evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
20.1 - General  (Rev. 1657, Issued: 12- 31-08, Effective: 01 -01-09, Implementation: 01- 05-09)  Reporting of HCPCS codes is required of acute care hospitals including those paid under alternate payment systems, e.g., Maryland, long- term care hospitals.  HCPCS codes are also required of rehabilitation hospitals, psychiatric hospitals, hospital -based RHCs, hospital -based FQHCs, and CAHs reimbursed under Method II (HCPCS required to be billed for fee reimbursed serv ices).  This also includes all -inclusive rate hospitals.  HCPCS includes the American Medical Associations Current Procedural Terminology, 4th Edition, (CPT -4) for physician services and CMS developed codes for certain nonphysician services.  All of the CPT -4 is contained within HCPCS, and is identified as Lev el I CPT codes consist of five numeric characters.  The CMS developed codes are known as Level II.  Level II codes are five- character codes that begin with an alpha character that is followed by either numeric or alpha characters.   Hospital -based and independent ESRD facilities must use HCPCS to bill for blood and blood products, and to bill for drugs and clinical laboratory services paid outside the composite rate.  In addition, the hospital is required to report modifiers as applic able and as described in 20.6.   The CAHs are required to report HCPCS only for Part B services not paid to them on a reasonable cost basis, e.g., screening mammographies and bone mass measurements.   The HCPCS codes are required for all outpatient hospital services unless specifically excepted in manual instructions.  This means that codes are required on surgery, radiology, other diagnostic procedures, clinical diagnostic laboratory, durable medical equipment, orthotic -prosthetic devices, take- home surgical dressings, therapies, preventative services, immunosuppressive drugs, other covered drugs, and most other services.
(Medicare Claims Processing Manual)
When medical and surgical supplies (other than prosthetic and orthotic devices as described in the Medicare Claims Processing Manual, Chapter 20, 10.1) described by HCPCS codes with status indicators other than H or N are provided incident to a physic ian's service by a hospital outpatient department, the HCPCS codes for these items should not be reported because these items represent supplies.  Claims containing charges for medical and surgical supplies used in providing hospital outpatient services ar e submitted to the Medicare contractor providing OPPS payment for the services in which they are used.  The hospital should include charges associated with these medical and surgical supplies on claims so their costs are incorporated in ratesetting, and pa yment for the supplies is packaged into payment for the associated procedures under the OPPS in accordance with 42 CFR 419.2(b)(4).   For example, if the hospital staff in the emergency department initiate the intravenous administration of a drug through an infusion pump described by HCPCS code E0781 (Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient), complete the drug infusion, and discontinue use of the infusion pump before the patient leaves the hospital outpatient department, HCPCS code E0781 should not be reported because the infusion pump was used as a supply and would be paid through OPPS payment for the drug administration service.  The hospital should include the charge associated with the infusion pump on the claim.   In another example, if hospital outpatient staff perform a surgical procedure on a patient in which temporary bladder catheterization is necessary and use a catheter described by HCPCS code A4338 (Indwelling catheter; Foley type, two- way latex with coating  (Teflon, silicone, silicone elastomer, or hydrophilic, etc.), each), the hospital should not report A4338 because the catheter was used as a supply and would be paid through OPPS payment for the surgical procedure.  The hospital should include the charge associated with the urinary catheter on the claim.
