evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
B. Effect on Payment   From CY 2018 through CY 2022, rural SCHs, childrens hospitals, and PPS -exempt cancer hospitals providers that were exempt from the 340B drug payment adjustment reported the informational modifier TB to identify OPPS separately payable drugs (reported with  status indicator K) purchased through the 340B discount program. The use of modifier TB did not trigger a payment adjustment, and these providers received and will continue to receive ASP plus 6 percent (or equivalent payment rate derived from the ASP m ethodology) for separately payable drugs furnished by these select providers. Furthermore, between CY 2019 and CY 2022, nonexcepted off -campus PBDs paid under the PFS (departments that bill the modifier PN on their claim lines) that furnished 340B -acquired  drugs and biologicals and were exempt from the 340B payment adjustment (because their hospital is a rural SCH or childrens hospital) were required to bill under the PFS using the institutional claim form and report the informational modifier TB for 340B -acquired drugs and biologicals, which did not trigger a payment adjustment, and these providers received ASP+6 percent for separately payable drugs furnished in CY 2019, even if such drugs were acquired under the 340B Program.  For CY 2023, the presence of modifier TB on a claim to indicate a drug is acquired under the 340B program will continue to not trigger a payment reduction and be used only for informational purposes. Claims for 340B drugs and biologicals identified with a TB modifier will be paid at the same statutory default rate as non -340B drugs and biologicals. Additionally, the requirement of the TB modifier to identify drugs acquired through the 340B Program complies with certain requirements of the Inflation Reduction Act because these modifiers are an established mechanism that have been in use by hospitals paid under the OPPS. The Inflation Reduction Act establishes a Part B inflation rebate by manufacturers for certain single source drugs and biologicals with prices increasing faster than the rate of inflation. However, it also specifically excludes units of drugs for which the manufacturer provides a discount under the 340B program from the units of drugs for which a manufacturer otherwise may have a Part B inflation rebate liability.
(Medicare Claims Processing Manual)
20.6.19 - Modifier CG                                                    (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  CG: Policy criteria applied   Effective January 1, 2019, modifier CG can be reported with certain device -intensive procedures to reflect situations in which a device was not used during the device -intensive procedure.  Refer to section 61.2.1 of this manual for further information on modifier CG.   This modifier would be reported on the UB 04 form (CMS Form 1450) for hospital outpatient device - intensive procedures. Reporting of this modifier is not required for Critical access hospitals (CAHs). While this modifier is required, it does not have an effect on payment.   20.7 - Billing of C HCPCS Codes by Non -OPPS Providers (Rev. 976, Issued: 06- 09-06, Effective: 10 -01-06, Implementation: 10- 02-06)  Prior to October 1, 2006, the C series of HCPCS codes were used exclusively by hospitals subject to OPPS to identify items that may have qualified for transitional pass through payment under OPPS or items or services for which an appropriate HCPCS code did not exist for the purposes of implementing the OPPS.  The C -codes could not be used to bill services payable under other payment systems.  CMS realized that these C -codes evolved and also target services that are uniquely hospital services that may be provided by an OPPS provider, other providers, or be paid under other payment systems.  Effective October 1, 2006, the following non- OPPS providers may elect to bill using the C-codes or an appropriate CPT code on Types of Bill (TOBs) 12X, 13X, or 85X:    Critical Access Hospitals (CAHs);  Indian Health Service Hospitals (IHS);   Hospitals located in American Samoa, Guam, Saipan or the Virgin Islands; and  Maryland waiver hospitals.
(Medicare Claims Processing Manual)
 Critical Access Hospitals (CAHs);  Indian Health Service Hospitals (IHS);   Hospitals located in American Samoa, Guam, Saipan or the Virgin Islands; and  Maryland waiver hospitals.  The OPPS providers shall continue to receive pass -through payment on items or services that qualify for pass through payment. Non- OPPS providers are not eligible for pass through payments.  The C -codes shall be replaced with permanent codes.  Whenever a permanent code is established to replace a temporary code, the temporary code is deleted and cross -referenced to the new permanent code.  Upon deletion of a temporary code, providers shall bill using the new permanent code.   Providers are encouraged to access the CMS Web site to view the quarterly HCPCS Code updates.  The URL to view the quarterly updates is http://www.cms.hhs.gov/HCPCSReleaseCodeSets/ .  The billing of C -codes by Method I and Method II Critical Access Hospitals (CAHs) is limited to the billing for facility (technical) services.  The C -codes shall not be billed by Method II CAHs for professional services with revenue codes 96X, 97X, or 98X.   30 - OPPS Coinsurance  (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)
(Medicare Claims Processing Manual)
30 - OPPS Coinsurance  (Rev. 2141, Issued: 01- 24-11, Effective: 01 -01-11, Implementation: 01- 03-11)  OPPS freezes coinsurance for outpatient hospital at 20 percent of the national median charge for the services within each APC (wage adjusted for the providers geographic area), but coinsurance for an APC cannot be less than 20 percent of the APC payment rate.  As the total payment to the provider increases each year based on market basket updates, the present or frozen coinsurance amount will become a smaller portion of the total payment until coinsurance represents 20 percent of the total payment.  Once coinsurance becomes 20 percent of the payment amount, the annual updates will also increase coinsurance so that  it continues to account for 20 percent of the total payment.  As previously stated, the wage -adjusted coinsurance for a service under OPPS cannot exceed the inpatient deductible amount.  Section 111 of BIPA accelerates the reduction of beneficiary copayment amounts by providing that for services furnished on or after April 1, 2001, and before January 1, 2002, the national unadjusted copayment amount for any ambulatory payment classificatio n (APC) group cannot exceed 57 percent of the APC payment rate.  The statute makes further reductions in future years so that national unadjusted copayment amounts cannot exceed 55 percent of the APC rate in 2002 and 2003, 50 percent in 2004, 45 percent in 2005, and 40 percent in 2006 and later years.   The annual update of the OPPS Pricer includes updated copayment amounts.  For screening colonoscopies and screening flexible sigmoidoscopies, the coinsurance amount is 25 percent of the payment rate, prior to January 1, 2011. Coinsurance does not apply to screening colonoscopies, screening sigmoidoscopies, and other specified services furnished on or after January 1, 2011.   Coinsurance does not apply to influenza virus vaccines, pneumococcal pneumonia vaccines, and clinical diagnostic laboratory services (which includes screening pap smears and screening prostate- specific antigen testing).   See 30.2 below for more detail.   Future updates will be issued in a Recurring Update Notification.
(Medicare Claims Processing Manual)
See 30.2 below for more detail.   Future updates will be issued in a Recurring Update Notification.    30.1 - Coinsurance Election  (Rev. 12423; Issued: 12- 20-23; Effective: 01 -01-24; Implementation: 01- 02-24)    The transition to the standard Medicare coinsurance rate (20 percent of the APC payment rate) will be gradual.  For those APC groups for which coinsurance is currently a relatively high proportion of the total payment, the process will be correspondingly l engthy.  The law offers hospitals the option of electing to reduce coinsurance amounts and advertise their reduced rates for all OPPS services.  They may elect to receive a coinsurance payment from Medicare beneficiaries that is less than the wage adjusted  coinsurance amount per APC.  That amount will apply to all services within that APC.  This coinsurance reduction must be offered to all Medicare beneficiaries.    Hospitals should review the list of APCs and their respective coinsurance amounts that is published in the Federal Register for the applicable year as a final rule.  After adjusting those coinsurance amounts for the wage index applicable to their MSA, hospitals must notify their A/B MACs (A) if they wish to charge their Medicare beneficiaries a lesser amount.  The election rem ains in effect until the following calendar year.  The first election must be filed by July 1, 2000, for the period August 1, 2000, through December 31, 2000.  Future calendar year elections must be made by December 1st of the year preceding the calendar y ear for which the election is being made.    Because the final rule on OPPS payment rates for 2002 was not published until March 1, 2002, providers were unable to make election decisions for 2002 by December 1 preceding the year the payment rates became effective, the typical deadline for making such elections.  The deadline for providers to make elections to reduce beneficiary copayments for 2002 was extended until April 1, 2002.  The elections are effective for services furnished on or after April 1, 2002.    The lesser amount elected:     May not be less than 20 percent of the wage adjusted APC payment amount;     May not be greater than the inpatient hospital deductible for that calendar year ($812 for 2002); and     Will not be wage adjusted by the A/B MAC (A) or CMS.
(Medicare Claims Processing Manual)
 May not be greater than the inpatient hospital deductible for that calendar year ($812 for 2002); and     Will not be wage adjusted by the A/B MAC (A) or CMS.    Once an election to reduce coinsurance is made, it cannot be rescinded or changed until the next calendar year.  National unadjusted and minimum unadjusted coinsurance amounts will be posted each year in the addenda of the OPPS final rule (enter CMS1005FC)  on CMS Web site ( http://cms.hhs.gov/ ).    This coinsurance election does not apply to partial hospitalization or intensive outpatient  services furnished by CMHCs , vaccines provided by a CORF, vaccines, splints, casts, and antigens provided by HHAs, or splints, casts, and antigens provided to a hospice patient for the treatment of a non- terminal illness.  It also does not apply to screening colonoscopies, screening sigmoidoscopies, or screening barium enemas, or to services not paid under OPPS.    Hospitals must utilize the following format for notification to the A/B MAC (A):    Provider number  1122334455      Provider name  XYZ Hospital  Eecve from  8/1/2000 -  12/31/2000  Provider contact  Joe Smith  Phone #  123-456-7890  Contact e -mail  Jsmith@XYZ.ORG  Fax #  123-456-7891    XYZ Hospital elects to reduce coinsurance to the amount shown for the following APCs:
(Medicare Claims Processing Manual)
A program payment percentage is calculated for each APC by subtracting the unadjusted national coinsurance amount for the APC from the unadjusted payment rate and dividing the result by the unadjusted payment rate.  The payment rate for each APC group is t he basis for determining the total payment (subject to wage -index adjustment) that a hospital will receive from the beneficiary and the Medicare program.  (A hospital that elects to reduce coinsurance, as described in 30.1, above, may receive a total payment that is less than the APC payment rate.)  The Medicare payment amount takes into account the wage index adjustment and the beneficiary deductible and coinsurance amounts.  In addition, the amount calculated for an APC g roup applies to all the services that are classified within that APC group.  The Medicare payment amount for a specific service classified within an APC group under OPPS is calculated as follows:   Step 1 -  Apply the appropriate wage index adjustment to the payment rate that is set annually for each APC group;   Step 2 -  Subtract from the adjusted APC payment rate the amount of any applicable deductible;   Step 3 -  Multiply the adjusted APC payment rate, from which the applicable deductible has been subtracted, by the program payment percentage determined for the APC group or 80 percent, whichever is lower.  This amount is the preliminary Medicare payment amount;   Step 4 -  Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less the amount of any applicable deductible.  If the resulting amount does not exceed the annual hospital inpatient deductible amount for the calendar year, the resulting amount is the beneficiary coinsurance amount.  If the resulting amount exceeds the annual inpatient hospital deductible amount, the beneficiary coinsurance amount is limited to the inpatient hospital deductible and the Medicare program pays the di fference to the provider.   Step 5 -  If the wage- index adjusted coinsurance amount for the APC is reduced because it exceeds the inpatient deductible amount for the calendar year, add the amount of this reduction to the amount determined in Step 3 above to get the final Medicare paym ent amount.  EXAMPLE 1:
(Medicare Claims Processing Manual)
The wage -adjusted payment rate for an APC is $300; the program payment percentage for the APC group is 70 percent; the wage -adjusted coinsurance amount for the APC group is $90; and the beneficiary has not yet satisfied any portion of his or her $100 annual Part B deductible.   A. Adjusted APC payment rate: $300.  B. Subtract the applicable deductible: $300 -  $100 = $200.  C. Multiply the remainder by the program payment percentage to determine the preliminary   Medicare payment amount: 0.7 x $200 = $140.  D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less any unmet deductible to determine the coinsurance amount, which cannot exceed the inpatient hospital deductible for the calendar year: $200 -  $140 = $60.  E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation.  $140 + $0 = $140.  In this case, the beneficiary pays a deductible of $100 and a $60 coinsurance, and the program pays $140, for a total payment to the provider of $300.  Applying the program payment percentage ensures that the program and the beneficiary pay the same propor tion of payment that they would have paid if no deductible were taken.   If the annual Part B deductible has already been satisfied, the calculation is as follows:   A. Adjusted APC payment rate: $300.  B. Subtract the applicable deductible: $300 -  0 = $300.  C. Multiply the remainder by the program payment percentage to determine the preliminary   Medicare payment amount: 0.7 x $300 = $210.  D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount.  The coinsurance amount cannot exceed the amount of the inpatient hospital deductible for the calendar year: $300 -  $210 = $90.
(Medicare Claims Processing Manual)
E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation: $210 + $0 = $210.  In this case, the beneficiary makes a $90 coinsurance payment and the program pays $210, for a total payment to the provider of $300.   EXAMPLE 2:   This example illustrates a case in which the inpatient hospital deductible limit on coinsurance amount applies.  Assume that the wage -adjusted payment rate for an APC is $2,000; the wage -adjusted coinsurance amount for the APC is $900; the program payment percentage is 55 percent; and the inpatient hospital deductible amount for the calendar year is $776.  The beneficiary has not yet satisfied any portion of his or her $100 Part B deductible.   A. Adjusted APC payment rate: $2,000.  B. Subtract the applicable deductible: $2,000 -  $100 = $1,900.  C. Multiply the remainder by the program payment percentage to determine the preliminary Medicare payment amount: 0.55 x $1,900 = $1,045.  D. Subtract the preliminary Medicare payment amount from the adjusted APC payment rate less deductible to determine the coinsurance amount.  The coinsurance amount cannot exceed the inpatient hospital deductible amount of $776: $1,900 -  $1,045 = $855, but the coinsurance is limited to $776.   E. Calculate the final Medicare payment amount by adding the preliminary Medicare payment amount determined in step (C) to the amount that the coinsurance was reduced as a result of the inpatient hospital deductible limitation ($855 -  $776 = $79).  $1,045 + $79 = $1,124.
(Medicare Claims Processing Manual)
In this case, the beneficiary pays a deductible of $100 and a coinsurance that is limited to $776 and the program pays $1,124 (which includes the amount of the reduction in beneficiary coinsurance due to the inpatient hospital deductible limitation) for a total payment to the provider of $2,000.  For calendar year 2002, the national unadjusted copayment amount for an ambulatory payment classification (APC) is limited to 55 percent of the APC payment rate established for a procedure or service.  In addition the wage -adjusted copayment amount for a p rocedure or service cannot exceed the inpatient hospital deductible amount for 2002 of $812.  These changes were implemented by changes to the OPPS Pricer effective for services furnished on or after January 1, 2002.   40 - Outpatient Code Editor (OCE)  (Rev. 1107, Issued: 11- 09-06, Effective: 07 -01-07, Implementation: 07- 02-07)  The CMS incorporates new processing requirements in the Outpatient Code Editor (OCE) by releasing a new or updated version of the software each quarter.  The OCE instructions and specifications are utilized under:    The OPPS for hospital outpatient departments, Community Mental Health Centers (CMHCs) and for limited services provided in a Home Health Agency (HHA) not under the Home Health Prospective Payment System or to a hospice patient for the treatment of a non- terminal illness;    The non- OPPS for Indian Health Service Hospitals, Critical Access hospitals (CAHs), Maryland hospitals, hospitals located in American Samoa, Guam, the Commonwealth of the Northern Mariana Islands.  In addition claims from Virgin Island hospitals with dates of service 1/1/02 and later, and hospitals that furnish only inpatient Part B services with dates of service 1/1/02 and later are edited in the non- OPPS OCE; and   All other outpatient institutional claims.   40.1 - Integrated OCE (July 2007 and Later)  (Rev. 1590, Issued: 09- 08-08, Effective: 10 -01-08, Implementation: 10- 06-08)
(Medicare Claims Processing Manual)
All other outpatient institutional claims.   40.1 - Integrated OCE (July 2007 and Later)  (Rev. 1590, Issued: 09- 08-08, Effective: 10 -01-08, Implementation: 10- 06-08)  Effective for claims with dates of service July 1, 2007 and after, the non- Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE) will be integrated into the OPPS OCE.  This integration will result in the routing of all institutional outpatient claims, including non- OPPS hospital claims, through a single integrated OCE eliminating the need to update two separate OCE software packages on a quarterly basis.  The integrated OCE does not change the current logic that is applied to outpatient bill types that already pass through the OPPS OCE software.  It merely expands the software usage to include non -OPPS hospitals.  This new software product will be referred to as the Integrated OCE (I/OCE).   The I/OCE instructions and specifications are provided via Recurring Update Notifications.  They are also posted on the Web at the following address: http://www.cms.hhs.gov/OutpatientCodeEdit/02_OCEQtrReleaseSpecs.asp#TopOfPage   40.1.1 - Patient Status Code and Reason for Patient Visit for the Hospital OPPS  (Rev. 243, Issued 07- 23-04, Effective: January 1, 2005/Implementation: January 3, 2005)   In order to  ensure that OPPS claims are being submitted and processed to payment in accordance with OPPS payment policy, CMS must be able to monitor information reported by hospitals on Form CMS -1450 in Form Locators (FLs) 22 (Patient Status) and 76 (Reason for Patie nt Visit).  This instruction requires the Shared System Maintainer to make changes to ensure that the information in FLs 22 and 76, from claims submitted on bill type 13x, is passed to the OPPS Outpatient Code Editor (OCE) and to the Common Working File (CWF).  This instruction also requires the Common Working File Maintainer to make changes to ensure that the information in FL 76, from claims submitted on bill type 13x, is passed to the National Claims History (NCH) files.
(Medicare Claims Processing Manual)
Outpatient Pricer determines the amount to pay as well as deductions for deductible and coinsurance.   This CMS -developed software is updated on a quarterly basis to determine the APC line item price (as well as applicable coinsurance/deductible) based on data from the Outpatient Provider Specific File (OPSF), the beneficiary deductible record and the OCE output file.  Pricer prepares an output data record with the following information:    All information passed from the OCE;    The APC line item payment amount;   The APC line item deductible;   The APC line item coinsurance amount;    The total cash deductible applied to the OPPS services on the claim;    The total blood deductible applied to the OPPS services on the claim;    The APC line item blood deductible;    The total outlier amount for the claim to be paid in addition to the line item APC payments.  This amount is to be reported to CWF via value code 17 as is the process for inpatient outlier payments; and    A Pricer assigned review code to indicate why or how Pricer rejected or paid the claim.   The Pricer implementation guide has information concerning Pricer processing reports, input parameters, and data requirements.  50.1 - Outpatient Provider Specific File  (Rev. 12369, Issued: 1 1-17-23; Effective: 01 -01-2023; Implementation: 01- 03-2023)   The Outpatient Provider Specific File (OPSF) contains the required information about each provider to enable the pricing software to calculate the payment amount. Data elements and formats are shown below. Contractors must maintain the accuracy of the data , and update the file as changes occur in data element values, e.g., changes in metropolitan statistical area (MSA), bed size, cost to charge ratio. An update is accomplished by preparing and adding an additional complete record showing new current values and the effective date of the change. The old record is retained without change.    Contractors must also furnish CMS a quarterly file in the same format.     NOTE : All data elements, whether required or optional, must have a default value of 0 (zero) if numerical, or blank if alphanumerical.