evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
All PTP edits have a Correct Coding Modifier Indicator (CCMI).  A denial of services due to a Procedure -to-Procedure (PTP) edit is a coding denial, not a medical necessity denial. The presence of an Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for Units of Service (UOS) denied based on a PTP. PTP edits with a CCMI of 0:  On appeal, if the CCMI is a 0, and the provider or supplier coded the claim correctly, there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider or supplier. If t he reviewer determines that the claim was coded incorrectly then, the review determination must repeat the generic language that appears in the MSN or remittance advice notice pertaining to the National Correct Coding Initiative (NCCI) edit. In addition, M edicare Administrative Contractors (MACs) must include the more detailed explanation of the NCCI edit, which can be found in the standard correspondence language for MACs in the Correspondence Language Manual for Medicare Services.  PTP edits with a CCMI of 1:  On appeal, if the correct coding initiative edit modifier indicator is a 1, the reviewer must determine whether the claim was coded correctly. For example, the reviewer should determine whether the provider or supplier reported an incorrect code, a medic ally unnecessary service, or simply neglected to use a modifier. The reviewer may change the initial determination only if the correct coding initiative edit has a modifier indicator of 1 and the reviewer determines that an NCCI -associated modifier could  have been appended to either code of a correctly coded edit code pair. If the reviewer determines that the claim was coded incorrectly then, the review determination must repeat the generic language that appears in the Medicare Summary Notice (MSN) or rem ittance advice notice pertaining to the NCCI edit. In addition, MACs must include the more detailed explanation of the NCCI edit, which can be found in the standard correspondence language for MACs in the Correspondence Language Manual for Medicare Services.  20.9.3.2- Medically Unlikely Edits  (MUEs)  (Rev.  10878, Issued: 07 -15-2021, Effective:08 -16-2021;
(Medicare Claims Processing Manual)
in the Correspondence Language Manual for Medicare Services.  20.9.3.2- Medically Unlikely Edits  (MUEs)  (Rev.  10878, Issued: 07 -15-2021, Effective:08 -16-2021; Implementation:08 -16-2021)
(Medicare Claims Processing Manual)
All Healthcare Common Procedure Coding System (HCPCS) codes with Medically Unlikely Edit (MUE) values have an MUE adjudication indicator (MAI).  MUEs for HCPCS codes with an MAI of 1:  MUEs for HCPCS codes with an MAI of 1 will be adjudicated as a claim line edit.  MUEs for HCPCS codes with an MAI of 2:  MUEs for HCPCS codes with an MAI of 2: MUEs for HCPCS codes with an MAI of 2 are absolute date of service edits. These are per day edits based on policy.   HCPCS codes with an MAI of 2 have been rigorously reviewed and vetted within CMS and obtain t his MAI designation because units of service (UOS) on the same date of service in excess of the MUE value would be considered contrary to statute, regulation, or subregulatory guidance. Subregulatory guidance includes clear correct coding policy that is bi nding on both providers or suppliers and the Medicare Administrative Contractors (MACs). As stated in CR 8853, while Qualified Independent Contractors (QICs) are not bound by subregulatory guidance, they should understand the policy nature of the MAI 2 i ndicator when considering whether to pay UOS in excess of the MUE value if claim denials based on these edits are appealed.
