evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
A patient who requires follow -up care or elective surgery may be discharged and readmitted or may be placed on a leave of absence.   Hospitals may place a patient on a leave of absence when readmission is expected and the patient does not require a hospital level of care during the interim period.  Examples could include, but are not limited to, situations where surgery could not be scheduled immediately, a specific surgical team was not available, bilateral surgery was planned, or when further treatment is indicated following diagnostic tests but cannot begin immediately.  Institutional providers must not use the leave of absence billing procedure when the second admission is unexpected.   The A/B MACs (A) may choose to review claims if data analysis deems it a priority.  AB/MACs (A) will review the claim selected, based on the medical record associated with that claim and make a payment determination on that claim.  They will then refer the claim to the QIO, in accordance with IOM 100 -08, chapter 6, 6.5.7.   The QIOs may review acute care hospital admissions occurring within 30 days of discharge from an acute care hospital if both hospitals are in the QIOs jurisdiction and if it appears that the two confinements could be related.  Two separate payments would be made for these cases unless the readmission or preceding admission is denied.  NOTE:  The QIOs authority to review and to deny readmissions when appropriate is not  limited to readmissions within 30 days.  The QIO has the authority to deny the second admission to the same or another acute PPS hospital, no matter how many days elapsed since the patient's discharge.   Placing a patient on a leave of absence will not generate two payments.  Only one bill and one DRG payment is made.  The A/B MACs (A) do not consider leave of absence bills as two admissions.  It may select such bills for review for other reasons.   When a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital on the same day for symptoms related  to, or for evaluation and management of, the prior stays medical condition, hospitals shall adjust the original claim generated by the original stay by combining the original and subsequent stay onto a single claim.
(Medicare Claims Processing Manual)
Services rendered by other entities during a combined stay must be paid by the acute care PPS hospital.  The acute care PPS hospital is responsible for the other entitys services per common Medicare practice.   NOTE:  Medicare does not reimburse other entities for services performed during two inpatient acute care PPS stays that are combined onto a single claim.  However, the other entitys services may be considered and billed as covered services, when appropriate, by the acute care PPS hospital.   When a patient is discharged/transferred from an acute care PPS hospital and is readmitted to the same acute care PPS hospital on the same day for symptoms unrelated  to, and/or not for evaluation and management of, the prior stays medical condition, hospitals shall place condition code (CC) B4 on the claim that contains an admission date equal to the prior admissions discharge date.   Upon the request of A/B MACs (A), hospitals must submit medical records pertaining to the readmission.  For Non- PPS acute care hospitals, such as Maryland waiver hospitals, the readmission bill (if related to original admission) does not have to be combined with the original bill if the stay spans a month.  However, the original bill would have to be adjuste d to change the patient status code to a 30 (still a patient).  Subsequent monthly bills for this admission would be billed as interim bills, 112, 113 or 114.  40.2.6 - Leave of Absence  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD -10: Upon Implementation of ICD- 10, Implementation: ICD -10: Upon Implementation of ICD -10, ASC X12: September, 23 2014)   Providers submit one bill for covered days and days of leave when the patient is ultimately discharged.  The provider bills for covered days with days of leave included in Noncovered Days.  Noncovered charges for leave of absence days (holding a bed) may be omitted from the bill or may be shown under revenue code 018x.  Providers will be instructed by their A /B MAC (A) on which billing method to use.  Occurrence span code 74 is used to report the dates the leave began and ended.  Although the Medicare program may not be billed for days of leave, the provider is not permitted to charge a beneficiary for them.
(Medicare Claims Processing Manual)
Where a patient on leave of absence from a non -PPS hospital who was shown as "Still Patient" (patient status code 30) on an interim bill:    Has not returned within 60 days, including the day leave began, or    Has been admitted to another institution at any time during the leave of absence, submit an adjusted bill.  The hospital shows the day the patient left the hospital as the date of discharge.  (A beneficiary cannot be an inpatient of two institutions at the same time.)   NOTE: Home health or outpatient services provided during a leave of absence do not affect the leave and no discharge bill is required unless the above events occur.  40.3 - Outpatient Services Treated as Inpatient Services  (Rev. 3030, Issued: 08- 22-14, Effective: ASC X12: January 1, 2012, ICD-10: Upon Implementation of ICD-10, Implementation: ICD-10: Upon Implementation of ICD-10, ASC X12: September, 23 2014)   A. - Outpatient Services Followed by Admission Before Midnight of the Following Day (Effective For Services Furnished Before October 1, 1991)  When a beneficiary receives outpatient hospital services during the day immediately preceding the hospital admission, the outpatient hospital services are treated as inpatient services if the beneficiary has Part A coverage.  Hospitals and A/B MACs (A) apply this provision only when the beneficiary is admitted to the hospital before midnight of the day following receipt of outpatient services.  The day on which the patient is formally admitted as an inpatient is counted as the first inpatient day.   When this provision applies, services are included in the applicable PPS payment and not billed separately.  When this provision applies to hospitals and units excluded from the hospital PPS, services are shown on the bill and included in the Part A payment.  See Chapter 1 for A/B MAC (A) requirements for detecting duplicate claims in such cases.   B. - Preadmission Diagnostic Services  (Effective for Services Furnished On or After January 1, 1991)
(Medicare Claims Processing Manual)
B. - Preadmission Diagnostic Services  (Effective for Services Furnished On or After January 1, 1991)  Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage.  For example, if a patient is admitted on a Wednesday, outpatient services provided by the hospital on Sunday, Monday, Tuesday, or Wednesday are included in the inpatient Part A payment.  This provision does not apply to ambulance services and maintenance renal dialysis services (see the Medicare Benefit Policy Manual, Chapters 10 and 11, respectively).  Additionally, Part A services furnished by skilled nursing facilities, home health agencies, and hospices are excluded from the payment window provisions.  For services provided before October 31, 1994, this provision applies to both hospitals subject to the hospital inpatient prospective payment system (IPPS) as well as those hospitals and units excluded from IPPS.  For services provided on or after October 31, 1994, for hospitals and units excluded from IPPS, this provision applies only to services furnished within one day prior to and including the date of the beneficiary's admission.  The hospitals and units that are excluded from IPPS are: psychiatric hospitals and units; inpatient rehabilitation facilities (IRF) and units; long -term care hospitals (LTCH); childrens hospitals; and cancer hospitals.  The 3 -day (or 1 -day) payment window policy does not apply when the admitting hospital is a critical access hospital (CAH).  Therefore outpatient diagnostic services rendered to a beneficiary by a CAH, or by an entity that is wholly owned or operated by a CAH, during the payment window, must not be bundled on the claim for the beneficiarys inpatient admission at the CAH.  However, outpatient diagnostic services rendered to a beneficiary at a CAH that is wholly owned or operated by a non-CAH hospital, during the payment window, are subject to the 3 -day (or 1-day) payment window policy.
(Medicare Claims Processing Manual)
The technical portion of any outpatient diagnostic service rendered to a beneficiary at a hospital -owned or hospital -operated physician clinic or practice during the payment window is subject to the 3- day (or 1- day) payment window policy (see MCPM, chapter  12, sections 90.7 and 90.7.1).  The 3 -day (or 1 -day) payment window policy does not apply to outpatient diagnostic services included in the rural health clinic (RHC) or Federally qualified health center (FQHC) all- inclusive rate (see MCPM, chapter 19, section 20.1).   Outpatient diagnostic services furnished to a beneficiary more than 3 days (for a non -subsection (d) hospital, more than 1 day) preceding the date of the beneficiarys admission to the hospital, by law, are not part of the payment window and must not be bundled on the inpatient bill with other outpatient services that were furnished during the span of the 3- day (or 1- day) payment window, even when all of the outpatient services were furnished during a single, continuous outpatient encounter.  Instead, the outpatient diagnostic services that were furnished prior to the span of the payment window may be separately billed to Part B.
(Medicare Claims Processing Manual)
An entity is considered to be "wholly owned or operated" by the hospital if the hospital is the sole owner or operator.  A hospital need not exercise administrative control over a facility in order to operate it.  A hospital is considered the sole operator of the facility if the hospital has exclusive responsibility for implementing facility policies (i.e ., conducting or overseeing the facility's routine operations), regardless of whether it also has the authority to make the policies.  For purposes of the 3- day (or 1 -day) payment window policy, a sponsorship is treated the same as an ownership, and a non- profit or not -for-profit entity is treated the same as a for -profit entity.  Thus, outpatient diagnostic services provided by the admitting not- for-profit hospital, or by an entity that is wholly sponsored or operated by the admitting not -for-profit hospital, to a beneficiary during the 3 days (or 1 day) immediately preceding and including the date of the beneficiarys inpatient  admission are deemed to be inpatient services and must be bundled on the claim for the beneficiarys inpatient stay at the not -for-profit hospital.  For this provision, diagnostic services are defined by the presence on the bill of the following revenue and/or CPT codes:
(Medicare Claims Processing Manual)
Code  Description  0254  Drugs incident to other diagnostic services  0255  Drugs incident to radiology  030X  Laboratory  031X  Laboratory pathological  032X  Radiology diagnostic  0341, 0343  Nuclear medicine, diagnostic/Diagnostic Radiopharmaceuticals  035X  CT scan  0371  Anesthesia incident to Radiology  0372  Anesthesia incident to other diagnostic services  040X  Other imaging services  Code  Description  046X  Pulmonary function  0471  Audiology diagnostic  0481, 0489  Cardiology, Cardiac Catheter Lab/Other Cardiology with CPT codes 93451-93464, 93503, 93505, 93530-93533, 93561-93568, 93571-93572, G0275, and G0278  diagnostic  0482  Cardiology, Stress Test  0483  Cardiology, Echocardiology  053X  Osteopathic services  061X  MRT  062X  Medical/surgical supplies, incident to radiology or other diagnostic services  073X  EKG/ECG  074X  EEG  0918 - Testing - Behavioral Health  092X  Other diagnostic services   The CWF rejects services furnished January 1, 1991, or later when outpatient bills for diagnostic services with through dates or last date of service (occurrence span code 72) fall on the day of admission or any of the 3 days immediately prior to admission  to an IPPS or IPPS- excluded hospital.  This reject applies to the bill in process, regardless of whether the outpatient or inpatient bill is processed first.  Hospitals must analyze the two bills and report appropriate corrections.  For services on or after October 31, 1994, for hospitals and units excluded from IPPS, CWF will reject outpatient diagnostic bills that occur on the day of or one day before admission.  For IPPS hospitals, CWF will continue to reject outpatient diagnostic bills for services tha t occur on the day of or any of the 3 days prior to admission.  Effective for dates of service on or after July 1, 2008, CWF will reject diagnostic services when the line item date of service (LIDOS) falls on the day of admission or any of the 3 days immediately prior to an admission to an IPPS hospital or on the day of admission or one day prior to admission for hospitals excluded from IPPS.
(Medicare Claims Processing Manual)
Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are subject to the 3-day payment window.  C. - Other Preadmission Services  (Effective for Services Furnished On or After  October 1, 1991 and Before June 25, 2010)  Nondiagnostic outpatient services that are related to a beneficiarys hospital admission and that are provided by the admitting hospital, or by an entity that is wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), to the patient during the 3 days immediately preceding and including the date of the beneficiarys admission are deemed to be inpatient services and are included in the inpatient payment.  Effective March 13, 1998, we defined nondiagnostic preadmission services as being related to the admission only when there is an exact match (for all digits) between the principal diagnosis code assigned for both the preadmission services and the inpatient stay.  Thus, whenever Part A covers an admission, the hospital may bill nondiagnostic preadmission services to Part B as outpatient services only if they are not related to the admission.  The A/B MAC (A) shall assume, in the absence of evidence to the contrary, that such bills are not admission related and, therefore, are not deemed to be inpatient (Part A) services.  If there are both diagnostic and nondiagnostic preadmission services and the nondiagnostic services are unrelated to the admission, the hospital may separately bill the nondiagnostic preadmission services to Part B.  This provision applies only when the beneficiary has Part A coverage.  This provision does not apply to ambulance services and maintenance renal dialysis.  Additionally, Part A services furnis hed by skilled nursing facilities, home health agencies, and hospices are excluded from the payment window provisions.  For services provided before October 31, 1994, this provision applies to both hospitals subject to IPPS as well as those hospitals and units excluded from IPPS (see section B above).
(Medicare Claims Processing Manual)
For services provided on or after October 31, 1994, for hospitals and units excluded from IPPS, this provision applies only to services furnished within one day prior to and including the date of the beneficiary's admission.  Hospitals must not include on a claim for an inpatient admission any outpatient nondiagnostic services that are not payable under Part B.  For example, oral medications that are considered self-administered drugs under Part B are not payable under the outpatient prospective payment system (OPPS) and must not be bundled on an inpatient claim for purposes of the 3-day (or 1-day) payment window policy.  The 3 -day (or 1 -day) payment window policy does not apply when the admitting hospital is a critical access hospital (CAH).  Therefore, outpatient nondiagnostic services rendered to a beneficiary by a CAH, or by an entity that is wholly owned or operated by a CAH, during the payment window, must not be bundled on the claim for the beneficiarys inpatient admission at the CAH.  However, admission- related outpatient nondiagnostic services rendered to a beneficiary at a CAH that is wholly owned or operated by a non- CAH hospital, during the payment window, are subject to the 3- day (or 1 -day) payment window policy.
(Medicare Claims Processing Manual)
The technical portion of any admission- related outpatient nondiagnostic service rendered to a beneficiary at a hospital-owned or hospital-operated physician clinic or practice during the payment window is subject to the 3-day (or 1-day) payment window policy (see MCPM, chapter 12, sections 90.7 and 90.7.1).  The 3 -day (or 1 -day) payment window policy does not apply to outpatient nondiagnostic services that are included in the rural health clinic (RHC) or Federally qualified health center (FQHC) all -inclusive rate (see MCPM, chapter 19, section 20.1).  Outpatient nondiagnostic services furnished to a beneficiary more than 3 days (for a non-subsection (d) hospital, more than 1 day) preceding the date of the beneficiarys admission to the hospital, by law, are not part of the payment window and must not be bundled on the inpatient bill with other outpatient services that were furnished during the span of the 3- day (or 1 -day) payment window, even when all of the outpatient services were furnished during a single, continuous outpatient encounter.  Instead, the outpatient nondiagnostic services that were furnished prior to the span of the payment window may be separately billed to Part B.
(Medicare Claims Processing Manual)
An entity is considered to be "wholly owned or operated" by the hospital if the hospital is the sole owner or operator.  A hospital need not exercise administrative control over a facility in order to operate it.  A hospital is considered the sole operator of the facility if the hospital has exclusive responsibility for implementing facility policies (i.e ., conducting or overseeing the facility's routine operations), regardless of whether it also has the authority to make the policies.  For purposes of the 3- day (or 1 -day) payment window policy, a sponsorship is treated the same as an ownership, and a non-profit or not- for-profit entity is treated the same as a for -profit entity.  Thus, admission -related outpatient nondiagnostic services provided by the admitting not- for-profit hospital, or by an entity that is wholly sponsored or operated by the admitting not- for-profit hospital, to a beneficiary during the 3 days (or 1 day) immediately preceding and including the date of the be neficiarys inpatient admission are deemed to be inpatient services and must be bundled on the claim for the beneficiarys inpatient stay at the not-for-profit hospital.   Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are subject to the 3-day payment window.  Effective for dates of service on or after July 1, 2008 and before June 25, 2010, CWF will reject claims for nondiagnostic services when the following is met:  1) There is an exact match (for all digits) between the principal diagnosis code assigned for both the preadmission services and the inpatient stay, and   2) The line item date of service (LIDOS) falls on the day of admission or any of the 3 days immediately prior to an admission to an IPPS hospital (or on the day of admission or one day prior to admission for hospitals excluded from IPPS).  D. - Other Preadmission Services  (Effective for Services Furnished On or After  June 25, 2010)
(Medicare Claims Processing Manual)
D. - Other Preadmission Services  (Effective for Services Furnished On or After  June 25, 2010)  Beginning on or after June 25, 2010, the definition of other services related to the admission (i.e., admission -related outpatient nondiagnostic services) is revised for purposes of the 3-day (or 1-day) payment window policy.  Except for the following changes, the other requirements in section 40.3.C continue to be applicable.   For outpatient nondiagnostic services furnished on or after June 25, 2010, all outpatient nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the date of a beneficiarys inpatient admission are deemed related to the admission, and thus, must be billed with the inpatient stay.  Also, outpatient nondiagnostic services, other than ambulance and maintenance renal dialysis services, provided by the hospital (or an entity wholly owned or wholly operated by the hospital) on the first, second, and third calendar days for a subsection (d) hospital paid under the IPPS (first calendar day for non-subsection (d) hospitals) preceding the date of a beneficiarys inpatient admission are deemed related to the admission, and thus, must be billed with the inpatient stay, unless the hospital attests to specific nondiagnostic services as being unrelated to the hospital claim (that is, the preadmission nondiagnostic services are clinically distinct or independent from the reason for the beneficiarys admission) by adding a condition code 51 (definition 51 - Attestation of Unrelated Outpatient Non-diagnostic Services) to the separately billed outpatient non-diagnostic services claim .  Beginning on or after April 1, 2011, providers  may submit outpatient claims with condition code 51 for outpatient claims that have a date of service on or after June 25, 2010.