evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Global test only codes: This indicator identifies stand alone codes for which there are associated codes that describe: a) the professional component of the test only and b) the technical component of the test only.  Modifiers 26 and TC cannot be used with these codes.  The total RVUs for global procedure only codes include values for physician work, practice expense, and malpractice expense.  The total RVUs for global procedure only codes equals the sum of the total RVUs for the professional and techni cal components only codes combined.  5 = Incident to codes: This indicator identifies codes that describe services covered incident to a physicians service when they are provided by auxiliary personnel employed by the physician and working under his or her direct supervision.  Payment may not be made by A/B MACs (B) for these services when they are provided to hospital inpatients or patients in a hospital outpatient department.  Modifiers 26 and TC cannot be used with these codes.  FIELD # & ITEM  LENGTH & PIC  6 = Laboratory physician interpretation codes: This indicator identifies clinical laboratory codes for which separate payment for interpretations by laboratory physicians may be made.  Actual performance of the tests is paid for under the lab fee schedule.   Modifier TC cannot be used with these codes.  The total RVUs for laboratory physician interpretation codes include values for physician work, practice expense and malpractice expense.  7 = Private practice therapists service:  Payment may not be made if the service is provided to either a hospital outpatient or a hospital inpatient by a physical therapist, occupational therapist, or speech -language pathologist in private practice.  8 = Physician interpretation codes: This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient.  This applies only to code 85060.  No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the PPS rate. No payment is recognized for code 85060 furnished to hospital outpatients or non- hospital patients.  The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test.  9 = Concept of a professional/technical component does not apply. 21 Multiple Procedure (Modifier 51)  Indicator indicates which payment adjustment rule for multiple procedures applies to the service.  0 = No payment adjustment rules for multiple procedures apply.  If procedure is reported on the same day as another procedure, base payment on the lower of: (a) the
(Medicare Claims Processing Manual)
51)  Indicator indicates which payment adjustment rule for multiple procedures applies to the service.  0 = No payment adjustment rules for multiple procedures apply.  If procedure is reported on the same day as another procedure, base payment on the lower of: (a) the actual charge or (b) the fee schedule amount for the procedure. 1 = Standard payment adjustment rules in effect before January 1, 1996, for multiple procedures apply.  In the 1996 MPFSDB, this indicator only applies to codes with procedure status of D. If a procedure is reported on the same day as another procedure w ith an indicator of 1,2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 25 percent, 25 percent, 25 percent, and by report).  Base payment on the lower of: (a) the actual charge or  (b) the fee schedule amount reduced by the appropriate percentage.  2 = Standard payment adjustment rules for multiple procedures apply.  If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee 1 Pic (x)1  FIELD # & ITEM  LENGTH & PIC  schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report).  Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate pe rcentage.  3 = Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure).  The base procedure for each code with this indicator is identified in f ield 31G. Apply the multiple endoscopy rules to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non- endoscopic procedure).  If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure.  Payment for the base procedure is included in the payment for the other endoscopy.  4 = Subject to 25% reduction of the TC diagnostic imaging (effective for services January 1, 2006 through June 30, 2010).
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for the base procedure.  Payment for the base procedure is included in the payment for the other endoscopy.  4 = Subject to 25% reduction of the TC diagnostic imaging (effective for services January 1, 2006 through June 30, 2010). Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1, 2010 and after). Subject to 25% reduction of the  PC of diagnostic imaging (effective for services January 1, 2012 through December 31, 2016).  Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2017 and after).  5 = Subject to 20% reduction of the practice expense component for certain therapy services furnished in office and other non-institutional settings, and 25% reduction of the practice expense component for certain therapy services furnished in institutiona l settings (effective for services January 1, 2011 and after). Subject to 50% reduction of the practice expense component for certain therapy services furnished in both institutional and non- institutional settings (effective for services April 1, 2013 and after).  6 = Subject to 25% reduction of the TC diagnostic cardiovascular services (effective for services January 1, 2013 and after).  7 = Subject to 20% reduction of the TC diagnostic ophthalmology services (effective for services January 1, 2013 and after).  9 = Concept does not apply. 22 Bilateral Surgery Indicator (Modifier 50)  This field provides an indicator for services subject to a payment adjustment.  0 = 150 percent payment adjustment for bilateral procedures does not apply.  If procedure is reported with modifier -50 or with 1 Pic (x)1  FIELD # & ITEM  LENGTH & PIC  modifiers RT and LT, base payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code.  Example: The fee schedule amount for code XXXXX is $125.  The physician report s code XXXXX- LT with an actual charge of $100 and XXXXX -RT with an actual charge of $100.  Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).  The bilateral adjustment is inappropriate for codes in this category because of (a) physiology or anatomy or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for
(Medicare Claims Processing Manual)
The bilateral adjustment is inappropriate for codes in this category because of (a) physiology or anatomy or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.  1 = 150 percent payment adjustment for bilateral procedures applies.  If code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150 percent of the fee schedule amount for a single code.  If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any applicable multiple procedure rules. 2 = 150 percent payment adjustment for bilateral procedure does not apply.  RVUs are already based on the procedure being performed as a bilateral procedure.  If procedure is reported with modifier - 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers with a 2 in the units field), base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code.  Example: The fee schedule amount for code YYYYY is $125.  The physician reports code YYYYY -LT with an actual charge of $100 and YYYYY- RT with an actual charge of $100.  Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The RVUs are based on a bilateral procedure because: (a) the code descriptor specifically states that the procedure is bilateral; (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally; or (c) the procedure is  usually performed as a bilateral procedure.  3 = The usual payment adjustment for bilateral procedures does not apply.  If procedure is reported with modifier - 50 or is reported for both sides on the same day by any other means (e.g., with RT and FIELD # & ITEM  LENGTH & PIC  LT modifiers or with a 2 in the units field), base
(Medicare Claims Processing Manual)
reported with modifier - 50 or is reported for both sides on the same day by any other means (e.g., with RT and FIELD # & ITEM  LENGTH & PIC  LT modifiers or with a 2 in the units field), base payment for each side or organ or site of a paired organ on the lower of: (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side.  If procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any applicable multiple procedure rules.  Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.  9 = Concept does not apply. 23 Assistant at Surgery  This field provides an indicator for services where an assistant at surgery is never paid for per IOM.  0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.  1 = Statutory payment restriction for assistants at surgery applies to this procedure.  Assistant at surgery may not be paid. 2 = Payment restriction for assistants at surgery does not apply to this procedure.  Assistant at surgery may be paid.  9 = Concept does not apply. 1 Pic (x)1  24 Co-Surgeons (Modifier 62)  This field provides an indicator for services for which two surgeons, each in a different specialty, may be paid.  0 = Co -surgeons not permitted for this procedure.  1 = Co -surgeons could be paid; supporting documentation required to establish medical necessity of two surgeons for the procedure.  2 = Co -surgeons permitted; no documentation required if two specialty requirements are met.  9 = Concept does not apply. 1 Pic (x)1  25 Team Surgeons (Modifier 66)  This field provides an indicator for services for which team surgeons may be paid.  0 = Team surgeons not permitted for this procedure.  1 = Team surgeons could be paid; supporting documentation required to establish medical necessity of a team; pay by report.  1 Pic (x)1  FIELD # & ITEM  LENGTH & PIC  2 = Team surgeons permitted; pay by report.  9 = Concept does not apply. 26 Filler  1 Pic (x)1  27 Site of Service Differential  For 1999 and beyond, the site of service differential no longer applies.  The following definitions will apply for all years after 1998:  0 = Facility pricing does not apply. 1 = Facility pricing applies.  9 = Concept
(Medicare Claims Processing Manual)
27 Site of Service Differential  For 1999 and beyond, the site of service differential no longer applies.  The following definitions will apply for all years after 1998:  0 = Facility pricing does not apply. 1 = Facility pricing applies.  9 = Concept does not apply. 1 Pic (x)1  28 Non-Facility Fee Schedule Amount  This field shows the fee schedule amount for the non- facility setting.  This amount equals Field 34. Note :  Field 33 D indicates if an additional adjustment should be applied to this formula. Non-Facility Pricing Amount for the File Year  [(Work RVU * Work GPCI) +  ( Non -Facility PE RVU * PE GPCI) +  (MP RVU * MP GPCI)] * Conversion Factor  9 Pic 9(7)v99 29 Facility Fee Schedule Amount  This field shows the fee schedule amount for the facility setting.  This amount equals Field 35. Note:  Field 33D indicates if an additional adjustment should be applied to this formula. Facility Pricing Amount for the File Year  [(Work RVU * Work GPCI) +  ( Facility PE RVU * PE GPCI) +  (MP RVU * MP GPCI)] * Conversion Factor  Place of service codes to be used to identify facilities.  02  Telehealth -Medicare pays telehealth services at the facility rate.  19  Off Campus -Outpatient Hospital  21 - Inpatient Hospital  22  On Campus -Outpatient Hospital 9 Pic 9(7)v99 FIELD # & ITEM  LENGTH & PIC  23 - Emergency Room - Hospital  24 - Ambulatory Surgical Center  In a Medicare approved ASC, for an approved procedure on the ASC list, Medicare pays the lower facility fee to physicians.   Beginning with dates of service January 1, 2008, in a Medicare approved ASC, for procedures NOT on the ASC list of approved procedures, contractors will also pay the lower facility fee to physicians.  26 - Military Treatment Facility  31 - Skilled Nursing Facility  34 - Hospice  41 - Ambulance - Land  42 - Ambulance Air or Water  51 - Inpatient Psychiatric Facility  52 - Psychiatric Facility Partial Hospitalization  53 - Community Mental Health Center  56 - Psychiatric Residential Treatment Facility  61 - Comprehensive Inpatient Rehabilitation Facility  29A Anti-markup Test Indicator  This field providers an indicator for Anti -markup Test HCPCS codes:  1 = Anti -markup Test HCPCS.  9 = Concept does not apply. 1 Pic x  30 Record Effective Date  This field identifies the effective date
(Medicare Claims Processing Manual)
field providers an indicator for Anti -markup Test HCPCS codes:  1 = Anti -markup Test HCPCS.  9 = Concept does not apply. 1 Pic x  30 Record Effective Date  This field identifies the effective date for the MPFSDB record for each HCPCS.  The field is in YYYYMMDD format.
(Medicare Claims Processing Manual)
NOTE:  This is not the date the HCPCS code was created.  It is the date the code was updated or added to the MPFSDB file for the current file year.  This field is set to January 1 for all codes during the annual update process. 8 Pic x(8)  31  Filler  28 Pic x(28)  31EE  Reduced therapy fee schedule amount  9Pic(7)v99 31DD  Filler  1Pic x(2)  FIELD # & ITEM  LENGTH & PIC  31CC  Imaging Cap Indicator  A value of 1 means subject to OPPS payment cap determination.  A value of 9 means not subject to OPPS payment cap determination.  1Pic x(1)  31BB  Non-Facility Imaging Payment Amount  9Pic(7)v99 31AA  Facility Imaging Payment Amount  9Pic(7)v99 31A Physician Supervision of Diagnostic Procedures  This field is for use in post payment review.  01 = Procedure must be performed under the general supervision of a physician.  02 = Procedure must be performed under the direct supervision of a physician. 03 = Procedure must be performed under the personal supervision of a physician.   (Diagnostic imaging procedures performed by a Registered Radiologist Assistant (RRA) who is certified and registered by The American Registry of Radiologic Technologists (ARRT) or a Radiology Practitioner Assistant (RPA) who is certified by the Certification Board for Radiology Practitioner Assistants (CBRPA), and is authorized to furnish the procedure under state law, may be performed under direct supervision.)
(Medicare Claims Processing Manual)
04 = Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist; otherwise must be performed under the general supervision of a physician. 05 = Not subject to supervision when furnished personally by a qualified audiologist, physician or non physician practitioner.  Direct supervision by a physician is required for those parts of the test that may be furnished by a qualified technician when a ppropriate to the circumstances of the test.  06 = Procedure must be personally performed by a physician or a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiological clinical specialist and is permitted to provide 2 Pic x(2)  FIELD # & ITEM  LENGTH & PIC  the procedure under State law.  Procedure may also be performed by a PT with ABPTS certification without physician supervision. 21 = Procedure may be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician.  Procedure may also be performed by a PT with ABPTS certification without phys ician supervision. 22 = May be performed by a technician with on- line real -time contact with physician.  66 = May be personally performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.  6A = Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.  77 = Procedure must be performed by a PT with ABPTS certification (TC & PC) or by a PT without certification under direct supervision of a physician (TC & PC), or by a technician with certification under general supervision of a physician (TC only; PC always physician).  7A = Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may personally supervise another PT, but only the PT with ABPTS certification may bill.  09 = Concept does not apply. 31B This field has been deleted to allow for the expansion of field 31A.   31C Facility Setting Practice Expense Relative Value Units  9 Pic(7)v99 31D Non-Facility Setting Practice Expense Relative Value Units  9 Pic(7)v99 31E Filler  9 Pic(7)v99 31F Filler  Reserved for future use.  1 Pic x(1)  31G Endoscopic Base Codes  This field identifies an endoscopic base code for each code with
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31E Filler  9 Pic(7)v99 31F Filler  Reserved for future use.  1 Pic x(1)  31G Endoscopic Base Codes  This field identifies an endoscopic base code for each code with a multiple surgery indicator of 3.  5 Pic x(5)  FIELD # & ITEM  LENGTH & PIC  32A 1996 Transition/Fee Schedule Amount  This field is no longer applicable since transitioning ended in 1996.  This field will contain a zero.  9 Pic 9(7)v99 32B 1996 Transition/Fee Schedule  This field is no longer applicable since transitioning ended in 1996.  This field will contain spaces.  1 Pic x(1)  32C 1996 Transition/Fee Schedule Amount When Site or Service Differential Applies  This field is no longer applicable since transitioning ended in 1996.  This field will contain a zero.  9 Pic 9(7)v99 33A Units Payment Rule Indicator  Reserved for future use.  9 = Concept does not apply. 1 Pic x(1)  33B Mapping Indicator  This field is no longer applicable since transitioning ended in 1996.  This field will contain spaces.  1 Pic x(1)  33C Anti-markup Locality Informational Use Locality used for reporting utilization of anti -markup services. NOT FOR A/B MAC (B) USE: These Medicare Advantage encounter pricing localities are for Shared System Maintainer purposes only.  The locality values were developed to facilitate centralized processing of encounter data by the Medicare Advantage organizations.  2 Pic x(2)  33D Calculation Flag  This field is informational only; the SSMs do not need to add this  field.  The intent is to assist A/B MACs (B) to understand how the fee schedule amount in fields 28 and 29 are calculated. The MMA mandates an additional adjustment to selected HCPCS codes.  A value of 1 indicates an additional fee schedule adjustment of 1.32 in 2004 and 1.03 in 2005.  A value of 0 indicates no additional adjustment needed.  A value of 2 indicates an additional fee schedule adjustment of 1.05 effective 7/1/2008. 1 Pic x(1)  FIELD # & ITEM  LENGTH & PIC  33 E Diagnostic Imaging Family Indicator  For services effective January 1, 2011, and after, family indicators 01 - 11 will not be populated.  01 = Family 1 Ultrasound (Chest/Abdomen/Pelvis  Non Obstetrical  02 = Family 2 CT and CTA
(Medicare Claims Processing Manual)
Imaging Family Indicator  For services effective January 1, 2011, and after, family indicators 01 - 11 will not be populated.  01 = Family 1 Ultrasound (Chest/Abdomen/Pelvis  Non Obstetrical  02 = Family 2 CT and CTA (Chest/Thorax/Abd/Pelvis)  03 = Family 3 CT and CTA (Head/Brain/Orbit/Maxillofacial/Neck)  04  = Family 4 MRI and MRA (Chest/Abd/Pelvis)  05 = Family 5 MRI and MRA (Head/Brain/Neck)  06 = Family 6 MRI and MRA (spine)  07 = Family 7 CT (spine)  08 = Family 8 MRI and MRA (lower extremities)  09 = Family 9 CT and CTA (lower extremities)  10 = Family 10 Mr and MRI (upper extremities and joints)  11 = Family 11 CT and CTA (upper extremities)  88 = Subject to the reduction of the TC diagnostic imaging (effective for services January 1, 2011, and after). Subject to the reduction of the PC diagnostic imaging (effective for services January 1, 2012 and after).  99 = Concept Does Not Apply 2Pic x(2)  33F Performance Payment Indicator  (For future use)  1 Pic x (1)  33G National Level Future Expansion 3 Pic x (3)  34 Non-Facility Fee Schedule Amount  This field replicates field 28.  9 Pic 9(7)v99 35 Facility Fee Schedule Amount  This field replicates field 29.  9 Pic 9(7)v99 36 Filler  1 Pic x(1)  37 7 Pic x(7)  FIELD # & ITEM  LENGTH & PIC  Future Local Level Expansion**  The Updated 1992 Transition Amount was previously stored in this field.  A/B MACs (B) can continue to maintain the updated transition amount in this field.  38A Future Local Level Expansion** The adjusted historical payment basis (AHPB) was previously stored in this field.  A/B MACs (B) can continue to maintain the AHPB in this field.  7 Pic x(7)