revenue Codes 381 and 382 should be used only to report charges for packed red cells and whole blood, respectively.
(Medicare Claims Processing Manual)
In general, when autologous (predeposited or obtained through intra - or postoperative salvage) or directed -donor transfusion is performed, OPPS providers should bill for the transfusion service and the number of units of the appropriate HCPCS code that des cribes the blood product.  Payment for the product is intended to cover the costs associated with providing the autologous or directed donor blood product service (e.g., collection, processing, transportation, and storage).  OPPS providers should bill the transfusion service and the blood product HCPCS code on the date that the transfusion took place and not on the date when the autologous blood was collected.   When an autologous blood product is collected but not transfused, OPPS providers should bill CPT 86890 (autologous blood or component, collection, processing, and storage; predeposited) or 86891(autologous blood or component, collection, processing, and storage; intra - or postoperative salvage) and the number of units collected but not transfused.  CPT 86890 and 86891 are intended to provide payment for the additional resources needed to provide these services, which are not captured when a blood product HCPCS code is not billed.  Because billing 86890 or 86891 is only indicated when autologous blood is collected but not transfused, the OPPS provider should bill 86890 or 86891 on the date when the OPPS provider is certain the blood will not be transfus ed (i.e., date of a procedure or date of outpatient discharge), rather than on the date of the products collection or receipt from the supplier.   When a directed donor blood product is collected but not transfused to the initial targeted recipient or to any other patient, refer to the section 231.7 titled Billing for Unused Blood.   231.4 - Billing for Split Unit of Blood  (Rev. 1487, Issued: 04- 08-08, Effective: 04 -01-08, Implementation: 04- 07-08)
(Medicare Claims Processing Manual)
applicable  P9051  Blood, l/r, cmv -neg Freezing and thawing are separately billable  P9052  Platelets, hla -m, l/r, unit  Freezing and thawing are separately billable  P9053  Plt, pher, l/r cmv -neg, irr  Freezing and thawing are separately billable  P9054  Blood, l/r, froz/degly/wash  Freezing and thawing codes not separately billable  P9055  Plt, aph/pher, l/r, cmv -neg Freezing and thawing are separately billable  P9056  Blood, l/r, irradiated  Freezing and thawing are separately billable  P9057  RBC, frz/deg/wsh, l/r, irrad  Freezing and thawing codes not separately billable  P9058  RBC, l/r, cmv -neg, irrad  Freezing and thawing are separately billable  P9059  Plasma, frz between 8 -24hour  Freezing and thawing codes not separately billable  HCPCS/CPT  Short Descriptor  Billing of Freezing/Thawing  P9060  Fr frz plasma donor retested  Freezing and thawing codes not separately billable
(Medicare Claims Processing Manual)
231.8 - Billing for Transfusion Services  (Rev. 496, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)  To report charges for transfusion services, OPPS providers should bill the appropriate CPT code for the specific transfusion service provided under Revenue Code 391 (Blood Administration).  Transfusion services codes are billed on a per service basis, and not by the number of units of blood product transfused.  For payment, a blood product HCPCS code is required when billing a transfusion service code.  A transfusion APC will be paid to the OPPS provider for transfusing blood products once per day, regardle ss of the number of units or different types of blood products transfused.   231.9 - Billing for Pheresis and Apheresis Services  (Rev. 496, Issued: 03- 04-05, Effective: 07 -01-05, Implementation: 07- 05-05)  Apheresis/pheresis services are billed on a per visit basis and not on a per unit basis.  OPPS providers should report the charge for an Evaluation and Management (E&M) visit only if there is a separately identifiable E&M service performed which extends beyond the evaluation and management portion of a typical apheresis/pheresis service.  If the OPPS provider is billing an E&M visit code in addition to the apheresis/pheresis service, it may be appropriate to use the HCPCS modifier - 25.  231.10 - Billing for Autologous Stem Cell Transplants  (Rev. 3556, Issued: 07- 01-2016; Effective: 01- 27-16; Implementation: 10 -03-16)  The hospital bills and shows all charges for autologous stem cell harvesting, processing, and transplant procedures based on the status of the patient (i.e., inpatient or outpatient) when the services are furnished.  It shows charges for the actual transplant, described by the appropriate ICD procedure or CPT codes in Revenue Center 0362 (Operating Room Services; Organ Transplant, Other than Kidney) or another appropriate cost  center.
(Medicare Claims Processing Manual)
The CPT codes describing autologous stem cell harvesting procedures may be billed and are separately payable under the Outpatient Prospective Payment System (OPPS) when provided in the hospital outpatient setting of care.  Autologous harvesting procedures are distinct from the acquisition services described in Pub. 100- 04, Chapter 3, 90.3.1 and 231.11 of this chapter for allogeneic stem cell transplants, which include services provided when stem cells are obtained from a donor and not from the patient undergoing the stem cell  transplant.   The CPT codes describing autologous stem cell processing procedures also may be billed and are separately payable under the OPPS when provided to hospital  outpatients.  231.11 - Billing for Allogeneic Stem Cell Transplants  (Rev. 11150; Issued: 12- 10-21; Effective: 01 -01-22; Implementation: 01 -03-22)  1. Definition of Acquisition Charges for Allogeneic Stem Cell Transplants   Acquisition charges for allogeneic stem cell transplants include, but are not limited to, charges for the costs of the following services:   1. National Marrow Donor Program fees, if applicable, for stem cells from an unrelated  donor;   2. Tissue typing of donor and recipient;   3. Donor  evaluation;   4. Physician pre -procedure donor evaluation services;   5. Costs associated with harvesting procedure (e.g., general routine and special care services, procedure/operating room and other ancillary services, apheresis services,  etc.);   6. Post-operative/post -procedure evaluation of donor;  and  7. Preparation and processing of stem  cells.   Payment for these acquisition services is included in the OPPS C -APC  payment for  the allogeneic stem cell transplant when the transplant occurs in the hospital outpatient setting.  The Medicare contractor does not make separate payment for these acquisition services, because hospitals may bill and receive payment only for services provided to the Medicare beneficiary who is the recipient of the stem cell transplant and whose illness is being treated with the stem cell transplant.  Recurring update notificat ions describing changes to and billing instructions for various payment policies implemented in the OPPS are issued  annually.
(Medicare Claims Processing Manual)
If C9899 is a separately payable Part B inpatient service, the contractor shall determine the payment amount as follows.  If the device has pass through status under the OPPS, the contractor shall establish the payment amount for the device at the product of the charge for the device and the hospital specific cost to charge ratio.  Where the device does not have pass through status under the OPPS, the contractor shall establish the payment amount for the device at the amount for a comparable device in the D MEPOS fee schedule where there is such an amount.  Payment under the DMEPOS fee schedule is made at the lesser of charges or the fee schedule amount and therefore if there is a fee for the specific item on the DMEPOS fee schedule, the payment amount for the item will be set at the lesser of the actual charges or the DMEPOS fee schedule amount.  Where the item does not have pass through payment status and where there is no amount for a comparable device in the DMEPOS fee schedule, the contractor shall establ ish a payment amount that is specific to the particular implanted prosthetic device for the applicable calendar year.  This amount (less applicable unpaid deductible and coinsurance) will be paid for that specific device for services furnished in the appli cable calendar year unless the actual charge for the item is less than the established amount). Where the actual charge is less than the established amount, the contractor will pay the actual charge for the item (less applicable unpaid deductible and coins urance).   In setting a contractor established payment rate for the specific device, the contractor takes into account the cost information available at the time the payment rate is established.  This information may include, but is not limited to, the amount of devi ce cost that would be removed from an applicable APC payment for implantation of the device if the provider received a device without cost or a full credit for the cost of the device.
(Medicare Claims Processing Manual)
See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals) and Pub 100- 04, Medicare Claims Processing Manual, Chapter 4,  10.12 (Payment Window for Outpatient Services Treated as Inpatient Services) regarding  services bundled into the original Part A claim under the 3 -day (1 -day for non- IPPS hospitals) payment window prior to the inpatient admission, that may be billed to Part B when Part A payment cannot be made.  Hospitals should use the following type of bill to report these services:    13X TOB (85X for a CAH) - Hospital outpatient services included in the payment window for outpatient services treated as inpatient services    14X TOB - Laboratory tests that are paid under the clinical laboratory fee schedule (see chapter 16, 40.3 of this manual), and included in the payment window for outpatient services treated as inpatient services   240.6 - Submitting Provider -Liable No- Pay Part A Claims and Beneficiary Liability (Rev. 2877, Issued: 02- 07-14, Effective: 10 -01-13, Implementation: 04 -07-14)  When Part A payment cannot be made for a hospital inpatient admission and the hospital, not the beneficiary, is liable under section 1879 of the Act for the cost of the Part A items and services, the hospital must submit a provider -liable no pay Part A claim (110 TOB) (see chapter 3 40.2.2,  Charges to Beneficiaries for Part A Services of this manual) .  Submission of this claim cancels any claim that may have already been submitted by the hospital for payment under Part A.  When a Medicare review contra ctor denies a Part A claim for medical necessity, the claims system converts the originally submitted 11X claim to a 110 TOB on behalf of the hospital.
(Medicare Claims Processing Manual)
When the hospital and not the beneficiary is liable for the cost of the Part A services (pursuant to the limitation on liability provision in Section 1879 of the Social Security Act), the beneficiary is not responsible for paying the deductible and coinsur ance charges related to the denied Part A claim and the beneficiarys Medicare utilization record is not charged for the services and items furnished.  The hospital must refund any payments (including coinsurance and deductible) made by the beneficiary or third party for a denied Part A claim when the provider is held financially liable for that denial (see section 1879(b) of the Act; 42 CFR  411.402; and chapter 30  30.1.2, Beneficiary Determined to Be Without Liability and 30.2.2, Provider/Practitioner/Supplier is Determined to Be Liable of this manual).   Medicare beneficiaries are liable for their usual Part B financial liability for services covered under Part B when Part A payment cannot be made, including Part B copayments for each payable Part B inpatient or Part B outpatient service.  The beneficiary is also liable for the cost of services not covered under Part B.   250 - Special Rules for Critical Access Hospital Outpatient Billing  (Rev. 1111, Issued: 11- 09-06, Effective: 04 -01-07, Implementation: 04- 02-07)  For cost reporting periods beginning before October 1, 2000, a CAH will be paid for outpatient services under the method in 250.1.  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  This provision was implemented with respect to cost reporting periods starting on or after October 1, 2001.
(Medicare Claims Processing Manual)
 Never split a single increment into a covered and non- covered portion.   250.2 - Optional Method for Outpatient Services:  Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional 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)  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  A CAH may elect to be paid for outpatient services in any cost re porting period under this method by filing a written election with the A/B MAC (A) on an annual basis at least 30 days before start of the Cost Reporting period to which the election applies.  An election of this payment method, once made for a cost report ing period, remains in effect for all of that period for the CAH.   Effective for cost reporting periods beginning on or after October 1, 2010 if a CAH elected the optional method for its most recent cost reporting period beginning before October 1, 2010 or chooses to elect the optional method on or after October 1, 2010, that election remains in place until it is terminated, an annual election is no longer required.  If a CAH elects the optional method on or after October 1, 2010, it must submit its request in writing to its A/B MAC (A) at least 30 days before the start of  the first cost reporting period for which the election is effective.  That election will not terminate unless the CAH submits a termination request to its A/B MAC (A) at least 30 days before the start of its next cost reporting period.
(Medicare Claims Processing Manual)
The Medicare Prescription Drugs, Improvement, and Modernization Act (MMA) of 2003, changed the requirement that each practitioner rendering a service at a CAH that has elected the optional method, reassign their billing rights to that CAH.  This provision allows each practitioner to choose whether to reassign billing rights to the CAH or file claims for professional services through their A/B MAC (B).  The reassignment will remain in effect for that entire cost reporting period.  The individual practitioner must certify, using the Form CMS -855R, if he/she wishes to reassign their billing rights.  The CAH must then forward a copy of Form CMS -855R to the A/B MAC (A), and the A/B MACs (B) must have the practitioner sign an attestation  that clearly states that the practitioner will not bill the A/B MAC (A) or A/B MAC (B) for any services rendered at the CAH once the reassignment has been given to the CAH.  This attestation will remain at the CAH.   For CAHs that elected the optional method before November 1, 2003, the provision is effective beginning on or after July 1, 2001.  For CAHs electing the optional method on or after November 1, 2003, the provision is effective for cost reporting periods beginning on or after July 1, 2004.  Under this election, a CAH will receive payment from their A/B MAC (A) for professional services furnished in that CAHs outpatient department. Professional services are those furnished by all licensed professionals who ot herwise would be entitled to bill the A/B MAC (B) under Part B.  Payment to the CAH for each outpatient visit (reassigned billing) will be the sum of the following:    For facility services, not including physician or other practitioner services, payment will be based on 101 percent of the reasonable costs of the services.  List the facility service(s) rendered to outpatients using the appropriate revenue code.  The A/B MAC will pay 101 percent of  the reasonable costs for the outpatient services less applicable Part B deductible and coinsurance amounts, plus:    Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.