evekhm/cms_iom_500 huggingface dataset:
Article - Billing and Coding: Hydration Services (A52732)
B. These codes are not intended to be reported/billed by the physician or other qualified healthcare professional in thefacilitysetting, as these codes most likely represent facility charges with applicable reimbursement through the respective fee schedule. However,in the physicianofficesetting (example, Place of Service 11), the physician may report these codes when the physicians clinical staff or the physician administers the fluids.C. Forfacilityreporting, an initial infusion is predicated on using a hierarchy.D. When administering multiple infusions (e.g. IV fluids and subsequent IV chemotherapy infusion on same date of service), only one primary infusion code should be reported for a given date, unless protocol requires that two separate IV sites must be used.E. Hydration cannot be reportedconcurrentlywith any other infusion or drug administration service.F. The definition of infusion time is inherent and presented in the guidelines for these codes. In other words, a minimum time duration of 31 minutes of hydration infusion is required to report the service.G. Consequently, infusion time is calculated from the time the administration commences (i.e. the infusion starts dripping) to when it ends (i.e. the infusion stops dripping).H. In accordance withMedicare Reasonable and Necessary Criteria,(Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2), the benefit must meet butdoes not exceedthe beneficiarys medical need, and as such, IV fluids should be avoided if not deemed clinically necessary.For example, although some conditions may warrant intravenous rehydration, if documentation supports the same benefit could be achieved by oral hydration, IV hydration would not be considered reasonable and necessary.However, it is understood that there are clinical scenarios in which the patient's need for hydration cannot wait for oral trials, even if an option. The intent should be understood within the body of documentation.I.Examplesof Additional Payable Scenarios:If therapeutic fluid administration is medically necessary:for the correction of dehydration or prevention of nephrotoxicity immediately before or after transfusion, chemotherapy, or administration of potentially nephrotoxic medications.immediately before or after IV contrast infusion for a diagnostic procedure in a patient with renal insufficiency.
Article - Billing and Coding: Hydration Services (A52732)
J.Non-payable scenarios :The following infusion circumstancesdo not represent hydrationand should not be reported using any of these CPT codes:If the sole purpose of the intravenous fluid is to maintain patency (i.e. keep open) of an IV line prior to, during, or subsequent to a chemotherapeutic or therapeutic infusion, or transfusion.If used as maintenance IV therapy replacing normal sensible and insensible fluid losses, not losses associated with a pathological condition.When the purpose of the infusion is to accommodate a therapeutic IV piggyback through the same IV access to safely infuse the agent (e.g. IV fluids infused simultaneously with drug administration).If the fluid is used as the diluent to mix the drug (i.e. the fluid is the vehicle in which the drug is administered).Hydration that is integral to the performance of a surgical procedure to establish an initial and underlying IV flow for a diagnostic or therapeutic infusion is not separately billable (e.g. IV fluids administered preoperatively, intraoperatively, and/or postoperatively).Routine administration of IV fluids, pre/post operatively while the patient is NPO for example, without documentation supporting signs and/or symptoms including those of dehydration or fluid loss is not supported as medically necessary.Infusion of IV fluids with electrolytes for the purpose of treating an electrolyte deficiency (e.g. hypokalemic patient being treated specifically for low potassium level for which 20 mEq of KCL is added to an IV fluid).
Article - Billing and Coding: Hydration Services (A52732)
In conclusion, themain question that should be asked when considering billing for 96360 and 96361 is whether IV hydration is an appropriate, accepted standard of medical practice as a diagnostic or specific treatment for a beneficiarys condition,is one that meets, BUT does NOT exceed the beneficiarys medical need, and cannot be met with oral hydration.Note:It is understood that depending on the clinical scenario, upon presentation, an IV line may be established, fluids initiated, labs drawn and sent for evaluation and imaging completed with examinations. Although it may be reasonable to start fluids upon presentation, in order to bill the IV hydration codes, the medical necessity for the hydration services must also be supported. If the final clinical assessment does not support intravenous hydration was necessary for beneficiarys medical needs, hydration codes should not be billedReferences:CPT Assistant Coding Update:Infusion/Injection services; February 2009; Volume 19, Issue 2, pages 17-21).CPT Assistant Coding Clarification;Facility reporting-Multiple Infusions (Codes 96360, 96361, 96365-96367); December, 2011; Volume 21, Issue 12, pages 3-5).National Institute for Health and Care Excellence (NICE) Guidelines; Intravenous Fluid Therapy in Adults in Hospital;December, 2013.2020 CMS NCCI Policy Manual for MC Services; Ch. 11, Medicine E/M Services CPT codes 90000-99999 and corresponding CMS NCCI edits.5. Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2 - Reasonable and Necessary Criteria
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Medicare Program Integrity Manual  Chapter 3 - Verifying Potential Errors and Taking Corrective Actions  Table of Contents   (Rev. 1 2056; Issued: 0 5-25-23)    Transmittals for Chapter 3   3.1 - Introduction  3.2 - Overview of Prepayment and Postpayment Reviews  3.2.1 - Setting Priorities and Targeting Reviews  3.2.2 - Provider Notice  3.2.2.1 - Maintaining Provider Information 3.2.3 - Requesting Additional Documentation During Prepayment and Postpayment Review  3.2.3.1 - Additional Documentation Requests (ADR) . 3.2.3.2 - Time Frames for Submission  3.2.3.3 - Third -Party Additional Documentation Request  3.2.3.4 - Additional Documentation Request Required and Optional Elements  3.2.3.5 - Acceptable Submission Methods  for Responses to ADRs 3.2.3.6 - Reimbursing Providers and HIHs for Additional Document ation  3.2.3.7 - Special Provisions for Lab Additional Documentation Requests  3.2.3.8 - No Response or Insufficient Response to Additional Documentation Requests  3.2.3.9 - Reopening Claims with Additional Information or Denied Due to Late or No Submission of Requested Information  3.2.3.10 - Record Retention and Storage  3.2.4 - Use of Claims History Information in Claim Payment Determinations  3.2.5 - Targeted Probe and Educate (TPE ) 3.3 - Policies and Guidelines Applied During Review  3.3.1 - Types of Review: Medical Record Review, Non- Medical Record Review and Automated Review
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3.3.1.1 - Medical Record Review  3.3.1.2 - Non -Medical Record Review  3.3.1.3  Automated Reviews  3.3.2 -  Medical Review Guidance  3.3.2.1 -  Documents on Which to Base a Determination  3.3.2.1.1 -  Progress Notes and Templates  3.3.2.1.2 DMEPOS Orders  3.3.2.2 -  Absolute Words and Prerequisite Therapies  3.3.2.3 -  Mandatory Policy Provisions  3.3.2.4 -  Signature Requirements  3.3.2.5  Amendments, Corrections and Delayed Entries in Medical Documentation  3.3.2.6 -  Psychotherapy Notes  3.3.2.7 -  Review Guideli nes for Therapy Services  3.3.2.8 -  MAC Articles  3.3.3 -  Reviewing Claims in the Absence of Policies and Guidelines  3.4 - Prepayment Review of Claims  3.4.1 -  Electronic and Paper Claims  3.4.1.1 -  Linking LCD and NCD ID Numbers to Edits  3.4.1.2 -  Not Otherwise Classified (NOC) Codes  3.4.1.3 -  Diagnosis Code Requirements  3.4.1.4 -  Prepayment Review of Claims Involving Utilization Parameters  3.4.1.5 -  Prepayment Review Edits  3.4.2 -  Prepayment Medical Record Review  Edits  3.5 - Postpayment Medical Record Review of Claims  3.5.1 -  Re-opening Claims  3.5.2 -  Case Selection  3.5.3 -  CMS Mandated Edits  3.5.4 -  Tracking Medicare Contractors  Prepayment and  Postpayment Reviews  3.6 - Determinatio ns Made During Review  3.6.1 -  Determining Overpayments and Underpayments  3.6.2 -  Verifying Errors  3.6.2.1 -  Coverage Determinations  3.6.2.2 -  Reas onable and Necessary Criteria  3.6.2.3 -  Limitation of Liability Determinations  3.6.2.4 -  Coding Determinations  3.6.2.5 -  Denial Types  3.6.3 -  Beneficiary Notification  3.6.4 -  Notifying the Provider  3.6.5 -  Provider Financial Rebuttal of Findings
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-  Coding Determinations  3.6.2.5 -  Denial Types  3.6.3 -  Beneficiary Notification  3.6.4 -  Notifying the Provider  3.6.5 -  Provider Financial Rebuttal of Findings  3.6.6 -  Review Determination Documentation Requirements  3.7 - Corrective Actions  3.7.1 -  Progressive Corrective Action (PCA)  3.7.1.1 -  Provider Error Rate  3.7.1.2 -  Vignettes  3.7.1.3 -  Provider Notification and Feedback  3.7.2 -  Comparative Billing Reports (CBRs)  3.7.3 -  Evaluating the Effectiveness of Corrective Actions  3.7.3.1 -  Evaluation of Prepayment Edits  3.7.3.2 -  Evaluating Effectiveness of Established Automated Edits  3.7.3.3 -  Evaluation of Postpayment Review Effectiveness  3.7.4 -  Tracking Appeals  3.7.5 -  Corrective Action Reporting Requirements  3.8 - Administrative Relief from MR During a Disaster  3.9 - Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings  3.9.1  Election of  Status  3.9.2 -  Coordination of  the ALJ Hearing  3.10  Prior Authorization 3.10.1 -   Prior Authorization Program for Certain DMEPOS  3.10.1.1 Voluntary Prior Authorization (PA) for DMEPOS Accessories  3.10.2 -  Prior Authorization Process for Certain Hospital Outpatient Department   (OPD) Services
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3.1  Introduction  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  All references to Medicare Administrative Contractors (MACs) include Affiliated Contractors (ACs). Affiliated Contractors are FIs and Carriers.   A. Goals   This section applies to Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT), and Recovery A uditors, as indicated.   The Medicare Administrative Contractors (MACs) shall analyze claims to determine provider compliance with Medicare coverage, coding, and billing rules and take appropriate corrective action when providers are found to be non- compliant. The goal of MAC administrative actions is to correct the behavior in need of change and prevent future inappropriate billing. The priority for MACs is to minimize potential future losses to the Medicare Trust Funds through targeted claims re view while using resources efficiently and treating providers and beneficiaries fairly.   For repeated infractions, MACs have the discretion to initiate progressively more severe administrative action, commensurate with the seriousness of the identified problem. (Refer to PIM chapter 3, 3.7.1). MACs shall deal with serious problems using the most substantial administrative actions available, such as 100 percent prepayment review of claims. Minor or isolated inappropriate billing shall be remediated through provider notification or feedback with reevaluation after notification. When medical review (MR) notification and feedback letters are issued, the MAC MR staff shall ensure that Provider Outreach and Education (POE) staff has access to copies of the letter s in case a provider requests further education or POE determines that future education is needed. While program savings are realized through denials of payment for inappropriate provider billing, the optimal result occurs when compliance is achieved and p roviders no longer incorrectly code or bill for non- covered services.
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The Medicare Fee For Service Recovery Audit program is a legislatively mandated program (Tax Relief and Health Care Act of 2006) that utilizes Recovery Auditors to identify improper payments paid by Medicare to fee -for-service providers. The Recovery Auditors identify the improper payments, and the MACs adjust the claims, recoup identified overpayments and return underpayments.  MAC, CERT and Recovery Auditor staff shall not expend Medic are Integrity Program (MIP)/ MR resources analyzing provider compliance with Medicare rules that do not affect Medicare payment. Examples of such rules include violations of conditions of participation (COPs), or coverage or coding errors that do not change the Medicare payment amount.  The COPs define specific quality standards that providers shall meet to participate in the Medicare program. A providers compliance with the COPs is determined by the CMS Regional Office (RO) based on the State survey agenc y recommendation. If during a review, any contractor believes that a provider does not comply with conditions of participation, the reviewer shall not deny payment solely for this reason. Instead, the contractor shall notify the RO and the applicable State  survey agency.   When a potential underpayment or overpayment is identified, certain steps are normally followed to determine if a payment error exists. These steps are referred to as the claims development process. The reviewer generally does the following:    Investigates the claims and associated  documentation;   Performs appropriate research regarding liability, benefit categories, statutory requirements,  etc.;   Determines if a payment error exists and the nature of the error;   Notifies the beneficiary and provider/supplier;  and  Starts the payment reconciliation  process.   B. New Provider/New Benefit Monitoring   This section applies to the MACs.  The MACs shall analyze data to identify patterns of billing aberrancies of providers new to the Medicare program. The MACs have the option of performing prepayment or postpayment review of claims submitted by new providers as needed. The CMS encourages the MACs to perform these reviews on a prepayment basis to have the greatest chance of identifying and reducing the error rate of new providers. When MACs review the claims of a new provider, the MACs shall perform a limited review of generally 20- 40 claims in order to evaluate accurate billing.
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The MACs shall also monitor for provider use of new statutory benefits and to ensure correct coverage, coding, and billing from the beginning. New benefit edits shall continue until the MAC is satisfied that the new b enefits are being used and billed appropriately or until the MAC determines that resources would best be spent on other types of review.   3.2  Overview of Prepayment and Postpayment Reviews (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementatio n: 08 -27-20)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes.   This section applies to MACs, CERT, RACs, SMRCs, and Unified P rogram Integrity Contractors (UPICs), as indicated.   A. Prepayment and Postpayment Review   Prepayment review occurs when a reviewer makes a claim determination before claim payment has been made. Prepayment review always results in an initial determination. Postpayment review occurs when a reviewer makes a claim determination after the claim has been paid. Postpayment review results in either no change to the initial determination or a revised determination indicating that an overpayment or underpayment has occurred.   B. Prepayment Edit  Capabilities   Prepayment edits shall be able to key on a be neficiary's Medicare beneficiary identifier (Mbi), National Provider Identifier (NPI) and specialty code, service dates, and diagnosis or procedure code(s) (i.e., Healthcare Common Procedure Coding System [HCPCS] and/or International Classification of Dise ases diagnoses codes), Type of Bill (TOB), revenue codes, occurrence codes, condition codes, and value codes.   The MAC systems shall be able to select claims for prepayment review using different types of comparisons. At a minimum, those comparisons shall include:
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The MAC systems shall be able to select claims for prepayment review using different types of comparisons. At a minimum, those comparisons shall include:    Procedure to Procedure - permits contractor systems to screen multiple  services at the claim level and in history.    Procedure to Provider -  permits selective screening of services that need review for a given  provider.    Frequency to Time - permits contractors to screen for a certain number of  services provided within a given time  period.   Diagnosis to Procedure - permits contractors to screen for services submitted with a specific diagnosis. For example, the need for a vitamin B12 injection is related to pernicious anemia, absent of the stomach, or distal ileum. Contractors must be able to establish edits where specific diagnosis/procedure relationships are considered in order to qualify the claim for  payment.    Procedure to Specialt y Code or TOB - permits contractors to screen  services provided by a certain specialty or  TOB.    Procedure to Place of Service-  permits selective screening of claims where the service was provided in a certain setting such as a comprehensive outpatient rehab ilitation  facility.   