evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
A. General Instructions for the Use of ABNs for Upgrading DMEPOS Items   Instruction  Description  1. An upgrade may be from one item to another within a single Heath Insurance Common Procedure Coding System (HCPCS) code, or may be from one HCPCS code to another.  When an upgrade is within a single code the upgraded item must include features that exceed t he official code descriptor for that item.  2. The upgrade must be within the range of items or services that are medically appropriate for the beneficiarys medical condition and the purpose of the physicians order.  ABNs may not be used to substitute a different item or service that is not medically  appropriate for the beneficiarys medical condition for the original item or service.  The upgraded item must still meet the intended medical purpose of the item the physician ordered.  3. Use of an ABN to furnish an upgraded item or service, with the beneficiary being personally responsible for the difference between the costs of the standard and upgraded item or service, does not change coverage or payment rules, statutory provisions, or m anual instructions for the particular benefit involved.   4. In cases where the DME MACs would make payment for the item the physician ordered on a rental basis, the supplier must furnish the upgrade on a rental basis.   5. A supplier furnishing an upgrade and using an ABN must submit a claim and include information on the claim that identifies the upgrade features.  Suppliers must submit a claim for upgraded items and services using the GA modifier on the upgraded line item to indicate that the beneficiary signed an ABN.  Suppliers must list upgrade features using the ASC X12 837 professional claim format or on the paper Form CMS -1500 in Item 19 or as an attachment to the claim for paper claims.  6. Denials should be based on medical necessity.   B. Billing Instructions:   Suppliers must bill 2 line items for upgraded DMEPOS items where the beneficiary requests an upgrade.  Suppliers must bill both lines on the same claim in the following order:
(Medicare Claims Processing Manual)
B. Billing Instructions:   Suppliers must bill 2 line items for upgraded DMEPOS items where the beneficiary requests an upgrade.  Suppliers must bill both lines on the same claim in the following order:   Line Instruction  Line 1:  Bill the appropriate HCPCS code for the upgraded item the supplier actually provided to the beneficiary with the dollar amount of the upgraded item.  If the supplier has a properly obtained ABN on file signed by the beneficiary, use the GA modifier.  If the supplier did not properly obtain an ABN signed by th e beneficiary, use the GZ modifier.  Line 2:  Bill the appropriate HCPCS code for the reasonable and necessary item with the actual charge for the item.  Use the GK modifier.   Suppliers should bill their full submitted charge on the claim line for the upgraded item (Line 1) and the full amount for the reasonable and necessary item (Line 2).  If the upgrade is within a code, suppliers still bill 2 line items, using the same code on both lines, but Line 1 would have the higher dollar amount.  Suppliers must bill both lines on the same claim in sequential order.  Line 1 and the associated Line 2 should follow each other.   DME MACs must return/reject applicable assigned claims that have invalid ABN upgrade information using appropriate messages.  If the claim is unassigned, DME MACs must issue a denial.   C. Definitions of Modifiers that May be Associated with ABNs   Modifier  Description  GA -  Waiver of Liability (expected to be denied as not reasonable and necessary, ABN on file)  GZ -  Item or Service not Reasonable and Necessary (expected to be denied as not reasonable and necessary, no ABN on file)  GK -  Reasonable and necessary item/service associated with GA or GZ modifier   D. Medicare Summary Notice (MSN) and Remittance Advice (RA)
(Medicare Claims Processing Manual)
D. Medicare Summary Notice (MSN) and Remittance Advice (RA)   MSN  Detailed text  36.01:  Our records show that you were informed in writing, before receiving the service that Medicare would not pay.  You are liable for this charge.  If you do not agree with this statement, you may ask for a review.  ASC X12 835, remittance advice remark code M 38 36.02:  It appears that you did not know that we would not pay for this service  so you are not liable.  Do not pay your provider for this service.  If you have paid your provider for this service, you should submit to this office three things 1) A copy of this notice, 2) Your providers bill, and 3) A receipt or proof that you have paid the bill.  You must file your written request for payment within 6 months of the date of this notice.  Future services of this type provided to you will be your responsibility. ASC X12 835 remittance advice remark code M25)  8.51:  You signed an Advanced Beneficiary Notice (ABN).  You are responsible for the difference between the upgrade amount and the Medicare payment.   Use the following messages when denying claims due to invalid ABN upgrade information:   MSN  Detailed text  8.53:  This item or service was denied because the upgrade information was invalid.  N108:  This item/service was denied because the upgrade information was invalid.   120.1 - Providing Upgrades of DMEPOS Without Any Extra Charge  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)
(Medicare Claims Processing Manual)
Instead of using ABNs and charging beneficiaries for upgraded items, suppliers in certain circumstances may decide to furnish beneficiaries with upgraded equipment but charge the Medicare program and the beneficiary the same price they would charge for a n on-upgraded item.  The reason for this may be that a supplier prefers to carry only higher level models of medical equipment in order to reduce the costs of maintaining an inventory that includes a wide variety of different models and products.  Also, a supplier may be able to reduce its costs for replacement parts and repairs if it includes in its inventory only certain product lines.  The supplier may also be accommodating a physician order for an upgrade.   Policy   Suppliers are permitted to furnish upgraded DMEPOS items and to charge the same price to Medicare and the beneficiary that they would charge for a non- upgraded item.  This policy allows suppliers to furnish to beneficiaries, at no extra costs to the Medica re program or the beneficiary, a DMEPOS item that exceeds what the non -upgraded item that Medicare considers to be medically necessary.  Therefore, even though the beneficiary received an upgraded DMEPOS item, Medicares payment and the beneficiarys coins urance would be based on the Medicare allowed amount for a non-upgraded item that does not include features that exceed the beneficiarys medical needs.   Billing Instructions   When a supplier decides to furnish an upgraded DMEPOS item but to charge Medicare and the beneficiary for the non- upgraded item, the supplier must bill for the non-upgraded item rather than the item the supplier actually furnished.  The claim must include only the charge and HCPCS code for the non- upgraded item.  The HCPCS code for the non- upgraded item must be accompanied by the following modifier:   Modifier  Detailed Text  GL  Medically Unnecessary Upgrade Provided Instead of Non -upgraded Item, No Charge, No ABN   Suppliers must show the upgrade using the ASC X12 837 professional claim format, or in Item 19 of a paper Form CMS -1500 claim, or as an attachment.  The supplier must specify the make and model of the item actually furnished, that is, the upgraded item, and describe why this item is an upgrade
(Medicare Claims Processing Manual)
DME MACs are to pay based on Medicares payment amount for the non- upgraded item if it meets Medicares coverage and payment requirements.  A certificate of medical necessity, if applicable, must be completed for the HCPCS code that identifies the non-upgraded item but not for the upgraded item.   MSN Message:   For items accompanied with a GL modifier, use:   MSN  Detailed Text  8.51:  You are not liable for any additional charge as a result of receiving an upgraded item.   130 - Billing for Durable Medical Equipment (DME) and Orthotic/ Prosthetic Devices  (Rev. 2629, Issued: 01- 04-13, Effective: - 02-05-13, Implementation: 02- 05-13)  See 01 of this chapter  for definition of provider and supplier.   130.1 - Provider Billing for Prosthetic and Orthotic Devices  (Rev. 2629, Issued: 01- 04-13, Effective: - 02-05-13, Implementation: 02- 05-13)  See  01 of this chapter for definition of provider.   These items  consist  of all prosthetic  and orthotic  devices  excluding parenteral/enteral  nutritional  supplies  and equipment  and intraocular  lenses.   Prosthetics  and orthotic  devices  when provided during inpatient care are  included in  the Part A PPS rate unless  specified  as being  outside  the rate.  The link for information on services included and excluded from the SNF PPS is http://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/index.html .  The DME MAC  will not separately pay for items of DME provided to a beneficiary in a SNF.   Prosthetics, orthotics and supplies  that are considered  outside  the PPS rate may  be billed  by the  supplier in the case of a SNF or  hospital  to the A/B MAC (A) , or if furnished by a  qualified  outside  entity,  that entity  may  bill its  normal  contractor.