(Medicare Claims Processing Manual)
Limitations created by anatomical or coding restrictions are incorporated in correct coding policy, both in the Health Insurance Portability & Accountability Act of 1996 (HIPAA) mandated coding descriptors and CMS approved coding guidance as well as specif ic guidance in the CMS and National Correct Coding Initiative (NCCI) Policy manuals. For example, it would be contrary to correct coding policy to report more than 1 unit of service for "ventilation assist and management . . . initial day" because such usa ge could not accurately describe 2 initial days of management occurring on the same date of service as would be required by the code descriptor.  The CMS establishes edits with an MAI of 2 based directly on regulation, statute or subregulatory guidance.  MUEs for HCPCS codes with an MAI of 3:  MUEs for HCPCS codes with an MAI of 3 are date of service edits. These are per day edits based on clinical benchmarks. If claim denials based on these edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of medical necessity of correctly reported units. If MACs have pre -payment evidence (e.g. medical revie w) that UOS in excess of the MUE value were actually provided, were correctly coded, and were medically necessary, the MACs may bypass the MUE for a HCPCS code with an MAI of 3 during claim processing, reopening, or redetermination, or in response to eff ectuation instructions from a reconsideration or higher level appeal.  General Instructions on MUEs:   MUEs are set high enough to allow for medically likely daily frequencies of services provided in most settings. Because MUEs are based on current coding instructions and practices, MUEs are prospective edits applicable to the time period for which the edit  is effective. A change in an MUE is not retroactive and has no bearing on prior services unless specifically updated with a retroactive effective date. In the unusual case of a retroactive MUE change, MACs are not expected to identify claims but should re open impacted claims that providers or suppliers bring to their attention.
(Medicare Claims Processing Manual)
 Since MUEs are auto -deny edits, denials may be appealed. Appeals shall be submitted to the appropriate MAC not the NCCI contractor. MACs adjudicating an appeal for a claim denial for a HCPCS code with an MAI of 1 or 3 may pay correctly coded correctly counted medically necessary UOS in excess of the MUE value.    A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of an Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for UOS denied based on an MUE. If during reopening or redetermination medical records are provided with respect to an MUE denial for an edit with an MAI of 3, MACs will review the records to determine if the provider or supplier actually furnished units in excess of the MUE, if the codes were used correctly, and whether the  services were medically reasonable and necessary. If the units were actually provided but one of the other conditions is not met, a change in denial reason may be warranted (for example, a change from the MUE denial based on incorrect coding to a determin ation that the item/service is not reasonable and necessary under section 1862(a)(1)). This may also be true for certain edits with an MAI of 1. The CMS interprets the notice delivery requirements under Section1879 of the Social Security Act (the Act) as  applying to situations in which a provider or supplier expects the initial claim determination to be a reasonable and necessary denial. Consistent with NCCI program guidance, denials resulting from MUEs are not based on any of the statutory provisions tha t give liability protection to beneficiaries under section 1879 of the Social Security Act. Thus, ABN issuance based on an MUE is NOT appropriate. A provider or supplier may not issue an ABN in connection with services denied due to an MUE and cannot bill the beneficiary for UOS denied based on an MUE.
(Medicare Claims Processing Manual)
 If a procedure is performed bilaterally and the HCPCS code descriptor does not state that it is a unilateral or bilateral procedure, report bilateral surgical procedures on a single claim line with modifier 50 and one (1) unit of service. For specific inst ructions for Ambulatory Surgical Centers, refer to Chapter 14, Section 40.5 of the "Medicare Claims Processing Manual" on the CMS website at: Regulations -and-Guidance.Ch14  When modifier - 50 is required by manual or coding instructions, claims submitted with 2 lines or 2 units and anatomic modifiers will be denied for incorrect coding. MACs may reopen or allow resubmission of those claims in accordance with their policies and with the policy in Chapter 34, Section 10.1, of the "Medicare Claims Processing Manual" on the CMS website at: Regulations -and-Guidance.Ch34    Clerical errors (which include minor errors and omissions) may be treated as reopenings.    Providers or suppliers may change and resubmit their own claims where possible but during reopening MACs may, when necessary, correct the claim to modifier - 50 from an equivalent 2 units of bilateral anatomic modifiers. The original submitted version of the claim is retained in the Medicare IDR (Integrated Data Repository).    Providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1- F9, TA, T1-T9, E1 -E4) and report procedures with differing modifiers on individual claim lines when appropriate. Many MUEs are based on the assumption that correct modifiers are used.   A/B MACs shall include with the review determination the more detailed explanation of the correct coding initiative edit, which can be found in the standard correspondence language for A/B MACs in the Correspondence Language Manual for Medicare Services .   MACs shall  assign MSN 15.6. CARC 151 with Group Code CO  for claims that fail the MUE edits, when the UOS on the claim exceeds the MUE value, and deny the entire claim line(s) for the relevant Healthcare Common Procedure Coding System  (HCPCS) code.
(Medicare Claims Processing Manual)
 MACs shall assign CARC 236 with Group Code CO and MSN 16.8 for claims that fail the PTP edits, and deny when this procedure or procedure/modifier combination is not compatible with another procedure or procedure/modifier combination provided on the same day according to the NCCI program or workers compensation state regulations/ fee schedule requirements.   20.9.4 Reserved for future use  (Rev. 4465; Issued: 11- 15-19, Effective: 01 -30-19, Implementation: 01- 30-19)  20.9.4.1 Reserved for future use  (Rev. 4465; Issued: 11- 15-19, Effective: 01 -30-19, Implementation: 01- 30-19)  20.9.5 - Adjustments  (Rev. 1, 10- 01-03)  A/B MACs (B) adjust for underpayment if the wrong, lower paying code is paid on the first of multiple claims submitted.  If the wrong, higher paying code is paid on the first of multiple claims submitted, A/B MACs (B) pay the subsequent claim(s) and initiate recovery action on the previously paid claim(s).   20.9.6 - Correct Coding Edit (CCE) File Record Format  (Rev. 10233; Issued: 07- 24-20, Effective: 06 -16-20, Implementation: 06- 16-20)  The following record layout for the Correct Coding Edit (CCE) File is available to the Shared Systems, A/B MACs (B), and the Regional Offices via Network Data Mover and CMS Data Center.   A/B MAC (B)/Shared Systems Record Format
(Medicare Claims Processing Manual)
A/B MAC (B)/Shared Systems Record Format   Field  Type  Record Position  Length  Comprehensive Column 1 Code or  Mutually Exclusive Column 1 Code  Character  1 5 Component Column 2 Code or  Mutually Exclusive Column 2 Code  Character  6 5 Prior Rebundled Code Indicator  * rebundled prior to 1996 edits   rebundled 1/1/1996 or later  Character  11 1 Correspondence Language Reference  Character  12 12 Effective Date (4 position year followed by Julian day)  Numeric  24 7 Deletion Date (4 position year followed by Julian day)  Numeric  31 7 Modifier Indicators  0 No CCE modifier allowed  1 CCE modifier acceptable  9 Use of CCE modifier not specified  Numeric  38 1 Savings Type Indicator Edit  1 CCE  2 Mutually Exclusive  Character  39 1  20.9.7 - National  Correct Coding Initiative (NCCI) Edits Quarterly Updates  (Rev.  10878, Issued: 07- 15-2021, Effective:08 -16-2021; Implementation:08- 16-2021)           Medicare Administrative Contractors (MACs) receive quarterly updates to National Correct Coding Initiative (NCCI) edits, indicating the version and the effective date, through a recurring update notification. At this time, the official method for providers or suppliers to receive the National Correct Coding Initiative (NCCI) edits is through the CMS website.   30 - Services Paid Under the Medicare Physicians Fee Schedule  (Rev. 1717, Issued: 04- 24-09, Effective: 07 -01-09, Implementation: 07- 06-09)  Following is a general description of services paid under the Medicare Physicians Fee Schedule (MPFS).   A. Physicians Services   Effective with services furnished on or after January 1, 1992, A/B MACs (B) pay for physicians services based on the MPFS.  The Medicare allowed charge for such physicians services is the lower of the actual charge or the fee schedule amount.  The Medicare payment is 80 percent of the allowed charge after the deductible is met for most services paid based on the fee schedule.  Exceptions to the rule, e.g., services for which deductible is not applicable, are specifically identified for the service where t he exception applies.   The Physicians Fee Schedule is used when paying for the following physicians services.
(Medicare Claims Processing Manual)
The Physicians Fee Schedule is used when paying for the following physicians services.    Professional services (including attending physicians services furnished in teaching settings) of doctors of medicine and osteopathy (including osteopathic practitioners), doctors of optometry, doctors of podiatry, doctors of dental surgery and dental med icine, and chiropractors;    Services covered incident to physicians services other than certain drugs covered as incident to services;    Physical and occupational therapy, and speech- language pathology services furnished by physical therapists, occupational therapists, and speech -language pathologists in private practices;    Diagnostic tests other than clinical laboratory tests.  See chapter 16 for payment for clinical diagnostic laboratory tests;   Radiology services; and    Monthly capitation payment (MCP) for physicians services associated with the continuing medical management of end stage renal disease (ESRD) services.   The fee schedule is not used to pay for direct medical and surgical services of teaching physicians in hospitals that have elected cost payment under 1861(b)(7)  of the Act.   When processing a claim, A/B MACs (B) continue to determine if a service is reasonable and necessary to treat illness or injury.  If a service is not reasonable and necessary to treat illness or injury for any reason (including lack of safety and efficacy because it is an experimental procedure, etc.), A/B MACs (B) consider the service noncovered notwithstanding the presence of a payment amount for the service in the Medicare fee schedule.  The presence of a payment amount in the MPFS and the Medicare physi cian fee schedule database (MPFSDB) does not imply that CMS has determined that the service may be covered by Medicare.  The nature of the status indicator in the database does not control coverage except where the status is N for noncovered.   A/B MACs (B) pay the above -mentioned physician services according to the physician fee schedule when billed by the following entities:    A physician or physician group including optometrists, dentists, oral and maxillofacial surgeons, podiatrists, and chiropractors;    A privately practicing physical therapist, (for outpatient physical therapy services);    A privately practicing speech -language pathologist (for outpatient speech- language services);    A privately practicing occupational therapist (for outpatient occupational therapy services);
(Medicare Claims Processing Manual)
 A privately practicing physical therapist, (for outpatient physical therapy services);    A privately practicing speech -language pathologist (for outpatient speech- language services);    A privately practicing occupational therapist (for outpatient occupational therapy services);    A nonphysician practitioner including a nurse practitioner, a physician assistant, and a clinical nurse specialist beginning January 1, 1998, with respect to services these practitioners are authorized to furnish under state law: payment is equal to 85 percent of the participating physician fee schedule amount for the same service;    A nurse midwife:  payment is equal to 65 percent of the participating physician fee schedule amount for the same service;    A registered dietitian  or nutrition professional, for medical nutrition therapy services provided as of January 1, 2002: payment is equal to 85 percent of the participating physician fee schedule amount for the same service ;   An audiologist, for services rendered to beneficiaries not in a skilled nursing facility (SNF) Part A covered stay;    A clinical psychologist who renders services in community mental health centers (CMHCs) on or after July 1, 1988, and in all settings on or after July 1, 1990;    A clinical social worker: The fee schedule for CSW services is set at 75 percent of the fee schedule for comparable services furnished by clinical psychologists;    Another entity that furnishes outpatient physical therapy, occupational therapy, and speech - language pathology services.  This could be a rehabilitation agency, a public health agency, a clinic, a skilled nursing facility, a home health agency (for benefi ciaries who are not eligible for home health benefits because they are not home bound beneficiaries entitled to home health benefits), hospitals (when such services are provided to an outpatient or to a hospital inpatient who is entitled to benefits under Part A but who has exhausted benefits during a spell of illness, or who is not entitled to Part A benefits) and comprehensive outpatient rehabilitation facilities (CORFs).  The fee schedule also applies to outpatient rehabilitation services furnished under  an arrangement with any of the enumerated entities that are to be paid on the basis of the physician fee schedule;    The supplier of the technical component of any radiology or diagnostic service;    An independent laboratory doing anatomic pathology services; and    Services billed by entities authorized to bill for physicians, suppliers, etc.  under the reassignment rules.   B. Hospice Services