(Medicare Claims Processing Manual)
When hospital outpatient staff provide a prosthetic or orthotic device, and the HCPCS code that describes that device includes the fitting, adjustment, or other services necessary for the patients use of the item, the hospital should not bill a visit or procedure HCPCS code to report the charges associated with the fitting, adjustment, or other related services.  Instead, the HCPCS code for the device already includes the fitting, adjustment or other similar services.  For example, if the hospital outpatie nt staff provides the orthotic device described by HCPCS code L1830 (KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment), the hospital should only bill HCPCS code L1830 and should not bill a visit or procedure HCPCS code t o describe the fitting and adjustment.   Claims with required HCPCS coding missing will be returned to the hospital for correction.  Future updates will be issued in a Recurring Update Notification.   20.2 - Applicability of OPPS to Specific HCPCS Codes  (Rev. 1536, Issued:  06- 19-08; Effective:  07 -01-08; Implementation: 07 -07-08)  The CPT codes generally are created to describe and report physician services, but are also used by other providers/suppliers to describe and report services that they provide.  Therefore, the CPT code descriptors do not necessarily reflect the facility co mponent of a service furnished by the hospital.  Some CPT code descriptors include reference to a physician performing a service.  For OPPS purposes, unless indicated otherwise, the usage of the term "physician" does not restrict the reporting of the code or application of related policies to physicians only, but applies to all practitioners, hospitals, providers, or suppliers eligible to bill the relevant CPT codes pursuant to applicable portions of the Social Security Act (SSA) of 1965, the Code of Federa l Regulations (CFR), and Medicare rules.  In cases where there are separate codes for the technical component, professional component, and/or complete procedure, hospitals should report the code that represents the technical component for their facility se rvices.  If there is no separate technical component code for the service, hospitals should report the code that represents the complete procedure.  Tables describing the treatment of HCPCS codes for OPPS are published in the Federal Register annually.
(Medicare Claims Processing Manual)
20.3 - Line Item Dates of Service  (Rev. 1, 10- 03-03)  Where HCPCS is required a line item date of service is also required.  (FL 45 on Form CMS -1450).  The A/B MAC (A) will return claims to hospitals where a line item date of service is not entered for each HCPCS code reported or if the line item dates of service reported are outside of the statement -covers period.  20.4 - Reporting of Service Units  (Rev. 1, 10- 03-03)  The definition of service units (FL 46 on the Form CMS -1450) where HCPCS code reporting is required is the number of times the service or procedure being reported was performed.   EXAMPLES:   If the following codes are performed once on a specific date of service, the entry in the service units field is as follows:  HCPCS Code  Service Units  90849 -  Multiple -family group psychotherapy  Units >  1 HCPCS Code  Service Units  92265 -  Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report  Units >  1 95004 -  Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, specify number of tests.  Units = no.  of tests performed 95861 -  Needle electromyography two extremities with or without related paraspinal areas  Units >  1  6 Units >  83 min.  to < 98 min. 7 Units >  98 min.  to < 113 min. 8 Units >  113 min.  to < 128 min.  The pattern remains the same for treatment times in excess of two hours.  Hospitals should not bill for services performed for less than eight minutes.  The expectation (based on the work values for these codes) is that a providers time for each unit will  average 15 minutes in length.  If hospitals have a practice of billing less than 15 minutes for a unit, their A/B MAC (A) will highlight these situations for review.   The above schedule of times is intended to provide assistance in rounding time into 15-minute increments.  It does not imply that any minute until the eighth should be excluded from the total count as the timing of active treatment counted includes time.
(Medicare Claims Processing Manual)
The above schedule of times is intended to provide assistance in rounding time into 15-minute increments.  It does not imply that any minute until the eighth should be excluded from the total count as the timing of active treatment counted includes time.   The beginning and ending time of the treatment should be recorded in the patients medical record along with the note describing the treatment.  (The total length of the treatment to the minute could be recorded instead.)  If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by the total treatment time.  For example, if 24 minutes of code 97112 and 23 minutes of code 97110 were furnished, then the total treatment time was 47 minutes; so only 3 units can be billed for the treatment.  The correct coding is two units of code 97112 and one unit of code 97110, assigning more units to the service that took more time.   20.5 - Clarification of HCPCS Code to Revenue Code Reporting  (Rev. 1487, Issued: 04- 08-08, Effective: 04 -01-08, Implementation: 04- 07-08)  Generally, CMS does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals assignment of cost vary. Where explicit instructions are not provided, providers should report their charges unde r the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.   20.6 - Use of Modifiers  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)
(Medicare Claims Processing Manual)
20.6 - Use of Modifiers  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  Modifiers are two -digit identifiers that are reported with CPT and HCPCS Level II codes to provide additional information about how an item, procedure, or service is provided, and improve the accuracy of coding. These two -digit modifiers can be alphabetic,  numeric, or a combination of both. The use of modifiers is not limited to certain code sets. Specifically, CPT modifiers may be used with HCPCS Level II codes when appropriate. Similarly, HCPCS Level II modifiers may be used with CPT codes to appropriatel y describe how an item, procedure, or service is provided. Providers may use any applicable modifier where appropriate. For Medicare purposes, modifiers are used either as pricing or informational/tracking indicators.  The Integrated Outpatient Code Editor (I/OCE) accepts all valid CPT and HCPCS Level II modifiers on OPPS claims. As of April 1, 2023, there are approximately 410 active and valid modifiers. Definitions for all valid modifiers may be found in the latest CPT  and HCPCS Level II code references. The complete descriptions for all CPT modifiers can be found in the latest CPT code book. Alternatively, the complete descriptions for the HCPCS Level II modifiers can be found in the latest HCPCS Level II code book, as  well as in the latest HCPCS Level II code file that is available on the CMS HCPCS website, specifically, at https://www.cms.gov/medicare/coding/hcpcsreleasecodesets/hcpcs -quarterly -update. Additional guidance on the use of modifiers can also be found on t he Medicare Administrative Contractors (MAC) websites. Note that, under the OPPS, the use of modifiers applies to services/procedures performed on the same calendar day.   The following subsections provide information on the use of certain modifiers under the hospital OPPS. For information on additional modifiers not described below, refer to your MAC website(s) for guidance.
(Medicare Claims Processing Manual)
The following subsections provide information on the use of certain modifiers under the hospital OPPS. For information on additional modifiers not described below, refer to your MAC website(s) for guidance.  20.6.1 - Where to Report Modifiers on the Hospital Part B Claim  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  Modifiers are reported on the hardcopy Form CMS -1450 with the HCPCS code. See Chapter 25 of this manual for related instructions. For electronic submissions, see  the ASC X12 837 Institutional Claim implementation guide for instructions related to HCPCS modifiers when using the ASC X12 837 institutional claim format. Note there is space for four modifiers on the hardcopy and electronic forms.   HOPDs are reminded that the most specific modifier should be used first. That is, when modifiers E1 through E4, FA through F9, LC, LD, RC, and TA through T9 apply, they should be used before modifiers LT, RT, or 59.   20.6.2 - Use of Modifiers -50, -LT, and -RT (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  50: Bilateral Procedure   Modifier 50 is used to report bilateral procedures that are performed on both sides of the body at the same operative session. Do not report modifiers RT and LT when modifier 50 applies. Do not submit two line items to report a bilateral procedure using modifier 50. Report one line with modifier 50 using one unit of service.   Modifier 50 applies to any bilateral procedure performed on both sides at the same operative session. The bilateral modifier 50 is restricted to operative sessions only. Modifier 50 may not be used:   To report surgical procedures identified by their terminology as bilateral, or  To report surgical procedures identified by their terminology as unilateral or bilateral.   The unit entry to use when modifier 50 is reported is one unit.  20.6.3 - Modifiers -LT and - RT (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)
(Medicare Claims Processing Manual)
LT:  Left side (used to identify procedures performed on the left side of the body)  RT:  Right side (used to identify procedures performed on the right side of the body)   Modifiers LT and RT apply to codes that identify procedures that can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries.   These modifiers should be used whenever a procedure is performed on only one side. Hospitals should report the appropriate RT or LT modifier to identify which of the paired organs was operated upon. Do not report modifiers RT and LT when modifier 50 applies.   20.6.4 - Modifiers 73 and 74 (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  73: Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia 74: Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia   A. General
(Medicare Claims Processing Manual)
73: Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia 74: Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia   A. General   Modifiers 73 and 74 provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for a procedure and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction applies t o both hospital outpatient departments (HOPDs) and to ambulatory surgical centers (ASCs).  Modifier 73 is used by the facility to indicate that a procedure requiring anesthesia was terminated due to extenuating circumstances or to circumstances that threatened the well -being of the patient after the patient had been prepared for the procedure (i ncluding procedural pre -medication when provided), and been taken to the room where the procedure was to be performed, but prior to administration of anesthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthes ia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, or general anesthesia. This modifier code was created so that the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) could be recognized for payment even though the procedure was discontinued.  Modifier 74 is used by the facility to indicate that a procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumsta nces or circumstances that threatened the well -being of the patient.
(Medicare Claims Processing Manual)
This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of anesthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (conscious sedation), deep sedation/analgesia, and general anesthesia. This modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion.  Coinciding with the addition of the modifiers 73 and 74, modifiers 52 and 53 were revised. Modifier 52 is used to indicate partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. Modifier 53 is used to indicate discontinuation of physician services and is not approved for use for outpatient hospital services.   Note that the elective cancellation of a procedure should not be reported.   Modifiers 73 and 74 are only used to indicate discontinued procedures for which anesthesia is planned or provided.  B. Effect on Payment
(Medicare Claims Processing Manual)
Note that the elective cancellation of a procedure should not be reported.   Modifiers 73 and 74 are only used to indicate discontinued procedures for which anesthesia is planned or provided.  B. Effect on Payment   Procedures that are discontinued after the patient has been prepared for the procedure and taken to the procedure room but before anesthesia is provided will be paid at 50 percent of the full OPPS payment amount. Modifier 73 is used for these procedures. A s of January 1, 2016, for device -intensive procedures that append modifier 73, we will reduce the APC payment amount for the discontinued device -intensive procedure by 100 percent of the device offset amount prior to applying the additional payment adjustments that apply when the procedure is discontinued as modified in the CY 2016 OPPS/ASC final rule that was published in the November 13, 2015 Federal Register (80 FR 70424-70426). Beginning January 1, 2017, device -intensive procedures are defined as those procedures requiring the insertion of an implantable device that also have a HCPCS -level device offset greater than 40 percent. From January 1, 2016, through December 31, 2016, device- intensive procedures were defined as those procedures that involve implantable devices that are assigned to a device- intensive APC (defined as those APCs with a device offset greater than 40 percent). Beginning January 1, 2019, device -intensive procedures are defined as procedures that involve the surgical implantation or insertion of an implantable device that is assigned a CPT or HCPCS code (including single -use de vices) and has a device offset amount that exceeds 30 percent of the procedures mean cost.   Procedures that are discontinued, partially reduced, or cancelled after the procedure has been initiated and/or the patient has received anesthesia will be paid at the full OPPS payment amount. Modifier 74 is used for these procedures.   Procedures for which anesthesia is not planned that are discontinued, partially reduced, or cancelled after the patient is prepared and taken to the room where the procedure is to be performed will be paid at 50 percent of the full OPPS payment amount. Modifier 52 is used for these procedures.    20.6.5 - Modifiers 76 and 77 (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)
(Medicare Claims Processing Manual)
76: Repeat procedure or service by same physician or other qualified health care professional  77: Repeat procedure by another physician or other qualified health care professional   Two repeat procedure modifiers are applicable for hospital use:    Modifier 76 is used to indicate that the same physician or qualified health care professional repeated a procedure or service.    Modifier 77 is used to indicate that another physician or qualified health care professional repeated a procedure or service.   Since OPPS claims generally span only one calendar day, modifier 76 and 77 should be used to report procedures or services that are performed in a separate operative session on the same day or separate encounter on the same day.   If there is a question regarding whom the ordering physician/provider was and whether or not the same physician/provider ordered the second procedure, the code selected is based on whether or not the physician/provider performing the procedure is the same. The procedure must be the same procedure. It is listed once and then listed again with the appropriate modifier.   20.6.6 - Modifiers for Radiology Services  (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  52: Reduced services  59: Distinct procedural service  76: Repeat procedure or service by same physician or other qualified health care professional  77: Repeat procedure by another physician or other qualified health care professional  Level II modifiers: use as applicable   Modifiers 52, 59, 76, and 77, and the Level II modifiers apply to radiology services.   When a radiology procedure is reduced, the correct reporting is to code to the extent of the procedure performed. If no HCPCS code exists for the service that has been completed, report the intended HCPCS code with modifier 52 appended.    20.6.7 - Modifier  CA (Rev. 11937; Issued: 03- 31-23; Effective: 04 -01-23; Implementation: 04 -03-23)  CA: Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission