evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Effective April 1, 2003, CWF established the new edit 7269 for services rendered to these beneficiaries with dates of service on or after April 1, 2001, for claims received on or after April 1, 2003.  Once CWF determines that a beneficiary is in a Part A s tay, prior to applying the edits that review procedure codes to determine if payment should be allowed, CWF will review the performing provider type of the submitting entity.  If the performing provider type is 80, CWF will reject the claim to the A/B MAC (B) or return an unsolicited response with new error code 7269.  The A/B MAC (B)  will then take the same adjustment and recovery action as for other rejects and unsolicited responses.  When A/B MACs (B)  receive the new reject code, they must deny the claim and use the following RA and MSN messages.   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: 96  RARC: N121  MSN: 13.10  Effective for claims with dates of service on or after April 1, 2001, CWF implemented revisions on January 2, 2008 to bypass edit 7269 when a claim with a date of service on or after April 1, 2001 is submitted and the date of service is within the From/Thr u dates with an occurrence Span code date of 74, 76, 77, 79, or M1 reported on a SNF inpatient claim 21x in history or the date of service is greater than the occurrence date on a SNF inpatient claim 21x in history with an occurrence code date of A3, B3, or C3.  This will allow for services to be separately payable outside of SNF consolidated billing during non-covered periods in the SNF.  110.2.6 - Edit for Therapy Services Separately Payable When Furnished by a Physician  (Rev. 1757, Issued: 06- 19-09, Effective: 07-20-09, Implementation: 07-20-09)
(Medicare Claims Processing Manual)
A number of therapy services are considered separately payable when provided by a physician and shall be paid separately by the A/B MAC (B).  However, these services are considered therapy when provided by a physical or occupational therapist and are subje ct to consolidated billing.  Effective for claims with dates of service on or after July 1, 2004, edits will be implemented in the claims processing system to correctly process claims for these services.  A complete list of these services can be found on the CMS website at https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/.  110.2.7 - Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay  (Rev. 1911; Issued:  02-05- 10; Effective Date:  01 -01-08; Implementation Date:  07-06-10)
(Medicare Claims Processing Manual)
The Balanced Budget Act (BBA) of 1997 required the implementation of a SNF prospective payment system and the consolidated billing of services provided to residents of the SNF.  Facility services provided by a freestanding non-hospital ASC are included under the SNF CB provisions.  This edit will prevent payment of those facility services when provided in an ASC to a beneficiary in a Part A SNF CB stay.  Effective for claims with dates of service on or after January 1, 2008 that are processed on or after July 6, 2010, when CWF receives a claim for a facility service from an ASC that is enrolled as a provider specialty type 49, and the service has a Type of Service F, and the patient is in a Part A SNF stay, it shall notify the A/B MACs (B) that they shall reject the claim line for the service(s).  It shall send the same trailer that is currently sent for services subject to SNF consolidated billing.  (The s ervices subject to this editing will also appear on the ASC Fee schedule.)   Also, when CWF receives a Part A SNF claim, it shall also notify A/B MACs (A), (B), or (HHH), and DME MACs through an unsolicited response of any facility services as described above that were incorrectly paid.  MACs shall follow current processes to recoup any overpayments.  A/B MACs (A), (B), (HHH), or DME MACs shall return the same messages found in Section 110.2.1C.  110.3 - CWF Override Codes  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)
(Medicare Claims Processing Manual)
A CWF override code has been developed for A/B MAC (B) or DME MAC use where, in the course of pursuing a reconsideration, a provider or supplier may bring to the attention of the A/B MAC (B) a situation where services on a claim have been denied, but shoul d actually be allowed to be paid through the A/B MAC (B)/DME MAC.  At the A/B MAC (B)/DME MACs discretion, to allow that claim to process through CWF to payment, enter a 2 in the SNF consolidated billing override field.  110.4 - Coding Files and Updates  (Rev. 1757, Issued: 06- 19-09, Effective: 07 -20-09, Implementation: 07- 20-09)  To correspond with the annual and quarterly coding and payment updates, CWF will be provided with files of codes that are not included in consolidated billing and can be paid through the A/B MAC (B) or DME MAC.  These codes are available for informational purposes on the CMS Web site at https://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/SNFPPS/ConsolidatedBilling.html.  Changes in designation of codes from excluded to included (or vice versa) in consolidated billing will be considered corrections  to align the codes with policy as opposed to changes in policy.  Newly established Healthcare Common Procedure Coding System codes will be added to CWF edits to allow A/B MACs (B)/DME MACs  to make appropriate payments.   110.4.1 - Annual Update Process  (Rev. 2802, Issued: 10- 25-13, Effective: 01 -01-14, Implementation: 01- 06-14)  Barring any delay in the Medicare Physician Fee Schedule, CMS will provide the new code files to CWF by November 1.  Should this date change, CWF will be notified through the appropriate mechanism.  All future updates will be submitted via a Recurring Update Notification form.  These Recurring Update Notifications also describe how the changes will be implemented.
(Medicare Claims Processing Manual)
CWF will be provided with 4 coding files (Physician Services, Professional Component of Physician Services to be Submitted with the 26 Modifier, Ambulance, and Therapy) that are effective based on dates of service January 1 through December 31 for that yea r.  New files shall be provided for each calendar year.  Quarterly updates to the four files will continue as usual.  A/B MACs (B)/DME MACs  must continue to respond to rejects and unsolicited responses received from CWF per current methodology.  A/B MACs (B)/DME MACs  must reopen and reprocess any claims brought to their attention for services that prior to this update were mistakenly considered to be subject to consolidated billing and therefore, not separately payable.  A/B MACs (B)/DME MACs  need not search claims history to identify these claims.  Prior to January 1 of each year, new codes files will be posted to the CMS Web site at.  https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/.  Should this date change, A/B MACs (B)/DME MACs  will be notified through the appropriate mechanism.  Coding changes throughout the year may also be made as necessary through a quarterly update process.  As soon as the new code files are posted to the CMS Web site, through their Web sites and list serves, A/B MACs (B)/DME MACs  must notify physician, non-physician practitioners, and suppliers of the availability of the files.   120 - Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)  (Rev. 4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)
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120 - Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)  (Rev. 4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)  SNFs billing on Type of Bill (TOB) 21X and rural hospital (non- CAH) swing -bed providers billing on TOB 18X (subject to SNF PPS), will be subject to these requirements. Currently, under the SNF PPS, revenue code 0022 indicates that this claim is being paid under the SNF PPS. This revenue code can appear on a claim as often as necessary to indicate different Health Insurance Prospective Payment System (HIPPS) Rate Code(s) and assessment periods. The HCPCS/Rates field must contain a 5 -digit HIPPS Code. Under the previous case- mix classification model, the Resource Utilization Groups, version 4 (RUG-IV), the first three positions of the code contained the RUG group, and the last two positions of the code contained a 2- digit assessment indicator (AI) code.  120.1 - HIPPS Updates and Structure Changes  (Rev. 4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)
(Medicare Claims Processing Manual)
Under PDPM, the HIPPS code is structured differently, as a result of there being five case-mix adjusted rate components under the revised model. The first position represents the Physical and Occupational Therapy case -mix group. The second position represents the Speech -Language Pathology case-mix group. The third character represents the nursing case-mix group. The fourth character represents the Non- Therapy Ancillary (NTA) case -mix group. The fifth character represents the AI code. CMS would note that this also affects the number of potentially valid HIPPS codes under PDPM, as compared to RUG- IV.  The PPS assessment schedule under PDPM is also significantly different from that used under RUG-IV. The only assessments under PDPM that would produce a HIPPS code would be the initial Medicare (5 -day) PPS assessment, which follows the same schedule as u nder the previous RUG-IV model, and the optional Interim Payment Assessment (IPA), which may be completed at any point during a PPS stay.  The initial SNF PDPM HIPPS Codes can be found online at: https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes.html
(Medicare Claims Processing Manual)
Note: AAA00 default will be replaced with ZZZZZ effective October 1, 2019.  120.2 - Interrupted Stay Policy  (Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)  PDPM includes an interrupted stay policy, which would combine multiple SNF stays into a single stay in cases where the patients discharge and readmission occurs within a prescribed window (i.e., interruption window), s imilar to that which exists currently in many other Medicare inpatient facilities.  Specifically, if a patient in a covered Part A SNF stay is discharged from the SNF but returns to the SNF no later than 11:59pm of the third consecutive calendar day after having left Part A coverage, then this would be considered a continuation of the same SNF stay. In such cases, no new patient assessments are required and the variable per diem adjustment is not reset.  If the patient returns to the same SNF outside the interruption window, or returns to a different SNF, then this would be considered a new stay.   The interruption window begins on the first non-covered day following a Part A- covered SNF stay and ends at 11:59pm on the third consecutive non-covered day.  The first non-covered day in this context may be different depending on whether the patient actua lly leaves the facility or simply leaves Part A coverage.  Specifically, if the patient physically leaves the SNF, the first day of the interruption window would be the day of departure itself, whereas if the patient simply discontinues Part A coverage but remains in the SNF, the first day of the interruption window would be the day following the final day of Part A coverage.
(Medicare Claims Processing Manual)
Specifying the endpoint of the interruption windows third day as occurring at 11:59 pm rather than at midnight is consistent with the regulations at 42 CFR 411.15(p)(3)(iv), which define a beneficiarys SNF resident status for consolidated billing purposes as ending whenever he or she is formally discharged (or otherwise departs) from the SNF, unless he or she is readmitted (or returns) to that or another SNF . . . before the following midnight (emphasis added). See 10.1 of this chapter, and also see 20.1 in the Medicare Benefit Policy Manual, Chapter 3, which specifies that in counting inpatient days, . . . a day begins at midnight and ends 24 hours later.  However, unlike similar interrupted stay policies under some of the other prospective payment systems, the SNF interrupted stay policy is not used in determining whether bundling would apply to services furnished during the interruption.  That determination would instead continue to follow the longstanding set of rules under 42 CFR 411.15(p)(3) regarding SNF resident status for consolidated billing purposes (see 10ff.).  The day of discharge (as noted above, this date could be different if the patient leaves the facility or simply leaves Part A coverage) is the FROM date and the last day the patient is not in the SNF at midnight is the THROUGH date.  Occurrence span code 74 should be reported for each interruption of more than ONE day.  The interrupted stay would be recorded on the claim in the same manner as is done for the IRF PPS, and as further discussed in the examples below.  Examples: 1) Patient is admitted to SNF on 11/07/19 and is in a covered Part A stay. Patient is discharged from the SNF and admitted to the hospital on 11/20/19.  Patient is readmitted to the same SNF on 11/25/19 and is in a covered Part A stay.  The readmission is a new stay because more than 3 days have passed from the date the patient was discharged from the SNF and the date the patient was readmitted to the same SNF.
(Medicare Claims Processing Manual)
New stay  Assessment Schedule: Reset; stay begins with new 5- day assessment.  Variable Per Diem (VPD): Reset: stay begins on Day 1 of VPD Schedule.  2) Patient is admitted to SNF on 11/07/19 and in a covered Part A stay.  The patient is discharged from Part A on 11/20/19 but remains in the facility.  The patient returns to a covered Part A stay on 11/22/19.  This is a continuation of a previous stay because the patient returned to a covered Part A stay within 3 days of being discharged from a covered Part A stay.   Continuation of previous stay Assessment Schedule: No PPS assessments required, IPA optional VPD: Continues from Day 14 (Day of Part A Discharge).  Billing Example : Patient is admitted to SNF on 10/1/2019 and discharged to home on 12/25/2019, with an interrupted stay to an IPPS on 10/20/2019-10/22/2019. This was an admission to an IPPS on 10/20/2019-10/22/2019.  10/1/2019  10/31/2019 first interim claim,  Claim must be billed with occurrence span code 74 and occurrence span dates 10/20  10/21/2019 to represent the interrupted stay, 11/1/2019  11/30/2019 second interim claim,  12/1/2019  12/25/2019 final interim claim,  (Occurrence span code 74 only appears on the claim in which its dates fall within the statement covers period  in this example only on October claim).
(Medicare Claims Processing Manual)
 Accommodation revenue code 018x is reported during the interrupted stay and is when the beneficiary is not present at the midnight census taking time.  Occurrence span code 74 and date range for the interruption.  Days for the interruption shall be reported as non-covered, not to exceed 3 days or it will be considered a new admission.  On the SNF Medicare bill, the presence of occurrence span code 74 indicates an interrupted stay has occurred.  Report occurrence span code 74 with the FROM and THROUGH dates of the interruption in the stay.  The day of discharge from the SNF is the FROM da te and the last day the patient is not in the SNF at midnight is the THROUGH date.  Report accommodation revenue code 18X (leave of absence) and the quantity of leave days.  Occurrence span code 74 should be reported for each interruption of more than 1 day along with the dates of each interruption.  Revenue code 018X should reflect the total number of days for all occurrence span code 74 entries.  In other words, revenue code 018X should be listed on one line, with all interrupted days included in the units column.  No charges should be added to this charge line.  120.3 - Variable Per Diem (VPD) Adjustment  (Rev.4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)
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120.3 - Variable Per Diem (VPD) Adjustment  (Rev.4409, Issued: 10- 04-19, Effective: 11-05-19, Implementation: 11-05-19)  The Social Security Act requires that Medicare Part A -covered SNF stays be paid on a per-diem basis. PDPM SNF PPS per diem payments will be reduced according to a prescribed schedule, referred to as the VPD adjustment. Specifically, the PDPM provides for an adjustment factor that is applied to certain components and changes the per diem rate over the course of the stay.  Thus, under PDPM, the per diem rate for a given day of the SNF PPS stay may be different from the prior day, depending on an adjustment factor that may be applied against the SNF PPS rate connected with the HIPPS code. Moreover, the VPD schedule applies only to the PT, OT, and NTA components of the per diem rate, with different schedules for the PT/OT components than for the NTA component. A similar adjustment exists under the Inpatient Psychiatric Facility (IPF) PPS.  For the PT, OT, and NTA components, the case- mix adjusted per diem rate is multiplied against the variable per diem adjustment factor, following a schedule of adjustments for each day of the patients stay   VPD Adjustment Schedules   PT & OT Components   Day in Stay Adjustment Factor  Day in Stay Adjustment Factor      1-20 1.00 63-69 0.86 21-27 0.98 70-76 0.84 28-34 0.96 77-83 0.82 35-41 0.94 84-90 0.80 42-48 0.92 91-97 0.78 49-55 0.90 98-100 0.76 56-62 0.88    NTA Component   Day in Stay Adjustment Factor    1-3 3.00 4-100 1.00
(Medicare Claims Processing Manual)
NTA Component   Day in Stay Adjustment Factor    1-3 3.00 4-100 1.00  120.4 - AIDS Adjustments  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19) As under the previous RUG -IV model, patients with a B20 ICD -10 diagnosis code on the SNF claim, meaning the patient has AIDS/HIV, receive an adjustment factor for their PPS rate. Under PDPM, the adjustment factor is different from that used under RUG -IV. Rather than a 128 percent adjustment for the entire PPS per diem rate, the adjustment under PDPM is an increase of 18 percent in the nursing component of the per diem rate and a reclassification under the NTA component to a higher rate category.  All other adjustment factors, such as adjustments for geographic variation in wage costs, remain the same under PDPM as under the previous RUG -IV model.   120.5 - Transition Claims  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)
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120.5 - Transition Claims  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  With regard to transition between RUG -IV and PDPM, a hard transition between the two systems has been implemented, such that days paid under RUG -IV would stop on September 30, 2019 and days would be paid under PDPM beginning October 1, 2019.  In order to receive a RUG -IV HIPPS code that can be billed for services furnished prior to October 1, 2019, providers must use an assessment with an ARD set for on or prior to September 30, 2019.  If the patients stay begins on or after October 1, 2019, then the provider would begin with the 5 -day assessment, as usual.   For patients admitted prior to October 1, 2019, but whose stays continue past this date, in order to receive a PDPM HIPPS code that can be used to bill for services furnished on or after October 1, 2019, providers must complete an IPA with an ARD no later than October 7, 2019 (i.e., transitional IPA):  October 1, 2019, will be considered Day 1 of the VPD schedule under PDPM, even if the patient began their stay prior to October 1, 2019.  Any transitional IPAs with an ARD after October 7, 2019, will be considered late and relevant penalty for late assessments would apply (described below).   120.6 - Default Billing  (Rev. 4409, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)  As under RUG -IV, there may be instances in which providers may bill the default rate on a SNF claim (e.g., when an MDS assessment is considered late).   The default rate refers to the lowest possible per diem rate.   The default code under PDPM is ZZZZZ, as compared to the default code under RUG- IV of AAA00.   Billing the default code under PDPM represents the equivalent of billing the following PDPM groups:   PT Payment Group: TP   OT Payment Group: TP   SLP Payment Group: SA   Nursing Payment Group: PA1  NTA Payment Group: NF
(Medicare Claims Processing Manual)
OT Payment Group: TP   SLP Payment Group: SA   Nursing Payment Group: PA1  NTA Payment Group: NF    Transmittals Issued for this Chapter  Rev#  Issue Date  Subject  Impl Date  CR#  R12283CP  10/05/2023 Internet Only Manual Updates to Pub. 100-02 and 100-04 to Implement Consolidated Appropriations Act 2023 Changes for Skilled Nursing Facility (SNF)  01/08/2023 13271 R11109CP  11/04/2021 Skilled Nursing Facility (SNF) Claims Processing Updates  01/03/2022 12344 R10904CP  08/10/2021 Skilled Nursing Facility (SNF) Claims Processing Updates   Rescinded and replaced by Transmittal 11109 01/03/2022 12344 R10880CP  06/08/2021 Internet Only Manual Updates to Pub. 100-01, 100-02, and 100-04 to Implement Consolidated Appropriations Act Changes and Correct Errors and Omissions (SNF) 11/08/2021 12009  R10569CP  01/14/2021 Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims   04/05/2021 11992 R10448CP  11/06/2020 Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) Claims  Rescinded and replaced by Transmittal 10569  04/05/2021 11992 R10236CP  07/31/2020 Update to the IOM Publication (Pub) 100-04, Medicare Claims Processing Manual, Chapters 1, 6, 8, 17, 20, 22, 24, and 31 Referencing the Active Universal Resource Locators (URLs) for the Washington Publishing Company (WPC) and the ASC X12 Organizations, and Updates to the HIPAA Eligibility Transaction System (HETS)  08/31/2020 11857 R10222CP  07/14/2020 Updates in the Fiscal Intermediary Shared System (FISS) Inpatient Provider Specific Files (PSF)  10/05/2020 11797 Rev#  Issue Date  Subject  Impl Date  CR#  R10140CP  05/15/2020 Updates in the Fiscal Intermediary Shared System (FISS) Inpatient Provider Specific Files (PSF) - Rescinded and replaced by Transmittal 10222 10/05/2020 11797
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01/09/2020 Updates to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)  04/06/2020 11513 R4409CP  10/04/2019 Manual Updates for CR11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) 11/05/2019 11454 R4247CP  03/01/2019 Update to Publication 100-04 Chapters 2, 6, and 18 to Provide Language-Only Changes for the New Medicare Card Project  04/01/2019 11155 R4157CP