(Medicare Claims Processing Manual)
 An independent laboratory doing anatomic pathology services; and    Services billed by entities authorized to bill for physicians, suppliers, etc.  under the reassignment rules.   B. Hospice Services   The Physicians Fee Schedule is used when paying for hospice physicians services by the A/B MAC (HHH).  Regular hospice services are paid under the hospice rate schedule (see chapter 11.)   C. Outpatient Rehabilitation Services   Effective with services furnished on or after January 1, 1999, A/B MACs (A) pay for outpatient rehabilitation services based on the MPFS.  Services included are physical therapy, speech- language pathology, occupational therapy, and certain audiology and CORF services.   Effective with services furnished on or after July 1, 2000, A/B MACs (A)  pay for all CORF services under the MPFS.  Effective with claims with dates of service on or after July 1, 2003, OPTs/Outpatient Rehabilitation Facilities (ORFs), (74X bill type) are required to report all their services utilizing HCPCS.  A/B MACs (A) are required to make payment for these services under the MPFS unless the item or service is currently being paid under the orthotic fee schedule or the item is a drug, biological, supply or vaccine.  The MPFS applies when these services are furnished by rehabilitation agencies, (outpatient physical therapy providers and CORFs), hospitals (to outpatients and inpatients who are not in a covered Part A stay), SNFs (to residents not in a covered Part A stay and to nonresidents who receive outpatient rehabilitation services from the SNF), and HHAs (to individuals who are not homebound or otherwise are not receiving services under a home health plan of treatment).  The MPFS is used as a method of payment for outpatient rehabilitation services furnished under arrangement with any of these providers.  The MPFS allowed charge for these services is the lower of the actual charge or the fee schedule amount.  The Medicare payment for the services is 80 percent of the allowed charge after the Part B deductible is met.  This is a final payment.  The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs).  CAHs are paid on a reasonable cost basis.   Application of the Outpatient Mental Health Treatment Limitation (A/B MACs (A))
(Medicare Claims Processing Manual)
Application of the Outpatient Mental Health Treatment Limitation (A/B MACs (A))   In accordance with 1833 of the Act, payment is made at 62 percent of the approved amount for outpatient mental health treatment services.  This provision will continue to be implemented in accordance with the Act when these services are furnished to beneficiaries by CORFs.  The refore, make payment at 62 percent of 80 percent of the approved amount (or in effect 50 percent) for outpatient mental health treatment services.   D. SNF Services   Effective with services furnished on or after April 1, 2001, A/B MACs (A)  pay for Part B services furnished to SNF Part B inpatients and outpatients (22X and 23X types of bill) under the MPFS and other applicable fee schedules.  Thus, where a fee schedule exists for the type of service, the fee amount (or charge if less than the applicable fee amount) is paid.  Fee schedules made effective for SNF on this date include: Therapy, Lab, and DMEPOS.  Effective for services furnished by a SNF on and after January 1, 2002, A/B MACs (A)  pay SNFs for radiology, other diagnostic, and other services under the MPFS.  Payment is the lower of billed charges or the fee schedule amount.  In either case, any applicable deductible and coinsurance amounts are subtracted from the payment amount prior to payment.  Coinsurance is calculated on the Medicare payment amount after the subtraction of any applicable deductible amount.  If there is no fee schedule for the service or item being billed, A/B MACs (A) and (HHH) are to make payment based on cost.  Consequently, all services billed under Part B are to be billed using HCPCS codes, whether the beneficiary resides in a certified b ed or a noncertified bed.   30.1 - Maintenance Process for the Medicare Physician Fee Schedule Database (MPFSDB)  (Rev. 1, 10- 01-03)