evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
If a Medicare Part A claim for inpatient hospital services is denied because the inpatient admission was not reasonable and necessary, or if a hospital determines under 42 CFR 482.30(d) or 485.641 after a beneficiary is discharged that the beneficiarys inpatient admission was not reasonable and necessary, and if waiver of liability payment is not made, the hospital may be paid for the following Part B inpatient services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as an inpatient, provided the beneficiary is enrolled in Medicare Part B:   1) Part B services paid under the outpatient prospective payment system (OPPS), excluding observation services and hospital outpatient visits that require an outpatient status.  Hospitals that are excluded from payment under the OPPS are instead paid under their alternative payment methodology (e.g., reasonable cost, all inclusive rate, or Maryland waiver) for the services that are otherwise payable under the OPPS.  2) The following services excluded from OPPS payment, that are instead paid under the respective Part B fee schedules or prospectively determined rates for which payment is made for these services when provided to hospital outpatients:   a. Physical therapy services, speech -language pathology services, and occupational therapy services (see chapter 15, 220 and 230 of this manual, Covered Medical and Other Health Services,).   b. Ambulance services.   c. Prosthetic devices, prosthetic supplies, and orthotic devices paid under the DMEPOS fee schedule (excludes implantable prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directl y related to colostomy care) and replacement of such devices).   d. Durable medical equipment supplied by the hospital for the patient to take home, except durable medical equipment that is implantable.   e. Certain clinical diagnostic laboratory services.   f. Screening and diagnostic mammography services.   g. Annual wellness visit providing personalized prevention plan services.
(Medicare Benefit Policy Manual)
e. Certain clinical diagnostic laboratory services.   f. Screening and diagnostic mammography services.   g. Annual wellness visit providing personalized prevention plan services.   Hospitals may also be paid under Part B for services included in the payment window prior to the point of inpatient admission for outpatient services treated as inpatient services (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 10.12, Pay ment Window for Outpatient Services Treated as Inpatient Services), including services requiring an outpatient status.  The hospital can only bill for services that it provided directly or under arrangement in accordance with Part B payment rules.  Outpat ient therapeutic services furnished at an entity that is wholly owned or wholly operated by the hospital and is not part of the hospital (such as a physicians office), may not be billed by the hospital to Part B.  Reference labs may be billed only if the referring laboratory does not bill for the laboratory test (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 16, 40.1, Laboratories Billing for Referred Tests).   The services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions.  Claims for Part B services submitted following a reasonable and necessary Part A claim denial or hospital utilization revie w determination must be filed no later than the close of the period ending 12 months or 1 calendar year after the date of service (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 1, 70 Time Limitations for Filing Part A and Part B Claims).  See Pub. 100- 04, Medicare Claims Processing Manual, chapter 4, 240 for required bill types.  10.2 - Other Circumstances in Which Payment Cannot Be Made Under Part A (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)  Part B payment could be made to a hospital for the medical and other health services listed in this section for inpatients enrolled in Part B if:   No Part A prospective payment is made at all for the hospital stay because of patient exhaustion of benefit days before or during the admission; or    The patient was not otherwise eligible for or entitled to coverage under Part A (see chapter 16, 180 of this manual for services received as a result of non -covered services).
(Medicare Benefit Policy Manual)
 The patient was not otherwise eligible for or entitled to coverage under Part A (see chapter 16, 180 of this manual for services received as a result of non -covered services).   Beginning in 2014, for hospitals paid under the OPPS these Part B inpatient services are separately payable under Part B, and are excluded from OPPS packaging if the primary service with which the service would otherwise be bundled is not a payable Part B inpatient service.   The following inpatient services are payable under the OPPS:    Diagnostic x- ray tests, diagnostic laboratory tests, and other diagnostic tests;    X-ray, radium, and radioactive isotope therapy, including materials and services of technicians;    Acute dialysis of a hospital inpatient with or without end stage renal disease (ESRD).  The charge for hemodialysis is a charge for the use of a prosthetic device, billed in accordance with Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 200.2, Hospital Dialysis Services for Patients With and Without End Stage Renal Disease (ESRD).    Screening pap smears;    Influenza, pneumococcal pneumonia, and hepatitis B vaccines;    Colorectal screening;    Bone mass measurements;    Prostate screening;    Hemophilia clotting factors for hemophilia patients competent to use these factors without supervision;    Immunosuppressive drugs;    Oral anti -cancer drugs;    Oral drug prescribed for use as an acute anti -emetic used as part of an anti -cancer chemotherapeutic regimen; and    Epoetin Alfa (EPO) that is not covered under the ESRD benefit.  The following inpatient services are payable under the non- OPPS Part B fee schedules or prospectively determined rates listed:   Surgical dressings, and splints, casts, and other devices used for reduction of fractures and dislocations (DMEPOS fee schedule);
(Medicare Benefit Policy Manual)
 Prosthetic devices (other than dental) which replace all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replacement of such devices and including one pair of conventional eyeglasses o r contact lenses furnished subsequent to each cataract surgery with insertion of intraocular lens (DMEPOS fee schedule, except for implantable prosthetic devices paid at the applicable rate under Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 240.3, Inpatient Part B Hospital Services -   Implantable Prosthetic Devices);    Leg, arm, back, and neck braces, trusses, and artificial legs, arms, and eyes including replacements if required because of a change in the patients physical condition (DMEPOS fee schedule);    Physical therapy services, speech -language pathology services, and occupational therapy services (see Chapter 15, 220 and 230 of this manual, Covered Medical and Other Health Services) (applicable rate based on the Medicare Physician Fee Schedule);    Ambulance services (ambulance fee schedule); and    Screening mammography services (Medicare Physician Fee Schedule).   Hospitals may also be paid under Part B for services included in the payment window prior to the point of inpatient admission for outpatient services treated as inpatient services (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 4, 10.12, Pay ment Window for Outpatient Services Treated as Inpatient Services), including services requiring an outpatient status.  The hospital can only bill for services that it provided directly or under arrangement in accordance with Part B payment rules.  Outpat ient therapeutic services furnished at an entity that is wholly owned or wholly operated by the hospital and is not part of the hospital (such as a physicians office), may not be billed by the hospital to Part B.  Reference labs may be billed only if the referring laboratory does not bill for the laboratory test (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 16, 40.1, Laboratories Billing for Referred Tests).
(Medicare Benefit Policy Manual)
The services billed to Part B must be reasonable and necessary and must meet all applicable Part B coverage and payment conditions.  Claims for these services must be filed no later than the close of the period ending 12 months or 1 calendar year after the date of service (see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 1, 70, Time Limitations for Filing Part A and Part B Claims).  See Pub. 100 -04, Medicare Claims Processing Manual, chap ter 4, 240 for required bill types.  10.3 - Hospital Inpatient Services Paid Only Under Part B  (Rev. 182, Issued: 03- 21-14, Effective: 10 -01-13, Implementation: 04- 21-14)  The services listed in Chapter 15, 250 of this manual, Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities, when provided to a hospital inpatient, may be covered under Part B, even though the patient has Part A coverage for the hospital stay.  This is because these services are covered under Part B and are not covered under Part A.   In all hospitals, all other services provided to a hospital inpatient must be treated as an inpatient hospital service to be paid for under Part A, if Part A coverage is available and the beneficiary is entitled to Part A.  This is because every hospital m ust provide directly or arrange for any nonphysician service rendered to its inpatients, and a hospital can be paid under Part B for a service provided in this manner only if Part A coverage does not exist.   However, note that in order to have any Medicare coverage at all (Part A or Part B), any nonphysician service rendered to a hospital inpatient must be provided directly or arranged for by the hospital.  20 - Outpatient Hospital Services  (Rev. 12425; Issued: 12- 21-23: Effective: 01 -01-24; Implementation: 01- 02-24)   Hospitals provide two distinct types of services to outpatients: services that are diagnostic in nature, and other services that aid the physician in the treatment of the patient. Part B covers both the diagnostic and the therapeutic services furnished by hospitals to outpatients.  The rules in this section pertaining to the coverage of outpatient hospital services are not applicable to the following services.
(Medicare Benefit Policy Manual)
 Physical therapy, speech- language pathology or occupational therapy services when they are furnished as therapy meaning under a therapy plan of care.  See chapter 15, sections 220 and 230 of this manual, for coverage and payment rules for these services,  which are paid at the applicable amount under the physician fee schedule.     Services that are covered and paid under the End Stage Renal Disease Prospective Payment System.  See Chapter 11, End Stage Renal Disease (ESRD) of this manual, for rules on the coverage of these services.    For policies in addition to this section that apply to partial hospitalization services, see chapter 6, section 70.3 of this manual, and Pub. 100- 04, Medicare Claims Processing Manual, chapter 4, section 260. For policies in addition to this section that apply to intensive outpatient services, see chapter 6, section 70.4 of this manual, and Pub. 100- 04, Medicare Claims Processing Manual, chapter 4, section 261.   For rules on the coverage of services and supplies furnished incident to a physicians professional services in an office or physician- directed clinic setting, refer to Chapter 15, Covered Medical and Other Health Services, section 60 of this manual.   20.1 - Limitations on Coverage of Certain Services Furnished to Hospital Outpatients  (Rev. 82; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08) Sources:  42 CFR 410.42(a) and 64 FR 18536, April 7, 2000  20.1.1 - General Rule  (Rev. 82; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)
(Medicare Benefit Policy Manual)
20.1.1 - General Rule  (Rev. 82; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  Except as provided in section 20.1.2 of this chapter, Medicare Part B does not pay for any item or service that is furnished to a hospital outpatient, as defined in section 20.2, during an encounter, as defined in section 20.3, by an entity other than the hospital unless the hospital has arrangements with that entity to furnish that particular service to its patients.  The arrangements must provide that Medicare payment made to the hospital that arranged for the services discharges the liability of the bene ficiary or any other person to pay for those services.  See the Medicare General Information, Eligibility, and Entitlement Manual, Pub.100- 01, chapter 5, section 10.3 for the definition of arrangements.  For the purposes of this section, the term hospit al includes a Critical Access Hospital (CAH).   20.1.2 - Exception to Limitation  (Rev. 82; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  The limitation stated in section 20.1.1 does not apply to the following services:    Physicians professional services that meet the following conditions:   o The services are personally furnished for an individual beneficiary by a physician;   o The services contribute directly to the diagnosis or treatment of an individual beneficiary;   o The services ordinarily require performance by a physician;   o In the case of radiology or laboratory services, additional requirements in 42 CFR 415.120 and 415.130, respectively of the Code of Federal Regulations are met.    Physician assistant services, as defined in section 1861(s)(2)(K)(i) of the Social Security Act (the Act);    Nurse practitioner and clinical nurse specialist services, as defined in section 1861(s)(2)(K)(ii) of the Act;    Qualified psychologist services, as defined in section 1861(ii) of the Act;    Services of an anesthetist, as defined in regulations in 42 CFR 410.69;    Services furnished to SNF residents as defined in regulations in 42 CFR 411.15(p).
(Medicare Benefit Policy Manual)
 Services of an anesthetist, as defined in regulations in 42 CFR 410.69;    Services furnished to SNF residents as defined in regulations in 42 CFR 411.15(p).   20.2 - Outpatient Defined  (Rev. 82; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  A hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital or CAH.  Where a tissue sample, blood sample, or specimen is taken by personnel that are neither employed nor arranged for by the hospital and is sent to the hospital for performance of tests, the tests are not outpatient hospital services since the patient does not directly receive services  from the hospital.  See s ection  70.5 for coverage of laboratory services furnished to nonhospital patients by a hospital laboratory unless the patient is also a registered hospital outpatient receiving outpatient services from the hospital on the same day and the hospital is not a CAH or Maryland waiver hospital.  Similarly, supplies provided by a hospital supply room for use by physicians in the treatment of private patients are not covered as an outpatient service since the patients receiving the supplies are not outpatients of the hos pital.  (See the Medicare Benefit Policy Manual, Pub. 100- 02, Chapter 1,Inpatient Hospital Services, section 10, for the definition of inpatient.)   Where the hospital uses the category "day patient," i.e., an individual who receives hospital services during the day and is not expected to be lodged in the hospital at midnight, the individual is considered an outpatient.  For information on outpatient observation status, refer to section 20.6 of this chapter and to the Medicare Claims Processing Manual, Pub.100- 04, chapter 4, section 290, Outpatient Observation Services.  For information on conditions when an inpatient admission may be changed to outpa tient status, refer to the Medicare Claims Processing Manual, Pub.100- 04, Chapter 1, General Billing Requirements, section 50.3.