(Medicare Claims Processing Manual)
The SNFs,  hospitals, or  other  entities  that furnish  prosthetic  and/or  orthotic  devices  to their patients  for whom  Part A benefits  are not  payable (i.e., no Part  A entitlement or  benefits  exhausted)  may  bill for such  items,  assuming other  billing  requirements  are met.   NOTE:  Items  such  as catheters  and ostomy supplies  are excluded  from  the fee schedule when  billed  by HHAs  for patients  under  a plan  of care.  In  this situation,  HHAs  bill for these items  as supplies  under  revenue code 0270.  Effective  with items  furnished on or  after  January  1, 1994, the  fee schedules  for ostomy, tracheostomy, and  urological  supplies  are calculated  using the  same method  used to calculate the  purchase  fee schedules  for inexpensive  or other  routinely  purchased  DME.   HCPCS  codes  A4214, A4310 through A4330, A4338 through A4359, and  A5102 through A5114 are excluded  from  the fee schedule when  billed  by hospitals  along with  an ASC  service.  Hospitals  bill for these items  as supplies, under  revenue code  0272.  In addition, HCPCS  codes  A5119 through A5131 are excluded  from  the fee schedule  unless  they are submitted  with  ostomy  related  ASC  procedure  codes  44340 through 44346, 44380, 44382, 44388 through 44392, or  50953 through 50961.  In all other  circumstances,  including HHAs  billing  for patients  not under  a plan  of care,  SNFs,  CORFs,  OPTs,  and hospitals  bill these items  as prosthetics  and orthotics  under  code  0274, along with the relevant HCPCS code.   DME MACs  only -  For all states that have licensure/certification requirements for provision of prosthetics and/or orthotics, DME MACs  shall process claims for Prosthetics and Certain Custom -Fabricated Orthotics only when the following specialty codes are forwarded to the DME MACs  from the NSC.  The specialty codes are:    Medical Supply Company with Orthotics Personnel -  Specialty Code 51;    Medical Supply Company with Prosthetics Personnel -  Specialty Code 52;    Medical Supply Company with Orthotics and Prosthetics Personnel -  Specialty Code 53;    Orthotics Personnel -  Specialty Code 55;
(Medicare Claims Processing Manual)
 Medical Supply Company with Prosthetics Personnel -  Specialty Code 52;    Medical Supply Company with Orthotics and Prosthetics Personnel -  Specialty Code 53;    Orthotics Personnel -  Specialty Code 55;    Prosthetics Personnel -  Specialty Code 56;    Orthotics Personnel, Prosthetics Personnel and Pedorthists -  Specialty Code 57,   Physical Therapist -  Specialty Code 65;    Occupational Therapist -  Specialty Code 67;    Ocularist -  Specialty Code B5; and    All Physician Specialty Codes listed in this manual [IOM] Chapter 26, 10.8.2  These specialties shall be licensed or certified by the state when applicable.  These specialties shall bill for Medicare services when State law permits such entity to furnish a prosthetic or orthotic.   Claims billed by other specialty codes for prosthetics and certain custom -fabricated orthotics shall be denied.   130.2 - Billing for Inexpensive or Other Routinely Purchased DME  (Rev.4027; Issued: 04- 27-18; Effective: 10 -01-18; Implementation: 10 -01-18) This is equipment with a purchase price not exceeding $150, or equipment that the Secretary determines is acquired by purchase at least 75 percent of the time, or equipment that is an accessory used in conjunction with a nebulizer, aspirator, or ventilator s that are either continuous airway pressure devices or intermittent assist devices with continuous airway pressure devices. Effective October 1, 2015, this category also includes speech generating devices and accessories necessary for the effective use of  speech generating devices.  Suppliers and providers other than HHAs bill the DME MAC or, in the case of implanted DME only, the A/B MAC (B). HHAs bill the A/B MAC (HHH) or the DME MAC.
(Medicare Claims Processing Manual)
Effective for items and services furnished after January 1, 1991, Medicare DME does not include seat lift chairs. Only the seat lift mechanism is defined under Medicare as DME. Therefore, seat lift coverage is limited to the seat lift mechanism. If a seat lift chair is provided to a beneficiary, A/B MACs (A), and (HHH), and DME MACs pay only for the lift mechanism portion of the chair. Some lift mechanisms are equipped with a seat that is considered an integral part of the lift mechanism. A/B MACs (A) and ( HHH), and DME MACs do not pay for chairs (HCPCS code E0620) furnished on or after January 1, 1991. The appropriate HCPCS codes for seat lift mechanisms are E0627, E0628, and E0629.   For TENS, suppliers and providers other than HHAs bill the DME MAC. HHAs bill the A/B MAC             (HHH) using revenue code 0291 for the 2 -month rental period (see 30.1.2), billing each month as a separate line item and revenue code 0292 for the actual  purchase along with the appropriate HCPCS code.  130.3 - Billing for Items Requiring Frequent and Substantial Servicing  (Rev. 1, 10- 01-03) A3-3629, B3- 4107.8   These are items such as intermittent positive pressure breathing (IPPB) machines and ventilators, excluding ventilators that are either continuous airway pressure devices or intermittent assist devices with continuous airway pressure devices.   Suppliers and providers other than HHAs bill the DME MAC.  HHAs bill the A/B MAC (HHH).   130.4 - Billing for Certain Customized Items (Rev. 1, 10- 01-03) A3-3629, B3- 4107.8   Due to their unique nature (custom fabrication, etc.), certain customized DME cannot be grouped together for profiling purposes.  Claims for customized items that do not have specific HCPCS codes are coded as E1399 (miscellaneous DME).  This includes circu mstances where an item that has a HCPCS code is modified to the extent that neither the original terminology nor the terminology of another HCPCS code accurately describes the modified item.
(Medicare Claims Processing Manual)
Suppliers and providers other than HHAs bill the A/B MAC (B) or DME MAC.  HHAs bill their A/B MAC (HHH), using revenue code 0 292 along with the HCPCS.   130.5 - Billing for Capped Rental Items (Other Items of DME)  (Rev. 1, 10- 01-03) A3-3629, B3- 4107.8   These are DME items, other than oxygen and oxygen equipment, not covered by the above categories.  Suppliers and providers other than HHAs bill the DME MAC.  HHAs bill the A/B MACs (HHH).     130.6 - Billing for Oxygen and Oxygen Equipment  (Rev.  3895, Issued: 10- 27-17, Effective: 04 -01-18, Implementation: 04-  02-18) The following instructions apply to all claims from providers and suppliers to whom payment may be made for oxygen.  The chart in 130.6.1 indicates what is payable under which situation. A. Monthly Billing  Fee schedule payments for stationary oxygen system rentals are all inclusive and represent a monthly allowance per beneficiary.  Accordingly, a supplier must bill on a monthly basis for stationary oxygen equipment and contents furnished during a rental month. A portable equipment add- on is also payable when portable oxygen is prescribed and it is determined to be medically necessary in accordance with Medicare coverage requirements.  The portable add- on must be claimed in order to be paid.  (See 30.6.)  B. HCPCS Codes  The HCPCS codes must be used to report the service.  One month of service equals one unit. C. Use of Payment Modifiers and Revenue Codes for Payment Adjustments  The monthly payment amount for stationary oxygen is subject to adjustment depending on the amount of oxygen prescribed (liters per minute (LPM)), and whether or not portable oxygen is also prescribed.  (See 30.6.)  HHAs billing the A/B MAC (HHH) for stationary equipment, supplies, or contents, which are not eligible for payment adjustment, bill under revenue code 0601.  Claims must indicate the appropriate HCPCS modifier described below, if applicable.   If the prescribed amount of oxygen is less than 1 LPM, suppliers use the modifier "QE"; HHAs use revenue code 0602.  The monthly payment amount for stationary oxygen is reduced by 50 percent.
(Medicare Claims Processing Manual)
 If the prescribed amount of oxygen is greater than 4 LPM, suppliers use the modifier "QG"; HHAs use revenue code 0603.  The monthly payment amount for stationary oxygen is increased by 50 percent.    If the prescribed amount of oxygen exceeds 4 LPM and portable oxygen is prescribed, suppliers use the modifier "QF"; HHAs use revenue code 0604.  The monthly payment for stationary oxygen is increased by the higher of 50 percent of the monthly stationary oxygen payment amount, or, the fee schedule amount for the portable oxygen add- on.  (A separate monthly payment is not allowed for the portable equipment.) Effective April 1, 2017, the modifier QF must be used with both the stationary and portable oxygen equipment codes.
