evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
In the other circumstances in which a beneficiary does not have Part A coverage of inpatient services on the date that such a device is implanted (that is, when furnished by a participating hospital to an inpatient who is not entitled to benefits under Par t A, has exhausted his or her Part A benefits, or receives services not covered under Part A), hospitals paid under the OPPS should report HCPCS code, C9899, Implanted Prosthetic Device, Payable Only for Inpatients who do not Have Inpatient Coverage, that is effective for services furnished on or after January 1, 2009.  This code allows an alternative Part B inpatient payment methodology for the device as discussed in this section, and may be reported only on claims with TOB 12X when the prosthetic device i s implanted on a day on which the beneficiary does not have coverage under Part A because he or she is not entitled to Part A benefits, has exhausted his or her Part A benefits, or receives services not covered under Part A.  The line containing this new code will be rejected if it is reported on a claim that is not a TOB 12X or if it is reported with a line item date of service on which the beneficiary has coverage of inpatient hospital services.  By reporting C9899, the hospital is reporting that the item  is eligible for separate OPPS payment because the primary procedure is not a payable Part B inpatient service under Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10.2 (Other Circumstances in Which Payment Cannot Be Made under Part A).
(Medicare Claims Processing Manual)
If C9899 is a separately payable Part B inpatient service, the contractor shall determine the payment amount as follows.  If the device has pass through status under the OPPS, the contractor shall establish the payment amount for the device at the product of the charge for the device and the hospital specific cost to charge ratio.  Where the device does not have pass through status under the OPPS, the contractor shall establish the payment amount for the device at the amount for a comparable device in the D MEPOS fee schedule where there is such an amount.  Payment under the DMEPOS fee schedule is made at the lesser of charges or the fee schedule amount and therefore if there is a fee for the specific item on the DMEPOS fee schedule, the payment amount for the item will be set at the lesser of the actual charges or the DMEPOS fee schedule amount.  Where the item does not have pass through payment status and where there is no amount for a comparable device in the DMEPOS fee schedule, the contractor shall establ ish a payment amount that is specific to the particular implanted prosthetic device for the applicable calendar year.  This amount (less applicable unpaid deductible and coinsurance) will be paid for that specific device for services furnished in the appli cable calendar year unless the actual charge for the item is less than the established amount). Where the actual charge is less than the established amount, the contractor will pay the actual charge for the item (less applicable unpaid deductible and coins urance).   In setting a contractor established payment rate for the specific device, the contractor takes into account  the cost information available at the time the payment rate is established.  This information may include, but is not limited to, the amount of device cost that would be removed from an applicable APC payment for implantation of the device if the provider received a device without cost or a full credit for the cost of the device.
(Medicare Claims Processing Manual)
If the contractor chooses to use this amount, see www.cms.hhs.gov/HospitalOutpatientPPS/ for the amount of reduction to the APC payment that would apply in these cases.  From the OPPS webpage, select Device, Radiolabeled Product, and Procedure Edits from  the list on the left side of the page.  Open the file Procedure to Device edits to determine the HCPCS code that best describes the procedure in which the device would be used.  Then identify the APC to which that procedure code maps from the most recent Addenda B on the OPPS webpage and open the file FB/FC Modifier Procedures and Devices.  Select the applicable years file of APCs subject to full and partial credit reductions (for example: CY 2008 APCs Subject to Full and Partial Credit Reduction Policy).  Select the Full offset reduction amount that pertains to the APC that is most applicable to the device described by C9899.  It would be reasonable to set this amount as payment for the device.  For example, if C9899 is reporting insertion of a single chamber pacemaker (C1786 or equivalent narrative description on the claim in remarks) the file of procedure to device edits shows that a single chamber pacemaker is the dominant device for APC 0090 (APC 0089 is for insertion of both pacemaker and electrodes and therefore would not apply if electrodes are not also billed).  The table of offset reduction amounts for CY 2008 shows that the estimated cost of a single chamber pacemaker for APC 0090 is $4881.77.  It would therefore be reasonable for the contractor/MAC to set the payment rate for a single chamber pacemaker to $4881.77. In this case the coinsurance would be $936.75 (20 percent of $4881.77, which is less than the inpatient deductible).
(Medicare Claims Processing Manual)
The beneficiary coinsurance is 20 percent of the payment amount for the device (i.e. the pass through payment amount, the DMEPOS fee schedule amount, the contractor established amount, or the actual charge if less than the DMEPOS fee schedule amount or the contractor established amount for the specific device), not to exceed the Medicare inpatient deductible that is applicable to the year in which the implanted prosthetic device is furnished.  When a hospital that is not paid under the OPPS furnishes an implantable prosthetic device other than dental), which replaces all or part of an internal body organ (including colostomy bags and supplies directly related to colostomy care), including replac ement of such a device, to an inpatient who has coverage under Part B but does not have Part A coverage, and the primary procedure is not a payable Part B inpatient service under Pub. 100-02, Medicare Benefit Policy Manual, chapter 6, 10.2 (Other Circums tances in Which Payment Cannot Be Made under Part A), payment for the implantable prosthetic device is made under the payment mechanism that applies to other hospital outpatient services (e.g., reasonable cost, all inclusive rate, waiver).   240.4 - Indian Health Service/Tribal Hospital Inpatient Social Admissions (Rev. 2877, Issued: 02- 07-14, Effective: 10 -01-13, Implementation: 04- 07-14)
(Medicare Claims Processing Manual)
240.4 - Indian Health Service/Tribal Hospital Inpatient Social Admissions (Rev. 2877, Issued: 02- 07-14, Effective: 10 -01-13, Implementation: 04- 07-14)  There may be situations when an American Indian/Alaskan Native (AI/AN) beneficiary is admitted to an IHS/Tribal facility for social reasons. These social admissions are for patient and family convenience and are not billable to Medicare.  There are also occasions where IHS/Tribal hospitals elect to admit patients prior to a scheduled day of surgery, or place a patient in a room after an inpatient discharge. These services are also considered to be social admissions as well.  For patients in a social admission status requiring outpatient services at another facility, Medicare disallows payment for inpatient Part B ancillary services, Type of Bill (TOB) 12X during a social admission stay when there is another bill from a differe nt facility for an outpatient service, TOB 13X or 72X. The Common Working File (CWF) returns an A/B crossover edit and creates an unsolicited response (IUR) in this situation.  The CWF also creates an IUR when a line item date of service on TOB 12X is equal to or one day following the discharge date on TOB 11X for the same provider.   The CWF bypasses both of these edits when the beneficiary is not entitled to Medicare Part A at the time the services on TOB 12X are rendered.   240.5 - Payment of Part B Services in the Payment Window for Outpatient Services Treated as Inpatient Services When Payment Cannot Be Made Under Part A  (Rev. 2877, Issued: 02- 07-14, Effective: 10 -01-13, Implementation: 04- 07-14)
(Medicare Claims Processing Manual)
See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 6, 10 (Medical and Other Health Services Furnished to Inpatients of Participating Hospitals) and Pub 100- 04, Medicare Claims Processing Manual, Chapter 4,  10.12 (Payment Window for Outpatient Services Treated as Inpatient Services) regarding  services bundled into the original Part A claim under the 3 -day (1 -day for non- IPPS hospitals) payment window prior to the inpatient admission, that may be billed to Part B when Part A payment cannot be made.  Hospitals should use the following type of bill to report these services:    13X TOB (85X for a CAH) - Hospital outpatient services included in the payment window for outpatient services treated as inpatient services    14X TOB - Laboratory tests that are paid under the clinical laboratory fee schedule (see chapter 16, 40.3 of this manual), and included in the payment window for outpatient services treated as inpatient services   240.6 - Submitting Provider -Liable No- Pay Part A Claims and Beneficiary Liability (Rev. 2877, Issued: 02- 07-14, Effective: 10 -01-13, Implementation: 04- 07-14)  When Part A payment cannot be made for a hospital inpatient admission and the hospital, not the beneficiary, is liable under section 1879 of the Act for the cost of the Part A items and services, the hospital must submit a provider -liable no pay Part A claim (110 TOB) (see chapter 3 40.2.2,  Charges to Beneficiaries for Part A Services of this manual) .  Submission of this claim cancels any claim that may have already been submitted by the hospital for payment under Part A.  When a Medicare review contra ctor denies a Part A claim for medical necessity, the claims system converts the originally submitted 11X claim to a 110 TOB on behalf of the hospital.
(Medicare Claims Processing Manual)
When the hospital and not the beneficiary is liable for the cost of the Part A services (pursuant to the limitation on liability provision in Section 1879 of the Social Security Act), the beneficiary is not responsible for paying the deductible and coinsur ance charges related to the denied Part A claim and the beneficiarys Medicare utilization record is not charged for the services and items furnished.  The hospital must refund any payments (including coinsurance and deductible) made by the beneficiary or third party for a denied Part A claim when the provider is held financially liable for that denial (see section 1879(b) of the Act; 42 CFR  411.402; and chapter 30  30.1.2, Beneficiary Determined to Be Without Liability and 30.2.2, Provider/Practitioner/Supplier is Determined to Be Liable of this manual).   Medicare beneficiaries are liable for their usual Part B financial liability for services covered under Part B when Part A payment cannot be made, including Part B copayments for each payable Part B inpatient or Part B outpatient service.  The beneficiary is also liable for the cost of services not covered under Part B.   250 - Special Rules for Critical Access Hospital Outpatient Billing  (Rev. 1111, Issued: 11- 09-06, Effective: 04 -01-07, Implementation: 04- 02-07)  For cost reporting periods beginning before October 1, 2000, a CAH will be paid for outpatient services under the method in 250.1.  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  This provisi on was implemented with respect to cost reporting periods starting on or after October 1, 2001.
(Medicare Claims Processing Manual)
For cost reporting period beginning on or after October 1, 2001, the CAH will be paid under the method in item 1 below unless it elects to be paid under the method in 250.1 of this manual.  If a CAH elects  payment under the elective method (cost -based facility payment plus fee schedule for professional services) for a cost reporting period, that election is effective for the entire cost reporting period to which it applies.  If the CAH wishes to make a new election or change a previous election, that election should be made in writing, made on an annual basis and delivered to the appropriate A/B MAC (A), at least 30 days in advance of the beginning of the affected cost reporting period.  All outpatient CAH services, other than pneumococcal pneumonia vaccines, influenza vaccines, administration of the vaccines, screening mammograms, and clinical diagnostic laboratory tests are subject to Part B deductible and coinsurance.  Regardless of the  payment method applicable for a period, payment for outpatient CAH services is not subject to the following payment principles:    Lesser of cost or charges,    Reasonable compensation equivalent (RCE) limits,    Any type of reduction to operating or capital costs under 42 CFR 413.124 or 413.30(j)(7) , or    Blended payment rates for ASC -type, radiology, and other diagnostic services.  See 250.4 below regarding payment for screening mammography services.   250.1 - Standard Method - Cost -Based Facility Services, With Billing of A/B MAC (B) for Professional Services  (Rev. 2581, Issued: 11- 02-12, Effective: 04 -01-13, Implementation: 04- 01-13)  Effective for cost reporting periods beginning on or after January 1, 2004, payment for outpatient CAH services under this method will be made for the lesser of: 1) 80 percent of 101 percent of the reasonable cost of the CAH in furnishing those services, or 2) 101 percent of the reasonable cost of the CAH in furnishing those services, less applicable Part B deductible and coinsurance amounts.
(Medicare Claims Processing Manual)
Payment for professional medical services furnished in a CAH to CAH outpatients is made by the A/B MAC (B)  on a fee schedule, charge, or other fee basis, as would apply if the services had been furnished in a hospital outpatient department. For purposes of CAH payment, professional medical services are defined as services provided by a physician or other pract itioner, e.g., a physician assistant that could be billed directly to a A/B MAC (B)  under Part B of Medicare or a nurse practitioner that could be bil led directly to a A/B MAC (B) under Part B of Medicare.   In general, payment for professional medical services, under the cost -based CAH payment plus professional services billed to the A/B MAC (B)  method should be made on the same basis as would apply if the services had been furnished in the outpatient department of a hospital.   Bill type 85X is used for all outpatient services including services approved as ASC services. Non-patient laboratory specimens (those not meeting the criteria for reasonable cost payment in 250.6) will be billed on a 14X type of bill.   (See Section 250.6 -  Clinical Diagnostic Laboratory Tests Furnished by CAHs.)   250.1.1 - Special Instructions for Non -covered Time Increments in Standard Method Critical Access Hospitals (CAHs)  (Rev. 1921, Issued: 02- 19-10, Effective: 04 -01-10, Implementation: 04- 05-10)  CAHs sometimes bill outpatient therapy services using HCPCS that by definition give specific time increments like those discussed in Chapter 5, sections 20 and 40.  However, standard method CAHs are not subject to payment on a fee basis under the Medicare Physician Fee Schedule, therefore these CAHs should follow the instructions below if there is a need to bill non- covered increments.
(Medicare Claims Processing Manual)
When HCPCS codes required for reporting do not specify an increment of billing in their definition (i.e., 15 minute intervals), the unit for the line item is 1, and CAHs should follow the general instructions given for billing non- covered charges in Chapter 1, section 60, either by the line item or on no payment claims.  Several of the outpatient therapy HCPCS codes, however, are defined in specific time increments, and units reported on line items should be consistent with these definitions. In such cases, when both covered and non- covered increments are provided in the s ame visit on the same date of service, CAHs should bill as follows:    Report covered and non- covered units in separate line items, even when part of the same visit, with one line item for all covered and non- covered increments in a visit, and another for all non- covered increments in that same visit;   Use ABN- related modifiers when appropriate to explain non- coverage and payment liability of specific lines (i.e., - GY, see Chapter 1, section 60 for details on these modifiers);    Do not report non- covered line items that are part of a partially covered service on a separate no payment claim (i.e., using condition code 21).  Instead, always report them on the same claim with the separate lines for the covered portion of the service.  No payment claims received for the same date, same beneficiary, same provider and same therapy service as a for -payment claim will be rejected. A distinct reason code will make providers aware of the reason for the rejection, and they can correct their bi lling to have covered and non- covered portions of the same service on the same claim;    Do not report non- covered line items as part of the required reporting of value codes 50, 51 and 52 for covered visits (i.e., where all increments are non- covered and there are no covered charges for the line item, since these line items are either part of an already counted partially covered visit, or an entirely non- covered visit); and    Never split a single increment into a covered and non- covered portion.
(Medicare Claims Processing Manual)
 Never split a single increment into a covered and non- covered portion.   250.2 - Optional Method for Outpatient Services:  Cost -Based Facility Services Plus 115 percent Fee Schedule Payment for Professional Services  (Rev. 3019, Issued: 08- 07-14, Effective: 01 -01-12, ICD -10: Upon Implementation of ICD-  10, Implementation: 09- 08-14, ICD -10: Upon Implementation of ICD - 10)  The BIPA legislation on payment for professional services at 115 percent of what would otherwise be paid under the fee schedule is effective for services furnished on or after July 1, 2001.  A CAH may elect to be paid for outpatient services in any cost re porting period under this method by filing a written election with the A/B MAC (A) on an annual basis at least 30 days before start of the Cost Reporting period to which the election applies.  An election of this payment method, once made for a cost report ing period, remains in effect for all of that period for the CAH.   Effective for cost reporting periods beginning on or after October 1, 2010 if a CAH elected the optional method for its most recent cost reporting period beginning before October 1, 2010 or chooses to elect the optional method on or after October 1, 2010, that election remains in place until it is terminated, an annual election is no longer required.  If a CAH elects the optional method on or after October 1, 2010, it must submit its request in writing to its A/B MAC (A) at least 30 days before the start of  the first cost reporting period for which the election is effective.  That election will not terminate unless the CAH submits a termination request to its A/B MAC (A) at least 30 days before the start of its next cost reporting period.
(Medicare Claims Processing Manual)
The Medicare Prescription Drugs, Improvement, and Modernization Act (MMA) of 2003, changed the requirement that each practitioner rendering a service at a CAH that has elected the optional method, reassign their billing rights to that CAH.  This provision allows each practitioner to choose whether to reassign billing rights to the CAH or file claims for professional services through their A/B MAC (B).  The reassignment will remain in effect for that entire cost reporting period.  The individual practitioner must certify, using the Form CMS -855R, if he/she wishes to reassign their billing rights.  The CAH must then forward a copy of Form CMS -855R to the A/B MAC (A), and the A/B MACs (B) must have the practitioner sign an attestation  that clearly states that the practitioner will not bill the A/B MAC (A) or A/B MAC (B) for any services rendered at the CAH once the reassignment has been given to the CAH.  This attestation will remain at the CAH.   For CAHs that elected the optional method before November 1, 2003, the provision is effective beginning on or after July 1, 2001.  For CAHs electing the optional method on or after November 1, 2003, the provision is effective for cost reporting periods beginning on or after July 1, 2004.  Under this election, a CAH will receive payment from their A/B MAC (A) for professional services furnished in that CAHs outpatient department. Professional services are those furnished by all licensed professionals who ot herwise would be entitled to bill the A/B MAC (B) under Part B.  Payment to the CAH for each outpatient visit (reassigned billing) will be the sum of the following:    For facility services, not including physician or other practitioner services, payment will be based on 101 percent of the reasonable costs of the services.  List the facility service(s) rendered to outpatients using the appropriate revenue code.  The A/B MAC will pay 101 percent of the reasonable costs for the outpatient services less applicable Part B deductible and coinsurance amounts, plus:    Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.
(Medicare Claims Processing Manual)
 Show the professional services separately, along with the appropriate HCPCS code (physician or other practitioner) in one of the following revenue codes - 096X, 097X, or 098X.   The A/B MAC (A) uses the Medicare Physician Fee Schedule (MPFS) amounts to pay for all the physician/nonphysician practitioner services rendered in a CAH that elected the optional method.  Payment is based on the lesser of the actual charge or the facility -specific MPFS amount less deductible and coinsurance times 1.15; and    AK -  Service rendered in a CAH by a non -participating physician   For a non -participating physician service, a CAH must place modifier AK on the claim.  Payment is based on the lesser of the actual charge or a reduced fee schedule amount of 95 percent. Payment is calculated as follows:    [(facility -specific MPFS amount times the non -participating physician reduction (0.95) minus (deductible and coinsurance] times 1.15.   GF -  Services rendered by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA)   GF - Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA).  (The GF modifier is not to be used for CRNA services.  If a claim is received and it has the GF  modifier for certified registered nurse anesthetist (CRNA) services, the claim is returned to the provider.)  Also, while this national GF modifier includes CRNs, there is no benefit under Medicare law that authorizes payment to CRNs for their services .  Accordingly, if a claim is received and it has the GF modifier for CRN services, no Medicare payment should be made.   Services billed with the GF modifier are paid based on the lesser of the actual charge or a reduced fee schedule amount of 85 percent.  Payment is calculated as follows:    [(facility -specific MPFS amount times the nonphysician practitioner services reduction (0.85) minus (deductible and coinsurance)] times 1.15.