(Medicare Benefit Policy Manual)
The inpatient of a SNF may be considered the outpatient of a participating hospital.  However, the inpatient of a participating hospital cannot be considered an outpatient of that or any other hospital.  Outpatient hospital services furnished in the emergency room to a patient classified as dead on arrival are covered until pronouncement of death, if the hospital considers such patients as outpatients for record -keeping purposes and follows its usual out patient billing practice for such services to all patients, both Medicare and non- Medicare.  This coverage does not apply if the patient was pronounced dead prior to arrival at the hospital.  20.3 - Encounter Defined  (Rev. 101, Issued: 01- 16-09, Effective: 01 -01-09, Implementation: 01- 05-09) Source:  42 CFR 410.2 and 482.12   A hospital outpatient encounter is a direct personal contact between a patient and a physician, or other person who is authorized by State licensure law and, if applicable, by hospital or CAH staff bylaws, to order or furnish hospital services for diagnosis or treatment of the patient.   The conditions of participation for hospitals under 42 CFR 482.12(c)(1)(i) through (c)(1)(vi) require that every Medicare patient is under the care of a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor of podiatric medicine, a doctor of optometry, a chiropractor, or a clinical psychologist; each practicing within the extent of the Act, the Code of Federal Regulations, and State law.  Further, 42 CFR 482.12(c)(4) requires that a doctor of medicine or osteopathy must be responsible for the care of each Medicare patient with respect to any medical or psychiatric condition that is present on admission or develops during hospitalization and is not specifically within the scope of practice of one of the other practitioners listed in 42 CFR 482.12(c)(1)(i) through (c)(1)(vi).   20.4 - Outpatient Diagnostic Services  (Rev. 82; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)
(Medicare Benefit Policy Manual)
20.4 - Outpatient Diagnostic Services  (Rev. 82; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  20.4.1 - Diagnostic Services Defined  (Rev. 82; Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  A service is diagnostic if it is an examination or procedure to which the patient is subjected, or which is performed on materials derived from a hospital outpatient, to obtain information to aid in the assessment of a medical condition or the identifica tion of a disease.  Among these examinations and tests are diagnostic laboratory services such as hematology and chemistry, diagnostic x- rays, isotope studies, EKGs, pulmonary function studies, thyroid function tests, psychological tests, and other tests given to determine the nature and severity of an ailment or injury.  20.4.2 - Reserved   20.4.3 - Coverage of Outpatient Diagnostic Services Furnished on or Before December 31, 2009  (Rev. 128, Issued: 05- 28-10, Effective: 07 -01-10, Implementation: 07- 06-10)  Covered diagnostic services to outpatients include the services of nurses, psychologists, technicians, drugs and biologicals necessary for diagnostic study, and the use of supplies and equipment.  When a hospital sends hospital personnel and hospital equipment to a patients home to furnish a diagnostic service, Medicare covers the service as if the patient had received the service in the hospital outpatient department.   For services furnished before August 1, 2000, hospital personnel may provide diagnostic services outside the hospital premises without the direct personal supervision of a physician.  For example, if a hospital laboratory technician is sent by the hospital  to a patients home to obtain a blood sample for testing in the hospitals laboratory, the technicians services are a covered hospital service even though a physician was not with the technician.   For services furnished on or after August 1, 2000, and before January 1, 2010, Medicare Part B makes payment for hospital or CAH diagnostic services furnished to outpatients, including drugs and biologicals required in the performance of the services (even if those drugs or biologicals are self -administered), if those services meet the following conditions:
(Medicare Benefit Policy Manual)
1. They are furnished by the hospital or under arrangements made by the hospital or CAH with another entity (see section 20.1 of this chapter);   2. They are ordinarily furnished by, or under arrangements made by the hospital or CAH to its outpatients for the purpose of diagnostic study;   3. They would be covered as inpatient hospital services if furnished to an inpatient; and  4. Payment is allowed under the hospital outpatient prospective payment system for diagnostic services furnished at a facility that is designated as provider -based only when those services are furnished under the appropriate level of supervision specified in accordance with the definitions at 42 CFR 410.32(b)(3)(i), (b)(3)(ii), and (b)(3)(iii), and as described in Chapter 15 of this manual, Section 80 Requirements for Diagnostic X -ray, Diagnostic Laboratory, and Other Diagnostic Tests, as though they are being furnished in a physicians office or clinic setting.  With respect to individual diagnostic tests, the supervision levels listed in the quarterly updated Medicare Physician Fee Schedule (MPFS) Relative Value File apply.  For diagnostic services not listed in the MPFS, Medicare contractors, in consultation wit h their medical directors, define appropriate supervision levels in order to determine whether claims for these services are reasonable and necessary.   Future updates to the MPFS relative value files will be issued in future Recurring Update Notifications.   As specified at 42 CFR 410.28(f), for services furnished on or after February 21, 2002, the provisions of paragraphs (a) and (d)(2) through (d)(4), inclusive, of 42 CFR 410.32 apply to all diagnostic laboratory tests furnished by hospitals and CAHs to outpatients.