Additional MAC system comparisons shall include, but are not limited to the following:    Diagnoses alone or in combination with related factors.    Revenue linked to the health care common procedure coding system  (HCPCS).    Charges related  to utilization, especially when the service or procedure has  an established dollar or number  limit.    Length of stay or number of visits, especially when the service or  procedure violates time or number  limits.    Specific providers alone or in combination w ith other  parameters.   The MR edits are coded system logic that either automatically pays all or part of a claim, automatically denies all or part of a claim, or suspends all or part of a claim so that a trained clinician or claims analyst can review the claim and associated documentation (including documentation requested after the claim is submitted) in order to make determinations about coverage and payment under Section 1862(a) (1) (A) of the Act.   Namely, the claim is for a service or device that is medically reasonable and necessary to diagnose or treat an injury or improve the functioning of a malformed body member. All non-automated review work resulting from MR edits shall:    Involve activities defined under the MIP at 1893(b)(1) of the  Act;   Be articulated in the MACs medical review  strategy;
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 Involve activities defined under the MIP at 1893(b)(1) of the  Act;   Be articulated in the MACs medical review  strategy;    Be designed in such a way as to reduce the MACs CERT error rate or prevent the MACs CERT error rate from increasing,  or;  Prevent improper payments identified by the RACs.  3.2.1  Setting Priorities and Targeting Reviews  (Rev. 399, Issued: 11- 04-11, Effective: 12 -05-11, Implementation: 12- 05-11)  This section applies to MACs and Recovery Auditors, as indicated. Recovery Auditors perform targeted reviews consistent with their statements of work (SOWs).   The MACs have the authority to review any claim at any time, however, the claims volume of the M edicare Program doesnt allow for review of every claim. The MACs shall target their efforts at error prevention to those services and items that pose the greatest financial risk to the Medicare program and that represent the best investment of resources. This requires establishing a priority setting process to assure MR focuses on areas with the greatest potential for improper payment.   The MACs shall develop a problem -focused, outcome -based MR strategy and Strategy Analysis Report (SAR) that defines what risks to the Medicare trust fund the MACs MR programs will address and the interventions that will be implemented during the fiscal/option year as addressed in PIM chapter 7.   The MACs shall focus their edits where the services billed have significant pot ential to be non-covered or incorrectly coded. Medical review staff may decide to focus review on problem areas that demonstrate significant risk to the Medicare program as a result of inappropriate billing or improper payments. The MACs shall have in plac e a program of systematic and ongoing analysis of claims and data from Recovery Auditors and CERT, among other sources, in order to focus intervention efforts on the most significant errors.   The MACs shall initiate a targeted provider -specific prepayment review only when there is the likelihood of sustained or high level of payment error. MACs are encouraged to initiate targeted service- specific prepayment review to prevent improper payments f or services identified by CERT or Recovery Auditors as problem areas, as well as, problem areas identified by their own data analysis.   The MACs have the discretion to select target areas because of:
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 High volume of services;   High cost;   Dramatic change in frequency of use;   High risk problem -prone areas; and/or,   Recovery Auditor, CERT, Office of Inspector General (OIG) or Government Accounting Office (GAO) data demonstrating vulnerability. Probe reviews are not required when targeted areas are based on data from these entities.   In an effort to identify the claims most likely to contain improper billing, MACs are encouraged to use prepayment and postpayment screening tools or natural language coding software. MACs shall not deny a payment for a service simply because the claim fails a single screening tool criterion. Instead, the reviewer shall make an individual determination on each claim. MACs have the discretion to post the screening tools in use to their Web site or otherwise disclose to the provide r community. Recovery Auditors shall use screening tools and disclose their use to the provider community consistent with the requirements in their statements of work (SOWs).   MACs and Recovery Auditors shall NOT target a provider for review solely based on the providers preferred method of maintaining or submitting documentation.  For example, a MAC or Recovery Auditor shall NOT choose a provider for review based only on the fact that the provider uses an electronic health record or responds to documentat ion requests using the Electronic Submission of Medical Documentation (esMD) mechanism.  (More information about esMD can be found in Section (3.2.3.5)   3.2.2 - Provider Notice  (Rev. 10365; Issued: 10- 02-20; Effective: 08 -27-20; Implementation: 08 -27-20)  This section applies to MACs, RACs, UPICs, and SMRC as indicated.