(Medicare Claims Processing Manual)
Effective April 1, 2017, portable oxygen QF modifier fee schedule amounts will be added to the DMEPOS fee schedule file.  The portable oxygen QF fee schedule amounts will represent the higher of 1) 50 percent of the monthly stationary oxygen payment am ount or 2) the fee schedule amount for the portable oxygen add -on.  There are three claims processing scenarios:  Scenario 1  A claim for stationary oxygen equipment is submitted with the QG modifier. The history is reviewed and it is discovered that portable oxygen equipment was billed AND paid within the last 30 days prior to the stationary oxygen equipments date of service. Since we have already paid the portable add -on, we cant pay the volume adjustment add- on, therefore billing with QG modifier is inappropriate and the claim should be returned as unprocessable.  Scenario 2  A claim for stationary oxygen equipment is submitted with the QG modifier and within 30 days, a claim for portable oxygen equipment is received. In this case we have already paid the volume add- on so the portable equipment add on is returned as unprocessable.   Scenario 3  A claim for stationary oxygen equipment is submitted with the QG modifier AND the portable oxygen equipment comes in with the same date of service. In this case EVERYTHING is returned as unprocessable due to the incorrect use of the modifier a nd neither is valid.  NOTE: All these claims are being returned as unprocessable since there is no way for Medicare to know whether the first claim submitted was billed incorrectly or if the subsequent claim was billed incorrectly.   Contractors shall use the following messages for claims that are returned as unprocessable:  Group Code: CO (Contractual Obligation)  CARC 4 -  The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.  RARC MA130 -  Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable.  Please submit a new claim with the complete/correct information.   The following three new pricing modifiers are added to the HCPCS file effective April 1, 2018:  QA PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS LESS THAN 1 LITER PER MINUTE (LPM)
(Medicare Claims Processing Manual)
QB PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED   QR PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS GREATER THAN 4 LITERS PER MINUTE (LPM)   Additionally, the existing QE, QF, and QG modifiers are revised to clarify that the prescribed flow rate at rest is used in accordance with regulations at 42 CFR 414.226(e)(3). This section instructs that if the prescribed flow rate is different for the patient at rest than for the patient at exercise, the flow rate for the patient at rest is used. Effective April 1, 2018, the modifiers are revised to read:   QE PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS LESS THAN 1 LITER PER MINUTE (LPM)   QF PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST EXCEEDS 4 LITERS PER MINUTE (LPM) AND PORTABLE OXYGEN IS PRESCRIBED   QG PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS GREATER THAN 4 LITERS PER MINUTE (LPM)   Beginning April 1, 2018, claims for monthly oxygen volume adjustments must indicate the appropriate HCPCS modifier described below as applicable. Oxygen fee schedule amounts are adjusted as follows:   If the prescribed amount of oxygen is less than 1 LPM, suppliers use either of the following modifiers with the stationary oxygen HCPCS code:    The modifier QE PRESCRIBED AMOUNT OF STATIONARY OXYGEN WHILE AT REST IS LESS THAN 1 LITER PER MINUTE (LPM); HHAs use revenue code 0602. The monthly payment amount for stationary oxygen is reduced by 50 percent.    The modifier QA PRESCRIBED AMOUNTS OF STATIONARY OXYGEN FOR DAYTIME USE WHILE AT REST AND NIGHTIME USE DIFFER AND THE AVERAGE OF THE TWO AMOUNTS IS LESS THAN 1 LITER PER MINUTE (LPM); The monthly payment amount for stationary oxygen is reduced by 50 perc ent. This modifier is used when the prescribed flow rate is different for nighttime use and daytime use and the average of the two flow rates is used in determining the volume adjustment.  If the prescribed amount of oxygen is greater than 4 LPM, suppliers use either of the following modifiers with the stationary oxygen HCPCS code: